Every finding on record at Edmond Health Care Center

Based on record review and interview, the facility failed to ensure:a. ordered pain medication was available for administration; andb. a resident received pain medication as ordered for 1 (#66) of 1 sampled resident reviewed for pain management.The administrator identified 72 residents resided in the facility.Findings: An Administering Medications policy, revised 04/2019, read in part, Medications are administered in accordance with prescriber orders, including any required time frame.A physician's order for Resident #66, dated 04/04/25, showed Percocet (an opioid medication) oral tablet 10-325 mg. Give one tablet by mouth every six hours for pain. Discontinue Percocet 7.5-325 mg upon arrival of Percocet 10-325 mg.Resident #66's quarterly resident assessment, dated 11/02/25, showed the resident had diagnosis of pain in unspecified joint. The assessment showed the resident's cognition was intact with a BIMS of 15.A physician's order, dated 11/17/25, showed Percocet oral tablet 7.5-325 mg. Give one tablet by mouth every 24 hours as needed for breakthrough pain, hold for sedation.A December 2025 MAR showed 9 for Percocet 10-325 mg on the 30th at the 6:00 a.m. administration. The MAR showed the medication was administered at 12:00 p.m. and 6:00 p.m.A CONTROLLED DRUG RECEIPT/RECORD/DISPOSITION FORM [narcotic sheet], dated 12/02/25, for Percocet 10-325 mg, showed the last dose was administered on 12/30/25 at 12:00 a.m.A CONTROLLED DRUG RECEIPT/RECORD/DISPOSITION FORM, dated 12/13/25, for Percocet 7.5-325 mg, showed the medication was administered on 12/30/25 at 12:30 p.m. and at 6:00 p.m.A CONTROLLED DRUG RECEIPT/RECORD/DISPOSITION FORM, dated 12/31/25, for Percocet 10-325 mg, showed the first dose was administered on 12/31/25 at 12:00 a.m.Percocet 10-325 mg was not available to administer on 12/30/25 at 6:00 a.m., 12:00 p.m., and 6:00 p.m. There was no documentation to show the reason the medication was not administered.On 12/30/25 at 7:28 a.m., Resident #66 stated the facility ran out of their routine Percocet medication. They stated they did not receive the medication at 6:00 a.m. Resident #7 rated their pain 7 out of 10 on the numerical scale.On 12/31/25 at 2:22 p.m., LPN #3 stated the 9 on the resident's December MAR meant other see progress notes. They stated they did not see any progress notes for the 9 documented.On 12/31/25 at 2:31 p.m., LPN #3 stated if there was a check mark on the MAR, the medication was administered. They stated they could assume the Percocet 10 mg was not administered at 6:00 a.m. on 12/30/25.On 01/02/26 at 8:31 a.m., CMA #2 stated they used the punch, initial, give method for medication administration. They stated they verified the resident's physician orders against the narcotic sheet before administering medications.On 01/02/26 at 8:34 a.m., CMA #2 stated Resident #66's order for Percocet 10-325 mg showed to administer 7.5-325 mg if the 10 mg was not available. They stated they were to document in the MAR and narcotic sheet the 7.5 mg was administered.On 01/02/26 at 8:36 a.m., CMA #2 reviewed the resident's December 2025 narcotic sheet. They stated the resident received 7.5 mg on 12/30/25 at 12:30 p.m. and at 6:00 p.m. but the 10 mg was documented in the resident's electronic MAR at 12:00 p.m. and 6:00 p.m.On 01/02/26 at 8:43 a.m., CMA #2 was asked if the resident's Percocet 7.5 mg order showed to administer routine if the 10 mg was not available. They stated, No.On 01/02/26 at 8:48 a.m., the DON stated the resident's order for Percocet 7.5 mg was to be given once every 24 hours as needed for breakthrough pain.On 01/02/26 at 8:51 a.m., the DON stated if the resident's order did not state to administer 7.5 mg in place of the 10 mg, then staff should not administer it. They stated staff were to ensure they refilled medications in a timely manner. The DON stated it was a medication error.

Based on observation, record review, and interview, the facility failed to:a. ensure weekly skin assessments were completed for 1 (#21), andb. complete wound treatment as ordered for 1 (#45) of 3 sampled residents reviewed for wounds.The administrator identified 72 residents resided in the facility. Findings: 1. On 01/02/26 at 10:55 a.m., CNA #1 and CNA #2 was observed assisting Resident #21 into bed via mechanical lift after providing shower assistance. CNA #1 donned a gown and gloves and continued to assist Resident #21 with catheter care and incontinent care. Resident #21 was observed to have an open area and multiple scabbed areas of various sizes to their left buttocks. A physician's order for Resident #21, dated 06/17/24, showed weekly skin assessments were to be done every Monday on the day shift. A care plan, updated on 05/08/25, showed to monitor wound dressing to left buttocks and change as needed if soiled. December 2025 monthly physician orders showed Resident #21 had diagnoses which included cerebrovascular infarction, traumatic brain injury, hemiplegia, chronic pain, and neuromuscular dysfunction of the bladder A skin assessment report for Resident #21, dated 12/11/25, showed no skin problems. No other skin assessments were shown to be completed after 12/11/25. A quarterly assessment, dated 11/24/25, showed a BIMS score of 6, indicating moderate cognitive deficit. No skin issues were identified. On 01/05/26 at 8:25 a.m., LPN #2 was asked what kind of treatment did Resident #21 receive to the wounds on their left buttocks. LPN #2 stated there was no order for wound care to Resident #21's left buttocks. LPN #2 stated there was no other weekly skin assessment performed since 12/11/25. On 01/05/26 at 8:40 a.m., the DON stated the wound care nurse was responsible for completing weekly skin assessments. 2. On 01/05/26 at 10:48 a.m., LPN #3 was observed performing Resident #45's wound treatment. They did not treat Resident #45's wound with silver alginate as ordered by the wound care provider. A physician's order for Resident #45, dated 12/28/25, showed to cleanse right anterior ankle with normal saline, pat dry, apply Medi-honey, cover with abdominal pad, wrap with Kerlix, secure with tape, initial and date. The order showed to treat daily and as needed if soiled until wound care consult was complete. A wound care visit report for Resident #45, dated 12/30/25, showed to cleanse right anterior lower leg with wound cleanser, apply honey gel and silver alginate, cover with border island dressing Monday, Wednesday, and Friday and as needed. On 01/05/26 at 11:35 a.m., LPN #3 stated the wound care provider was responsible the resident's wound orders. On 01/05/26 at 11:38 a.m., LPN #3 stated the wound care provider changed Resident #45's wound orders on 12/30/25 and the new order was to use wound cleanser, honey gel, silver alginate, super absorbent dressing Monday, Wednesday, and Friday. On 01/05/26 at 11:39 a.m., LPN #3 stated they did not update the resident's orders. They stated the orders should have been updated when they were changed. On 01/05/26 at 11:40 a.m., LPN #3 stated they did not complete Resident #45's wound treatment as ordered.

Based on record review and interview, the facility failed to ensure:a. a discharge assessment was encoded and transmitted for 1 (#3) of 3 sampled residents whose discharge assessments were reviewed for encoding and transmission; andb. a quarterly assessment was completed, encoded, and transmitted for 1 (#66) of 18 sampled residents whose quarterly assessments were reviewed for completion, encoding, and transmission.The administrator identified 72 residents resided in the facility. Findings: A policy titled Electronic Transmission of the MDS, dated [DATE], read in part, All MDS assessments .and discharge and reentry records are completed and electronically encoded and transmitted .in accordance with current OBRA [Omnibus Budget Reconciliation Act] regulations. A Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, read in part, For a Quarterly, Significant Correction to Prior Quarterly, Discharge, or PPS [prospective payment system] assessment, encoding must occur within 7 days after the MDS Completion Date. 1. A Quarterly MDS, dated [DATE], showed Resident #3 was admitted to the facility on [DATE] with diagnoses to include quadriplegia and respiratory failure. A Discharge Return Anticipated MDS, dated [DATE], showed Resident #3's MDS assessment was in progress. On 12/31/25 at 11:21 a.m., the MDS coordinator was asked what their process was for completing and transmitting discharge assessments. They stated, I complete it the day the resident goes out. The MDS coordinator was asked when Resident #3's discharge assessment from 12/05/25 was to be completed and transmitted. They stated, It was supposed to already be done. 2. Resident #66's quarterly resident assessment, dated 12/04/25, showed the assessment was in progress. The assessment showed it was to be completed by 12/17/25. On 12/31/25 at 1:57 p.m., the MDS coordinator stated the required time frame to complete the assessment was about seven days. They stated it did not take them long to complete the assessments, but they were running behind on all of them.

Based on observation, record review, and interview, the facility failed to ensure the physician was notified of a change in condition for 1 (#21) of 3 sampled residents reviewed for changes in skin condition. The administrator identified 72 residents resided in the facility. Findings: On 01/02/26 at 10:55 a.m., CNA #1 and CNA #2 were observed assisting Resident #21 into their bed via mechanical lift after providing shower assistance. Resident #21 was observed to have an open area and multiple scabbed areas of various sizes to their left buttocks. A physician's order for Resident #21, dated 06/17/24, showed weekly skin assessments were to be done every Monday on the day shift. A skin assessment report for Resident #21, dated 12/11/25, showed no skin problems. No other skin assessments were completed after 12/11/25. On 01/05/26 at 8:25 a.m., LPN #2 was asked if the physician had been notified of the areas on Resident #21's left buttocks and what kind of treatment was performed on the wounds. LPN #2 stated there was no documentation the physician had been notified of Resident #21's skin problems or a physician's order for wound care to the resident's left buttocks.

Based on observation, record review, and interview, the facility failed to ensure:a. linens were stored in a manner to promote infection control,b. the laundry room floor was cleaned for 1 of 1 laundry visit, andc. infection control precautions were used during activities of daily living care for 1 (#21) of 3 sampled residents reviewed for enhanced barrier precautions.The administrator identified 72 residents resided in the facility and 17 residents required enhanced barrier precautions. Findings: 1. On 01/02/26 at 10:55 a.m., CNA #1 and CNA #2 were observed assisting Resident #21 into bed via mechanical lift after providing shower assistance. No enhanced barrier precautions were observed to be practiced evidenced by both CNAs not wearing a gown. On 01/02/26 at 10:57 a.m., CNA #1 was observed to don a gown and gloves and continued to provide Resident #21 with catheter care and incontinent care. CNA #1 was observed to hold a tissue up to Resident #21's mouth so they could spit out a substance which they coughed, while wearing the same gloves used when providing catheter care and incontinent care. CNA #1 was observed to put on a clean brief and clean gown on Resident #21 while still wearing the same gloves. An EBP policy, dated 04/01/24, read in part, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. EBP refer to an infection control intervention that employs targeted gown and gloves use during high contact resident care activities. A physician's order for Resident #21, dated 05/23/24, showed enhanced barrier precautions every shift. On 01/02/26. at 11:00 a.m., CNA #1 was asked if they believed they practiced correct enhanced barrier precautions which they stated yes. 2. On 01/02/26 at 11:56 a.m., a tour of the clean linen storage room was conducted. The following observations were made: a. pillows on a shelf were stored to the ceiling, b. multiple blankets on a shelf were stored to the ceiling, and c. multiple bags, shoes, and sheets were laying around on the floor. On 01/02/26 at 12:13 p.m., a tour of the laundry room was conducted. There were moderate brown dirt stains on the floor. There were leaves and tissues on the floor. An Infection Prevention and Control Program policy, dated 05/12/23, read in part, Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection. On 01/02/26 at 12:07 p.m., the housekeeping supervisor stated the above items in the linen storage room were not stored appropriately. On 01/02/26 at 12:18 p.m., the housekeeping supervisor stated the last time the laundry room was cleaned was on 12/23/25. On 01/02/26 at 12:25 p.m., the housekeeping supervisor stated the laundry room was not clean.

Based on record review and interview, the facility failed to ensure labs were completed in a timely manner for 1 (#3) of 3 sampled residents reviewed for lab results.The DON identified 10 residents required hemoglobin A1c monitoring. Findings: An undated Lab Policy and Procedure, read in part, All laboratory tests will be done as ordered by the physician in a timely manner and the results reported to the physician. A Physician's Order, dated 07/09/25, read in part, Laboratory: Hemoglobin a1c every 3 months (Jan [January], April [April], July [July], Oct [October]). A Lab Results Report, dated 07/16/25, showed Resident #3's hemoglobin A1c (a blood test that shows an average blood sugar) was obtained on 07/14/25. A Hospital Care Timeline, dated 10/15/25, showed Resident #3 was discharged from the hospital on [DATE] and no hemoglobin A1c lab was obtained. A Quarterly MDS, dated [DATE], showed Resident #3 was admitted to the facility on [DATE] with diagnoses to include diabetes mellitus. On 01/02/26 at 10:23 a.m., LPN #1 was asked who was responsible ensuring lab orders were completed according to physician orders. They stated, Usually me. LPN #1 was asked to show where Resident #3 had a hemoglobin a1c lab drawn in October 2025. They stated, It probably fell off because [they were] in the hospital and the practitioner didn't order it when [they] came back. On 01/02/26 at 10:36 a.m., the DON was asked who was responsible for canceling standing orders when a resident was admitted to a hospital. They stated, The nurse does if the resident is gone for 14 days and then the doctor usually resumes previous orders. The DON was asked if Resident #23's hemoglobin A1c lab order for October 2025 was canceled when they were admitted to the hospital. The DON stated it was still in their system from July and if the hospital did not draw it, the lab order was not completed.

On 07/31/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to:a. ensure Residents #1 and #2 were free from abuse;b. act on Resident #2's known behavioral patterns; andc. protect Resident #1 from serious harm.Resident #2 with known behavioral patterns was observed by staff to be impaired and suspected of being under the influence of drugs on the night or early morning hours of 07/24/25 with glossy eyes, dilated pupils, talking to themselves and with noted confusion. Resident #2 was documented as entering other resident rooms while suspected of being under the influence of drugs and with impaired decision making. The facility did not implement interventions. The following night the resident was observed to be speaking to themself using profane language in the hallway after returning from the community and subsequently sexually assaulted (raped) Resident #1 on the early hours of 07/25/25. These failures put all residents at risk of serious harm. An admission resident assessment, dated 06/04/25, showed Resident #2's cognition was intact (BIMS 15). The assessment showed the resident exhibited verbal behavioral symptoms directed toward others that significantly disrupted care or the living environment. The assessment showed the resident required supervision or touching assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, sitting to standing, and chair/bed-to-chair transfer. An annual resident assessment, dated 06/16/25, showed Resident #1's cognitive skills for daily decision making were severely impaired per staff assessment for mental status. The assessment showed the resident required substantial/maximum assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, and was dependent on staff for chair to bed transfers.A quarterly resident assessment, dated 06/29/25, showed Resident #4's cognition was severely impaired (BIMS 04). The assessment showed the resident was independent for rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfers, and walking 10 feet.A nurse progress note, dated 07/25/25 at 3:30 a.m., showed at approximately 3:25 a.m., RN #1 was alerted by another resident (Resident #4) to a situation occurring in their room. Upon entering the room, RN #1 observed concerning behavior between (Resident #1 and Resident #2). RN #1 instructed Resident #2 to stop and leave the area. A CNA (CNA #1) was directed to supervise and escort Resident #2 out of the room while RN #1 contacted the DON for further guidance. The note showed Resident #1 was briefly assessed with no visible injuries noted at the time. The note showed Resident #2 was placed on 1:1 supervision for close monitoring. The note showed the provider on call and facility administration were notified and appropriate reporting procedures were initiated per protocol. The initial report, dated 07/25/25, showed the DON and administrator were notified Resident #2 was in Resident #1's room. The initial report showed the residents were immediately separated and Resident #2 left the property. The initial report showed Resident #1 was sent to the emergency room for precautionary evaluation. The initial report showed the police, family, physician, resident's legal representative, and APS were notified. The initial report was received by the state agency on 07/25/25 at 7:14 a.m. The final report, dated 07/25/25, was received by the state agency on 07/30/25 at 12:12 p.m. The final report contained additional information in the description of the incident. The final report showed at 3:42 a.m., (RN #1) contacted the DON regarding (Resident #2) in (Resident #1's) room and in (Resident #1's) bed. The final report showed staff reported (Resident #2) was in (Resident #1's) room with (Resident #2's) pants halfway pulled down. The final report showed (Resident #2) was on the bed with (Resident #1). The DON notified (RN #1) to immediately separate the residents. (Resident #2) was to be placed on 1:1. (Resident #2) then exited the facility while staff was attempting to talk with them. Police were notified and (Resident #1) was sent to the emergency room for precautionary evaluation. The final report showed staff stayed with (Resident #1) until they left to the emergency room. The final report showed (Resident #1) was transported via ambulance and report was given. When police arrived, (Resident #2) was taken into custody by the police department. The DON notified the administrator at 3:48 a.m. The final report showed (Resident #1's) most recent BIMS was 0/15, required total assistance with ADLs, and had diagnoses which included dementia. The final report showed investigation of the incident revealed staff was present on the hall at 2:42 a.m. giving medication to (Resident #2). At 2:49 a.m., (Resident #2) entered (Resident #1's) room. At 2:52 a.m., (Resident #2) shut (Resident #1's) door. At 3:06 a.m. (Resident #4) heard (Resident #2) enter, got up, and reported to staff (name not provided) that (Resident #2) was in their room. At 3:09 a.m., (RN #1) went down to the room and when they entered, (RN #1) saw (Resident #2) in the bed with (Resident #1) appearing to be engaged in sex. (RN #1) reported they told (Resident #2) to stop and exit the room and (Resident #2) was getting up and attempting to explain what (Resident #2) was doing when (RN #1) exited the room to call the DON. At 3:12 a.m., (CNA #1) walked into (Resident #1's) room and (Resident #2) was still in the bed with (Resident #1). (CNA #1) separated (Resident #2 and #1) and (Resident #2) was placed on 1:1. The police department was contacted by the DON along with the facility administrator. (Resident #2) exited the building while staff was attempting 1:1 supervision with (Resident #2) until the police arrived. The police department escorted (Resident #2) back into the building and took them into custody. (Resident #1's) family was notified of the incident and of the resident being transported to the emergency room. (Resident #1) was sent to the emergency room for evaluation and treatment. A SANE exam was completed. (Resident #1) returned to the facility and was moved to a room closer to the nurse's station for family comfort. Psych NP to see (Resident #1) upon return from the hospital to evaluate and treat as needed. Safe surveys for all resident's completed with each resident. No concerns for safety or incidents of abuse reported. In-service with staff completed, small roundtables completed with staff over abuse types, appropriate interventions related and who to report abuse to. In house counselor made available for staff and residents as needed. Immediate QAPI completed and ongoing QAPI review. (RN #1) suspended indefinitely.Resident #1's hospital records, dated 07/25/25, showed final diagnosis of sexual assault of adult, initial encounter. The hospital records showed a staff member had gone into Resident #1's room on 07/25/25 and found another resident (Resident #2) vaginally penetrating Resident #1. The hospital records showed Resident #1 was nonverbal. The hospital records showed Resident #1 had diagnoses which included anxiety, brain tumor, dementia with behavioral disturbance, and traumatic brain injury.On 07/31/25 at 9:20 a.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation.On 07/31/25 at 9:24 a.m., the administrator and DON were notified of the IJ situation and a copy of the IJ template was provided.On 08/01/25 at 2:39 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, In response to the IJ called 7/31/25 the facility submits this plan of removal to ensure systems are in place to assess, intervene, and evaluate residents for appropriate care and treatment. The facility will be in compliance by July 31, 2025, at 4pm.a. Facility staff will have immediate and ongoing education pertaining to resident behaviors, interventions, and reporting guidelines. Further education will include recognizing resident behaviors, appropriate & timely intervention, and reporting requirements. This education will be completed by 4pm today, July 31, 2025 by the DON and/or Regional Director of Operations. It will also be added to all new hire orientation and annual training. When abnormal behaviors are reported the facility IDT will ensure reports are investigated and assessed for any necessary interventions/protective measures.b. Facility staff were immediately re-educated on Abuse/Neglect types as well as expected staff response. Staff have had ongoing education in the form of in-service and small group round table scenarios. This training was conducted by the DON, ADON, and Administrator. The perpetrator was immediately removed from the facility and will not return The victim was sent for medical for medical assessment, testing, and treatment if indicated Mental health evaluations were completed for the victim and will be ongoing and as needed. [name withheld] from [name withheld] Mental Health Service completed resident #1's evaluation on 7/27/25. Resident #4 had a mental health evaluation on 7/25/25 and will have ongoing and as needed visits Facility Wide safe surveys were completed 7/25/25 with no voiced concerns of feeling unsafe. Those surveys included education as to the Ombudsman Program as APS services and how to report any concerns in and outside of the facility. Resident's who could or would not participate in the safe survey process are being addressed with contact to their responsible party by the facility SSD. There are 11 residents in the facility without a responsible party/emergency contact. Of those 11, six are moderately to severely cognitively impaired. The facility has completed initial skin assessments for signs/symptoms of abuse and will continue weekly assessments for any resident who cannot verbalize that they are free from abuse. The facility has completed weekly skin assessments for the six residents between 7/28/25 and the 1st. The nurse involved was suspended 7/25/25 at 0452 [4:52 a.m.] and remains as such. Upon DON arrival to facility and beginning of investigative process, the nurse was removed from patient care. [They] remained in facility to provide statements and timeline of events, etc. related to incident. [The nurse] has not worked since. A facility representative will continue ongoing communication with families involved to ensure open communication and collaboration.o Resident #1's family was called Friday, July 25, 2025, at 557am with no answer; family returned that call at 642. This call was made and returned to the Regional Director of Operations, [name withheld]. There were further conversations throughout the day with the RDO [name withheld] and with the administrator, [name withheld]. The family was in the facility at the time of Resident #1's return and contact information was shared for continued communication. Upon completion of investigation, follow up communication completed Wednesday, July 30, 2025, with ongoing weekday communication to be completed by SSD or facility designee.o The investigation outcome revealed one possible witness. This resident, #4, reported to staff, I heard something weird and saw a man in my room who did not belong. I got mad because my roommate has trouble making decisions and I didn't want him to get my snacks. I minded my own damn business because they seemed like they were having a good time. Resident further stated [the resident] is ok, not emotionally upset and wants to enjoy [their] snacks from [their] [family member] and go on about [their] day. Facility leadership (Admin/DON) spoke to her family mid-morning, mid-afternoon, and around dinner time on 7/25/25. Upon completion of investigation, follow up communication completed Wednesday, July 31, 2025, with ongoing weekday communication to be completed by SSD or facility designee.o All residents and responsible parties were sent letters from the facility on 8/1/25 to inform them about the process for any communication, concerns, or needs. Contract employees will be required to complete education prior to working any shift beginning July 31, 2025. Facility core staff were educated by 4pm on July 31, 2025. Any employee on vacation or unable to be reached will be in-serviced before working their next shiftWhat interventions are being placed to address psychosocial concerns with the residents? All residents have standing orders for mental health services as needed contracted by the facility. In-house counseling has been made available to residents, families, and employees at their discretion and request. The facility has agreed to fund any request for mental health services to prevent payor source obstacles.What is going to be put in place to address the residents' fear of abuse in the facility?Safe surveys were completed for all residents by 8/1/25 and the facility will complete ongoing safe surveys monthly. The IJ was lifted, effective 07/31/25, when all components of the plan of removal had been verified as completed. The facility removed the perpetrator, notified authorities and resident family representatives, provided medical/psychiatric care to all residents directly and indirectly affected by the incident, retrained staff with in-service, surveyed residents/families regarding safety concerns, and implemented QAPI actions to strengthen protections and oversight. Staff from multiple departments were interviewed and asked questions regarding in- service trainings. Staff were able to communicate they were trained in identifying, reportioning, and protecting residents from abuse. The deficient practice remained at an isolated level with the potential for more than minimal harm.Based on observation, record review, and interview, the facility failed to:a. ensure residents were free from abuse for 2 (#1 and #4);b. act on a resident's known behavioral patterns for 1 (#2); andc. protect a resident from serious harm for 1 (#1) of 6 sampled residents reviewed for abuse. The BOM identified 78 residents resided in the facility.Findings: An abuse, neglect, exploitation or misappropriation policy, revised 04/2021, read in part, All reports of resident abuse (including injuries of unknown origin), 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.If resident abuse .is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies .The resident's representative.Immediately is defined as .within two hours of an allegation involving abuse.The administrator ensures that he resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator.Witness statements are obtained in writing, signed, and dated. An abuse and neglect policy, dated 05/02/25, read in part, It is the Policy of any [name withheld] Long Term Care managed facility that no resident shall be subject to abuse and/or neglect.All incidents to include suspected resident abuse will be reported to the Administrator and Director of Nursing.Any occurrence of abuse/neglect will be evaluated at the time for removal of a resident to a more appropriate facility.Following the initial verbal investigation, the Administrator will take written statements from all employees, residents, any witness if any, and will determine action to be taken.Administration will evaluate and analyze any occurrence and make any necessary changes that would prevent the situation from recurring in the future. 1. On 07/30/25 at 9:28 a.m., the room with Resident #2's name on it was observed. Resident #2's side of the room was free from any personal items from a resident and did not have a resident on that side of the room. A significant change resident assessment, dated 04/28/25, showed Resident #7's (who was Resident #2's roommate at the time of the incident) cognition was intact (BIMS 13). Resident #2 admission health record, dated 05/28/25, showed they were admitted with diagnoses which included osteomyelitis, acquired absence of the left leg above the knee, and schizoaffective disorder. An admission resident assessment, dated 06/04/25, showed Resident #2's cognition was intact (BIMS 15). The assessment showed the resident exhibited verbal behavioral symptoms directed toward others that significantly disrupted care or the living environment. The assessment showed the resident required supervision or touching assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, sitting to standing, and chair/bed-to-chair transfer. Resident #2's care plan for behaviors, dated 06/16/25, showed the resident had a focus for behaviors which showed they had a history of being verbally aggressive and has the potential for being manipulative. The focus showed the resident had a history of homelessness, begging for money, food, and personal items in the community. Resident #2's behavior note, dated 06/15/25, showed another Resident #2 was threatened by another resident. The police were notified and came and spoke with the residents. Resident #2's behavior note, dated 06/16/25, showed Resident #2 was calling staff names and refusing to do ADL's. Resident #2's behavior note, dated 06/18/25, showed Resident #2 became loud in a care plan meeting and would not let staff talk or assist them with alternative activities that would separate them from other residents. The resident stated they will do what they want, and no one was going to tell them anything. The note showed the resident continued to yell at staff and was hard to redirect. The facility's document titled Behavioral Contract, dated 06/19/25, read in part, This agreement is between [Resident #2] and [name of facility withheld]. In efforts to better care for you, the following expectations are required to maintain and effective provider relationship. You were witnessed to have inappropriate conversations of a sexual nature, scream at other residents, and treat residents and staff negatively. You have been made aware that these actions are unacceptable verbally on numerous occasions. Resident is aware that all residents, including [themselves], have the right to live in a home like environment free from abuse/neglect/exploitation. Resident is expected to respect the rights of other residents, just as [their] rights are respected, going forward. I [Resident #2] have read and understand the above-listed behavioral expectations. I also understand that failure to meet these expectations may result in termination of the provider relationship. This is a 30-day contract to ensure you are able to comply with the facility policy. Resident #2's Behavioral Contract, dated 06/19/25 was signed by Resident #2. the ex-administrator, and SSD. A review of incident reports, state reportables, progress notes, and Resident #2's care plan did not document inappropriate conversations of a sexual nature. Resident #2's behavior note, dated 06/20/25, showed Resident #2 was visited by the social services director and administrator regarding a reported concerns related to illicit drugs. The resident's room had a non-invasive search. No illicit drugs were found. The resident was reminded of the drug and alcohol policy. Resident #2's alert note, dated 06/21/25 at 12:06 p.m., showed Resident #2 went to the lobby, signed themselves out, and the consequences were explained for leaving AMA. Resident #2's nurse notes, dated 06/23/25 at 7:43 a.m., showed Resident #2 signed out at 3:00 a.m., came back and left at 6:00 am but refused to sign out and left against medical advice (AMA). Resident #2's nurse note, dated 06/23/25 at 9:57 a.m., showed Resident #2 returned to the facility and was educated on the safety risk related to leaving AMA. Resident #2's behavior note, dated 07/24/25 at 6:43 a.m., showed the resident had been up all-night wandering around in the hallways going into other residents' room and waking them up. The note showed the resident was told not to go into other residents' room and the resident was talking when nobody was in the area. Resident #2's nurse notes, dated 07/24/25 at 4:06 p.m., read in part, resident came back to the facility with glossy eyes pupils dilatated, increased respirations, and noted confusion and resident talking to [themselves] with impaired decision making. FNP (facility nurse practitioner) notified and ordered a drug urinalysis and blood work. Notified resident that [they]would have to take a ua (urinalysis) and give blood and resident had an aggressive attitude toward this nurse and stated [they] was not going to give urine or let lab take blood work. Resident #2's behavior notes, dated 07/24/25 at 10:53 p.m., read in part, resident returned from outside, with two bags of fast foods. Resident was talking to himself loud on the hallway, this nurse redirected the Resident but refused to comply, Resident was offered ice in his pitcher but refused, I don't want ice water in that pitcher. Resident continued to be loud and cursing using profane language. On 07/30/25 at 9:24 a.m., Resident #7 (who was Resident #2's roommate the day of the incident) stated they had not been a roommate with (Resident #2) for long. Resident #7 stated Resident #2 Went to jail. Resident #7 stated the reason Resident #2 went to jail was because they were a sexual predator. Resident #7 stated Resident #2 had shared stories with them parenting children at the age of eight. On 07/30/25 at 5:16 p.m., the ex-administrator stated they were unaware of the Behavior Contract, dated 06/19/25. They stated Resident #2 would argue with other residents and had to be redirected frequently. On 07/31/25 at 4:42 a.m., the social services director (SSD) was asked about Resident #2's, Behavior Contract, dated 06/19/25. The SSD stated the administrator and themself went to Resident #2's room because there were allegations Resident #2 had crack cocaine, and Resident #2 allegedly said something inappropriate to staff or residents. The SSD stated they were not sure exactly to who or what Resident#2 said. The SSD stated, the DON gave them the Behavior Contract to go over with the Resident #2. The SSD stated they did a soft search of Resident #2's room and did not locate any drugs. The SSD stated Resident #2 denied making any inappropriate sexual remarks. They stated the Administrator said Resident #2 had to sign the Behavior Contract. On 07/31/25 at 6:40 a.m., the DON stated they were not aware of the Behavior Contract, dated 06/19/25, because they had a care plan meeting scheduled and Resident #2 refused to participate. They stated they were unaware of any incidents of sexual inappropriate behaviors with other residents. On 08/04/25 at 8:19 a.m., the MDS coordinator stated they were unaware of the Behavior Contract, dated 06/19/25. 2.On 07/30/25 at 10:10 a.m., Resident #1's name was observed outside the fourth room down from the nurse's station on the right side of hall 300. Resident #1 was not observed inside the room. On 07/30/25 at 10:14 a.m., Resident #1 was observed seated in a standard wheelchair at the beginning of hall 300. Resident #1 was observed wearing a light green shirt with a flower on it, blue/grey pants, and tan skid proof socks on. Resident #1 was able to identify their first name, but was unable to provide any additional information to the surveyor. On 07/30/25 at 11:32 a.m., Resident #1 was observed in the television room on hall 300 seated in a standard wheelchair at the front of all other residents in the room, watching a movie. An annual resident assessment, dated 06/16/25, showed Resident #1's cognitive skills for daily decision making were severely impaired per staff assessment for mental status. The assessment showed the resident required substantial/maximum assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, and was dependent on staff for chair to bed transfers. An initial facility reported incident, dated 07/25/25, showed the DON and administrator were notified Resident #2 was in Resident #1's room. The initial report showed the residents were immediately separated and Resident #2 left the property. The initial report showed Resident #1 was sent to the emergency room for precautionary evaluation. The initial report showed the police, family, physician, resident's legal representative, and APS were notified. The initial report was received by the state agency on 07/25/25 at 7:14 a.m. A final facility reported incident, dated 07/25/25, was received by the state agency on 07/30/25 at 12:12 p.m. The final report contained additional information in the description of the incident. The final report showed at 3:42 a.m., (RN #1) contacted the DON regarding (Resident #2) in (Resident #1’s) room and in (Resident #1’s) bed. The final report showed staff reported (Resident #2) was in (Resident #1’s) room with (Resident #2’s) pants halfway pulled down. The final report showed (Resident #2) was on the bed with (Resident #1). The DON notified (RN #1) to immediately separate the residents. (Resident #2) was to be placed on 1:1. (Resident #2) then exited the facility while staff was attempting to talk with them. Police were notified and (Resident #1) was sent to the emergency room for precautionary evaluation. The final report showed staff stayed with (Resident #1) until they left to the emergency room. The final report showed (Resident #1) was transported via ambulance and report was given. When police arrived, (Resident #2) was taken into custody by the police department. The DON notified the administrator at 3:48 a.m. The final report showed (Resident #1’s) most recent BIMS was 0/15, required total assistance with ADLs, and had diagnoses which included dementia. The final report showed investigation of the incident revealed staff was present on the hall at 2:42 a.m. giving medication to (Resident #2). At 2:49 a.m., (Resident #2) entered (Resident #1’s) room. At 2:52 a.m., (Resident #2) shut (Resident #1’s) door. At 3:06 a.m. (Resident #4) heard (Resident #2) enter, got up, and reported to staff (name not provided) that (Resident #2) was in their room. At 3:09 a.m., (RN #1) went down to the room and when they entered, (RN #1) saw (Resident #2) in the bed with (Resident #1) appearing to be engaged in sex. (RN #1) reported they told (Resident #2) to stop and exit the room and (Resident #2) was getting up and attempting to explain what (Resident #2) was doing when (RN #1) exited the room to call the DON. At 3:12 a.m., (CNA #1) walked into (Resident #1’s) room and (Resident #2) was still in the bed with (Resident #1). (CNA #1) separated (Resident #2 and #1) and (Resident #2) was placed on 1:1. The police department was contacted by the DON along with the facility administrator. (Resident #2) exited the building while staff was attempting 1:1 supervision with (Resident #2) until the police arrived. The police department escorted (Resident #2) back into the building and took them into custody. (Resident #1’s) family was notified of the incident and of the resident being transported to the emergency room. (Resident #1) was sent to the emergency room for evaluation and treatment. A SANE exam was completed. (Resident #1) returned to the facility and was moved to a room closer to the nurse’s station for family comfort. Psych NP to see (Resident #1) upon return from the hospital to evaluate and treat as needed. Safe surveys for all resident’s completed with each resident. No concerns for safety or incidents of abuse reported. In-service with staff completed, small roundtables completed with staff over abuse types, appropriate interventions related and who to report abuse to. In house counselor made available for staff and residents as needed. Immediate QAPI completed and ongoing QAPI review. (RN #1) suspended indefinitely. The immediate QAPI provided for this abuse investigation, dated 07/25/25, showed the COO was called, the administrator was notified, and the DON, ADON, and the SSD were present for the QAPI. The immediate QAPI showed Resident #1 and #2 were placed on 1:1 on 07/25/25 and an in-service was held for all types of abuse. The immediate QAPI showed the physician, nursing board, police, OSDH, and APS were notified of the event and Resident #1 was went to the emergency room for an evaluation. There was no documentation of the 1:1 for Resident #1 and Resident #2 provided to the surveyors. There was no documentation of any monitoring component for this immediate QAPI. Resident #1's hospital records, dated 07/25/25, showed final diagnosis of sexual assault of adult, initial encounter. The hospital records showed a staff member had gone into Resident #1's room on 07/25/25 and found another resident (Resident #2) vaginally penetrating Resident #1. The hospital records showed Resident #1 was nonverbal. The hospital records showed Resident #1 had diagnoses which included anxiety, brain tumor, dementia with behavioral disturbance, and traumatic brain injury. On 07/30/25 at 10:10 a.m., CNA #8 stated Resident #1 had just moved to hall 300 because there was an incident on hall 100. CNA #8 stated they did not know the details of the incident, but if something traumatic did occur, [they] wouldn't want [Resident #1] returned to the same room. On 07/30/25 at 2:33 p.m., family member #4 stated the first call they received from the facility was on 07/25/25 at 5:57 a.m. Family Member #4 stated the regional director of operations informed family member #4 Resident #1 had been sexually assaulted. Family Member #4 stated no details were provided from the facility at the time. Family member #4 stated the next call they received was from the hospital to obtain consent for a rape kit. Family Member #4 stated they were with Resident #1 at the hospital all day and returned with the resident to the facility around 3:00 p.m. Family Member #4 stated the facility informed them (Resident #2) was found in (Resident #1's) room and they did not have pants on. Family Member #4 stated they did not know the details until they saw the story come across their social media page. On 07/30/25 at 2:36 p.m., family member #4 stated, at this time, Resident #1 doesn't even know who family member #4 is when they visit. Family Member #4 stated Resident #1 could not consent for anything. Family Member #4 stated Resident #1 was able to speak, but just can't speak up for [themselves]. On 07/30/25 at 2:38 p.m., family member #4 stated they came up to the facility on Tuesday (07/29/25) and asked Resident #1 if they remembered anything about what happened, but the resident went on to talk about something that occurred in the 1990s. Family Member #4 stated they did not know at the time who raped Resident #1, but since the news broadcast, they looked Resident #2 up and discovered they were a convicted felon. On 07/30/25 at 2:40 p.m., family member #4 stated right after the assault, the nurse completed a rape exam and there was redness in the area. Family Member #4 stated Resident #1 showed signs of discomfort in that area (private area). Family Member #4 stated, That was confirmation to me that [Resident #2] did rape [Resident #1]. On 07/30/25 at 2:42 p.m., family member #4 stated staff had reported they were going to move Resident #1 by the nurses' station, but they did not. Family Memb[TRUNCATED]

Based on observation, record review, and interview, the facility failed to ensure a resident who had a mental health disorder and observed a traumatic event at the facility [NAME]. a care plan developed that thoroughly described the distress from a person-centered perspective; andb. appropriate interventions in place to address the trauma the resident experienced for 1 (#4) of 6 sampled residents reviewed for abuse. The BOM identified 78 residents resided in the facility.Findings: On 07/30/25 at 9:13 a.m., Resident #4 was observed seated on the bed in their room with family member #1 present in the room. A quarterly resident assessment, dated 06/29/25, showed Resident #4's cognition was severely impaired (BIMS 04). The assessment showed the resident had diagnoses which included bipolar disorder. An initial facility reported incident, dated 07/25/25, showed the DON and administrator were notified Resident #2 was in Resident #1's room. The initial report showed the residents were immediately separated and Resident #2 left the property. The initial report showed Resident #1 was sent to the emergency room for precautionary evaluation. The initial report showed the police, family, physician, resident's legal representative, and APS were notified. The initial report was received by the state agency on 07/25/25 at 7:14 a.m. A final facility reported incident, dated 07/25/25, was received by the state agency on 07/30/25 at 12:12 p.m. The final report contained additional information in the description of the incident. The final report showed at 3:42 a.m., (RN #1) contacted the DON regarding (Resident #2) in (Resident #1's) room and in (Resident #1's) bed. The final report showed staff reported (Resident #2) was in (Resident #1's) room with (Resident #2's) pants halfway pulled down. The final report showed (Resident #2) was on the bed with (Resident #1). The DON notified (RN #1) to immediately separate the residents. (Resident #2) was to be placed on 1:1. (Resident #2) then exited the facility while staff was attempting to talk with them. Police were notified and (Resident #1) was sent to the emergency room for precautionary evaluation. The final report showed staff stayed with (Resident #1) until they left to the emergency room. The final report showed (Resident #1) was transported via ambulance and report was given. When police arrived, (Resident #2) was taken into custody by the police department. The DON notified the administrator at 3:48 a.m. The final report showed (Resident #1's) most recent BIMS was 0/15, required total assistance with ADLs, and had diagnoses which included dementia. The final report showed investigation of the incident revealed staff was present on the hall at 2:42 a.m. giving medication to (Resident #2). At 2:49 a.m., (Resident #2) entered (Resident #1's) room. At 2:52 a.m., (Resident #2) shut (Resident #1's) door. At 3:06 a.m. (Resident #4) heard (Resident #2) enter, got up, and reported to staff (name not provided) that (Resident #2) was in their room. At 3:09 a.m., (RN #1) went down to the room and when they entered, (RN #1) saw (Resident #2) in the bed with (Resident #1) appearing to be engaged in sex. (RN #1) reported they told (Resident #2) to stop and exit the room and (Resident #2) was getting up and attempting to explain what (Resident #2) was doing when (RN #1) exited the room to call the DON. At 3:12 a.m., (CNA #1) walked into (Resident #1's) room and (Resident #2) was still in the bed with (Resident #1). (CNA #1) separated (Resident #2 and #1) and (Resident #2) was placed on 1:1. The police department was contacted by the DON along with the facility administrator. (Resident #2) exited the building while staff was attempting 1:1 supervision with (Resident #2) until the police arrived. The police department escorted (Resident #2) back into the building and took them into custody. (Resident #1's) family was notified of the incident and of the resident being transported to the emergency room. (Resident #1) was sent to the emergency room for evaluation and treatment. A SANE exam was completed. (Resident #1) returned to the facility and was moved to a room closer to the nurse's station for family comfort. Psych NP to see (Resident #1) upon return from the hospital to evaluate and treat as needed. Safe surveys for all resident's completed with each resident. No concerns for safety or incidents of abuse reported. In-service with staff completed, small roundtables completed with staff over abuse types, appropriate interventions related and who to report abuse to. In house counselor made available for staff and residents as needed. Immediate QAPI completed and ongoing QAPI review. (RN #1) suspended indefinitely. Resident #4's care plan, last revised 07/30/25, did not contain information regarding Resident #4 experiencing the traumatic event of seeing their roommate (Resident #1) being raped by Resident #2. The care plan did not include interventions for staff to implement following Resident #4 observing their roommate (Resident #1) being raped by Resident #2. On 07/30/25 at 10:34 a.m., Resident #4 stated they reported, [Resident #2's] laying on top of [Resident #1]. Family Member #1 stated (Resident #1) had been moved out of Resident #4's room. Family Member #1 stated the incident was on the news on 07/29/25. Resident #4 stated when they saw the two residents, Resident #2 told Resident #4 to shut the door, so they did. Resident #4 stated Resident #1 had to be sexually assaulted because [Resident #2] was on top of [Resident #1]. Resident #4 stated once facility staff came in to get Resident #1 and #2, Resident #4 walked out because they didn't want any part of it. On 07/30/25 at 10:46 a.m., Resident #4 stated, It was very scary. On 07/30/25 at 10:52 a.m., Resident #4 stated, Yeah, it was very scary. Resident #4 stated they reported it when they heard someone coming. Resident #4 reported seeing a firetruck at the facility. On 07/30/25 at 1:19 p.m., family member #2 and family member #3 reported there was a rape that occurred in Resident #4's room on 07/25/25. Family Member #2 stated Resident #4 was woke up and went to the door to their room that was closed. Family Member #2 stated as Resident #4 was going to open the door, they noticed (Resident #2) in bed on top of (Resident #1). Family Member #2 stated Resident #4 left to go to the nurse's station and report (Resident #2) in their room. On 07/30/25 at 1:27 p.m., family member #2 stated there were two additional family members at the facility on 07/25/25 to visit Resident #4. They visit the resident often. Family Member #2 stated the additional family members reported on 07/25/25, Resident #4 was not waiving goodbye to them as they always did. On 07/30/25 at 1:30 p.m., family member #3 stated all the facility would tell them was there was an incident. Family Member #3 stated, If [Resident #4] was in the room where the incident started, don't you think we should have been notified? They stated the facility went into HIPAA. Family Member #3 stated they were not asking about the other resident, they wanted to know the incident that involved Resident #4 and (an opposite sex individual) being in their room. On 07/30/25 at 1:32 p.m., family member #3 stated, But is [Resident #4] safe? On 07/30/25 at 1:43 p.m., family member #2 stated after 5:00 p.m. that day (07/25/25), they spoke with the regional director of operations. Family Member #2 stated that was when the regional director of operations informed them a criminal act had occurred and a police report was made. They stated the regional director of operations told them you need to know the person who committed the crime was no longer in the facility. Family Member #2 stated at 7 o'clock at night [07/25/25], that's the first time we were told [Resident #2] was gone. They stated the only reason the regional director of operations was answering them was because they were asking the questions and the regional director of operations started covering it up. They stated that was the first time the facility staff had told family member #2 the police were involved. On 07/30/25 at 1:45 p.m., family member #3 stated the lieutenant called and spoke with them about the event. The lieutenant told family member #2 there was a person arrested at the facility for an alleged assault in the first degree, rape. Family Member #3 stated what the lieutenant did not know was Resident #4 was in the room when it happened. Family Member #3 stated the facility never told the police Resident #4 was in the room. They stated the facility was acting like their staff was who discovered the incident. On 07/30/25 at 1:52 p.m., family member #3 stated the detective only told them it was first degree rape. They stated no one from the facility would talk to them or give them information for three days which was why they went to the news station. Family Member #3 stated they believed the facility was trying to cover it up and it needed to be investigated. They stated on 07/29/25, a reporter from the news station came to them and read them the police report. They stated that was the only way they knew exactly what occurred because the facility still had not communicated the information to them. On 07/30/25 at 1:58 p.m., family member #3 stated when they found out (Resident #2) was in the room raping (Resident #1), (Resident #4) was also in the room, and went and got staff, and the police report omits that (Resident #4) was who discovered it because they were not told was concerning. Family Member #3 stated, then (Resident #2) got into a wheelchair, unassisted from the bed of (Resident #1), left the room, and told staff (Resident #2) was going to go outside and smoke while they were giving aide to (Resident #1). Meanwhile the police came to the facility and (Resident #2) was nowhere to be found. The police located (Resident #2) two blocks away from the facility and arrested them in a mobile wheelchair. Family Member #3 stated the facility can't detain someone who committed rape? Family Member #3 stated, Where's the protection for the residents in the facility? Family Member #3 stated, Where's the accountability for this place? Family Member #2 stated They need to be shut down. On 07/30/25 at 2:03 p.m., family member #2 stated, At night [Resident #4] can't sleep. Family Member #2 stated Resident #4 was scared and their eyes were black from lack of sleep. Family Member #2 stated Resident #4 reported they were going to climb out the window today. Family Member #2 stated, [Resident #4] is just scared! On 07/30/25 at 2:04 p.m., family member #2 stated the facility had not addressed their concerns at all. Family Member #2 stated no one had come back to talk to Resident #4 or family member #2. Family Member #2 stated Resident #4 reported They are all scared in there. Family Member #2 stated (Surveyor 1) was the only person who had come into Resident #4's room to talk with the resident. On 07/30/25 at 2:05 p.m., family member #3 stated, Here's the difference in [their], [Resident #4's] scared. Family Member #3 stated, [Resident #4] wants out of there. Family Member #3 stated it already happened but, [The resident] keeps reliving it. On 07/31/25 at 12:05 a.m., CNA #1 stated they had been told by staff Resident #2 had been caught in the therapy room with a resident of the opposite sex previously, but they did not know the details. CNA #1 stated on 07/25/25 when the allegation between Resident #1 and Resident #2 occurred, they were assisting CNA #2 with a resident on another hall. CNA #2 stated they saw Resident #4 come out of their room and go to the nurses' station. CNA #1 stated, [Resident #4] was never up that early in the morning. CNA #1 stated it was between 3:00 a.m. and 3:30 a.m. They stated Resident #4 was with RN #1 wearing a knit sweater type covering. CNA #1 stated they asked RN #1 to check Resident #4 because they usually slept with no clothes on. On 07/31/25 at 12:14 a.m., CNA #1 stated when they finished helping CNA #2, LPN #1 was sitting in the hall at a bedside table, and wanted CNA #1 to get Resident #4 (who was sitting in the living room on hall 300) dressed. CNA #1 stated Resident #4 also requested to have their purse. On 07/31/25 at 12:16 a.m., CNA #1 stated they had gone down to Resident #4's room to get clothes for the resident to put on 07/25/25. They stated when they walked in the room they saw Resident #2 in Resident #1's bed. They stated Resident #1 was in the bed too. They stated no one else was in the room at the time. They stated it had to be around 3:00 a.m. to 3:30 a.m. CNA #1 stated Resident #1's brief was ripped off and their gown was off. They stated Resident #2 was in the bed with their shorts pulled down to their knees. CNA #1 reported saying What are you doing? CNA #1 reported saying Did you just rape [Resident #1]? CNA #1 stated Resident #2 said, No, [Resident #1] invited me in. CNA #1 told Resident #2 that Resident #1 could not have invited them in the room because the resident was unable to speak like that. CNA #1 stated, You need to get out of her bed. CNA #1 stated they were so upset when they saw what happened. They stated they observed a wet towel next to Resident #1 in the bed. They stated Resident #2 was prepared to wipe themselves off afterwards. CNA #1 stated there was nothing in the bed besides the blankets and the resident when they previously left Resident #1's room after providing care. On 07/31/25 at 12:21 a.m., CNA #1 stated Resident #2 started to get out of Resident #1's bed and sat in their wheelchair. They stated Resident #2 transferred themselves to their electric wheelchair and started rubbing Resident #1's leg saying, I saw your [family member] at the store. CNA #1 told Resident #2 You don't even know [Resident #1's] family. CNA #1 told Resident #2 stop rubbing on [Resident #1's] leg. CNA #1 stated if they did not take Resident #2 to jail, they were not going to work for the facility anymore. They stated, I'm not working at a place that allows someone to rape a resident. CNA #1 stated after Resident #2 left the room, CNA #1 proceeded to get clothes and dress Resident #4. They stated Resident #4 stated [Resident #2] had told [them] when [they] walked out the room to close the door. CNA #1 stated that was the point when police, the DON, and everyone came to the facility. On 07/31/25 at 12:29 a.m., CNA #1 stated when they returned to work the 11:00 p.m. to 7:00 a.m. shift (07/25/25 into the morning of 07/26/25), they checked on Resident #4 who was asleep with a gown on. On 07/31/25 at 12:32 a.m., CNA #1 stated they were not aware of anything the facility did in response to the abuse allegation. On 07/31/25 at 12:33 a.m., CNA #1 stated they did not know what the facility had done to address what Resident #4 had experienced. They stated they had not been instructed on any new interventions for Resident #4 for their plan of care. On 07/31/25 at 3:24 a.m., MDS coordinator #1 stated they would discuss any changes with residents during the daily morning meetings at the facility. They stated they would try to update resident care plans as much as they could. MDS Coordinator #1 stated if they were told anything new on a resident or any new behaviors, they would try to include it in the care plan. On 07/31/25 at 3:30 a.m., MDS Coordinator #1 stated on 07/25/25 the DON had called them and said there was a possible incident between Resident #2 and Resident #1. MDS Coordinator #1 stated they had sat with Resident #4 in the television room. MDS Coordinator #1 stated Resident #4 had told them when they got up to use the bathroom, their door was shut. MDS Coordinator #1 stated the resident reported they observed (Resident #2) in the room who asked Resident #4 to shut the door. MDS Coordinator #1 stated the resident was unsure of who (Resident #2) was, but Resident #4 left the room. MDS Coordinator #1 stated they were unaware of what had actually occurred and only knew of hearsay. On 07/31/25 at 3:36 a.m., MDS Coordinator #1 stated what they were told was a sexual assault had occurred. On 07/31/25 at 3:43 a.m., MDS Coordinator #1 stated Resident #4 had information related to the bipolar diagnosis in their care plan. They stated they did not know what they could have put into the resident's plan of care after they experienced the above incident (Resident #2 raping Resident #1). MDS Coordinator #1 stated Resident #4's care plan was not updated following this incident. On 07/31/25 at 6:07 a.m., the DON stated the facility was able to review video footage and identified Resident #2 entered Resident #1's room at 2:49 a.m. and Resident #4 came out of the room and told CNA #1 there was a person (Resident #2) in their room who got RN #1. They stated at 3:09 a.m., RN #1 entered Resident #1's room and saw Resident #2 with their pants down. They stated RN #1 called them at 3:34 a.m. because that was when they could no longer see them on the video footage. The DON stated RN #1 leaving the room did not follow the facility abuse policy. The DON stated the policy showed once residents were observed in abusive behavior, staff were supposed to separate the residents. The DON stated RN #1 missed separating the residents. The DON stated the abuse policy was not followed. The DON stated when CNA #1 entered the room, Resident #2 was still in bed with Resident #1. The DON stated CNA #1 separated the residents and stayed in the room with Resident #1. The DON stated when Resident #2 came out of Resident #1's room, RN #1 and Resident #2 were observed on the video footage in the hallway together by Resident #2's room. On 07/31/25 at 6:09 a.m., the DON stated MDS coordinator #1 spoke with Resident #4 and wrote down their statement after the abuse allegation on 07/25/25. On 07/31/25 at 6:34 a.m., the DON reviewed Resident #4's care plan and stated there was nothing in the care plan related to Resident #4 observing and reporting the abuse allegation between Resident #1 and Resident #2. On 07/31/25 at 6:36 a.m., the DON stated they did not think the facility put any interventions in place for Resident #4. The DON stated there was nothing in Resident #4's care plan that would alert staff Resident #4 had experienced seeing their roommate being sexually assaulted. On 07/31/25 at 7:04 a.m., the DON asked MDS coordinator #1 where the statement from Resident #4 was (for the allegation of abuse investigation). MDS Coordinator #1 stated, I didn't write anything down on it. On 07/31/25 at 8:22 a.m., the COO was identified as the person who would answer questions for the administrator who was on vacation. On 07/31/25 at 8:55 a.m., the COO stated they were not aware of any interventions put in place for Resident #4 who observed this abuse event.

Based on observation, record review, and interview, the facility failed to implement their abuse policy for 3 (#1, 2, and #4) of 6 sampled residents reviewed for abuse. The BOM identified 78 residents resided in the facility.Findings: On 07/30/25 at 9:13 a.m., Resident #4 was observed seated on the bed in their room with family member #1 present in the room. On 07/30/25 at 9:28 a.m., the room with Resident #2's name on it was observed. Resident #2's side of the room was free from any personal items from a resident and did not have a resident on that side of the room. On 07/30/25 at 10:10 a.m., Resident #1's name was observed outside the fourth room down from the nurse's station on the right side of hall 300. Resident #1 was not observed inside the room. On 07/30/25 at 10:14 a.m., Resident #1 was observed seated in a standard wheelchair at the beginning of hall 300. Resident #1 was observed wearing a light green shirt with a flower on it, blue/grey pants, and tan skid proof socks on. Resident #1 was able to identify their first name, but was unable to provide any additional information to the surveyor. An abuse, neglect, exploitation or misappropriation policy, revised 04/2021, read in part, All reports of resident abuse (including injuries of unknown origin), 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. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator.Witness statements are obtained in writing, signed, and dated.A significant change resident assessment, dated 04/28/25, showed Resident #7's cognition was intact (BIMS 13).An abuse and neglect policy, dated 05/02/25, read in part, It is the Policy of any [name withheld] Long Term Care managed facility that no resident shall be subject to abuse and/or neglect.All incidents to include suspected resident abuse will be reported to the Administrator and Director of Nursing.Any occurrence of abuse/neglect will be evaluated at the time for removal of a resident to a more appropriate facility.Following the initial verbal investigation, the Administrator will take written statements from all employees, residents, any witness if any, and will determine action to be taken.Administration will evaluate and analyze any occurrence and make any necessary changes that would prevent the situation from recurring in the future. An admission resident assessment, dated 06/04/25, showed Resident #2's cognition was intact (BIMS 15). The assessment showed the resident exhibited verbal behavioral symptoms directed toward others that significantly disrupted care or the living environment. The assessment showed the resident required supervision or touching assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, sitting to standing, and chair/bed-to-chair transfer. An annual resident assessment, dated 06/16/25, showed Resident #1's cognitive skills for daily decision making were severely impaired per staff assessment for mental status. The assessment showed the resident required substantial/maximum assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, and was dependent on staff for chair to bed transfers. A quarterly resident assessment, dated 06/29/25, showed Resident #4's cognition was severely impaired (BIMS 04). The assessment showed the resident was independent for rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfers, and walking 10 feet. A nurse progress note, dated 07/25/25 at 3:30 a.m., showed at approximately 3:25 a.m., RN #1 was alerted by another resident (Resident #4) to a situation occurring in their room. Upon entering the room, RN #1 observed concerning behavior between (Resident #1 and Resident #2). RN #1 instructed Resident #2 to stop and leave the area. A CNA (CNA #1) was directed to supervise and escort Resident #2 out of the room while RN #1 contacted the DON for further guidance. The note showed Resident #1 was briefly assessed with no visible injuries noted at the time. The note showed Resident #2 was placed on 1:1 supervision for close monitoring. The note showed the provider on call and facility administration were notified and appropriate reporting procedures were initiated per protocol. An initial facility reported incident, dated 07/25/25, showed the DON and administrator were notified Resident #2 was in Resident #1's room. The initial report showed the residents were immediately separated and Resident #2 left the property. The initial report showed Resident #1 was sent to the emergency room for precautionary evaluation. The initial report showed the police, family, physician, resident's legal representative, and APS were notified. The initial report was received by the state agency on 07/25/25 at 7:14 a.m. The final facility reported incident, dated 07/25/25, was received by the state agency on 07/30/25 at 12:12 p.m. The final report contained additional information in the description of the incident. The final report showed at 3:42 a.m., (RN #1) contacted the DON regarding (Resident #2) in (Resident #1's) room and in (Resident #1's) bed. The final report showed staff reported (Resident #2) was in (Resident #1's) room with (Resident #2's) pants halfway pulled down. The final report showed (Resident #2) was on the bed with (Resident #1). The DON notified (RN #1) to immediately separate the residents. (Resident #2) was to be placed on 1:1. (Resident #2) then exited the facility while staff was attempting to talk with them. Police were notified and (Resident #1) was sent to the emergency room for precautionary evaluation. The final report showed staff stayed with (Resident #1) until they left to the emergency room. The final report showed (Resident #1) was transported via ambulance and report was given. When police arrived, (Resident #2) was taken into custody by the police department. The DON notified the administrator at 3:48 a.m. The final report showed (Resident #1's) most recent BIMS was 0/15, required total assistance with ADLs, and had diagnoses which included dementia. The final report showed investigation of the incident revealed staff was present on the hall at 2:42 a.m. giving medication to (Resident #2). At 2:49 a.m., (Resident #2) entered (Resident #1's) room. At 2:52 a.m., (Resident #2) shut (Resident #1's) door. At 3:06 a.m. (Resident #4) heard (Resident #2) enter, got up, and reported to staff (name not provided) that (Resident #2) was in their room. At 3:09 a.m., (RN #1) went down to the room and when they entered, (RN #1) saw (Resident #2) in the bed with (Resident #1) appearing to be engaged in sex. (RN #1) reported they told (Resident #2) to stop and exit the room and (Resident #2) was getting up and attempting to explain what (Resident #2) was doing when (RN #1) exited the room to call the DON. At 3:12 a.m., (CNA #1) walked into (Resident #1's) room and (Resident #2) was still in the bed with (Resident #1). (CNA #1) separated (Resident #2 and #1) and (Resident #2) was placed on 1:1. The police department was contacted by the DON along with the facility administrator. (Resident #2) exited the building while staff was attempting 1:1 supervision with (Resident #2) until the police arrived. The police department escorted (Resident #2) back into the building and took them into custody. (Resident #1's) family was notified of the incident and of the resident being transported to the emergency room. (Resident #1) was sent to the emergency room for evaluation and treatment. A SANE exam was completed. (Resident #1) returned to the facility and was moved to a room closer to the nurse's station for family comfort. Psych NP to see (Resident #1) upon return from the hospital to evaluate and treat as needed. Safe surveys for all resident's completed with each resident. No concerns for safety or incidents of abuse reported. In-service with staff completed, small roundtables completed with staff over abuse types, appropriate interventions related and who to report abuse to. In house counselor made available for staff and residents as needed. Immediate QAPI completed and ongoing QAPI review. (RN #1) suspended indefinitely. The immediate QAPI provided for this abuse investigation, dated 07/25/25, showed the COO was called, the administrator was notified, and the DON, ADON, and the SSD were present for the QAPI. The immediate QAPI showed Resident #1 and #2 were placed on 1:1 on 07/25/25 and an in-service was held for all types of abuse. The immediate QAPI showed the physician, nursing board, police, OSDH, and APS were notified of the event and Resident #1 was went to the emergency room for an evaluation. There was no documentation of the 1:1 for the residents provided to the surveyors. There was no documentation of any monitoring component the facility completed to ensure the ongoing safety of the residents in the facility for this immediate QAPI. There was documentation the facility had interviewed Resident #4 and obtained a statement for this abuse investigation. Resident #1's hospital records, dated 07/25/25, showed final diagnosis of sexual assault of adult, initial encounter. The hospital records showed a staff member had gone into Resident #1's room on 07/25/25 and found another resident (Resident #2) vaginally penetrating Resident #1. The hospital records showed Resident #1 was nonverbal. The hospital records showed Resident #1 had diagnoses which included anxiety, brain tumor, dementia with behavioral disturbance, and traumatic brain injury. On 07/30/25 at 9:24 a.m., Resident #7 (who was Resident #2's roommate the day of the incident) stated they had not been a roommate with (Resident #2) for long. Resident #7 stated Resident #2 Went to jail. Resident #7 stated the reason Resident #2 went to jail was because they were a sexual predator. Resident #7 stated Resident #2 had shared stories with them parenting children at the age of eight. On 07/30/25 at 10:10 a.m., CNA #8 stated Resident #1 had just moved to hall 300 because there was an incident on hall 100. CNA #8 stated they did not know the details of the incident, but if something traumatic did occur, [they] wouldn't want [Resident #1] returned to the same room. On 07/30/25 at 10:34 a.m., Resident #4 stated they reported, [Resident #2's] laying on top of [Resident #1]. Family Member #1 stated (Resident #1) had been moved out of Resident #4's room. Family Member #1 stated the incident was on the news on 07/29/25. Resident #4 stated when they saw the two residents, Resident #2 told Resident #4 to shut the door, so they did. Resident #4 stated Resident #1 had to be sexually assaulted because [Resident #2] was on top of [Resident #1]. Resident #4 stated once facility staff came in to get Resident #1 and #2, Resident #4 walked out because they did not want any part of it. On 07/30/25 at 10:46 a.m., family member #1 stated family member #2 (who could be reached by phone) would be the best person to talk to about the incident. Family Member #1 stated they only knew what was on the news and what was in the police report. Family Member #1 stated they were alarmed by the information and came up to the facility. Resident #4 stated, It was very scary. On 07/30/25 at 10:52 a.m., Resident #4 stated, Yeah, it was very scary. Resident #4 stated they reported it when they heard someone coming. Resident #4 reported seeing a firetruck at the facility. On 07/30/25 at 1:19 p.m., family member #2 and family member #3 reported there was a rape that occurred in Resident #4's room on 07/25/25. Family Member #2 stated Resident #4 was woke up and went to the door to their room that was closed. Family Member #2 stated as Resident #4 was going to open the door, they noticed (Resident #2) in bed on top of (Resident #1). Family Member #2 stated Resident #4 left to go to the nurse's station and report (Resident #2) in the room. Family Member #2 stated the facility would not give family member #2 any information on anything and family member #2 was Resident #4's legal representative. On 07/30/25 at 1:28 p.m., family member #2 stated they still had not received any phone calls from the facility about the incident. On 07/30/25 at 1:30 p.m., family member #3 stated all the facility would tell them was there was an incident. Family Member #3 stated, If [Resident #4] was in the room where the incident started, don't you think we should have been notified? They stated the facility went into HIPAA. Family Member #3 stated they were not asking about the other resident, they wanted to know the incident that involved Resident #4 and (an opposite sex individual) being in their room. On 07/30/25 at 1:32 p.m., family member #3 stated, But is [Resident #4] safe? On 07/30/25 at 1:43 p.m., family member #2 stated after 5:00 p.m. that day (07/25/25), they spoke with the regional director of operations. Family Member #2 stated that was when the regional director of operations informed them a criminal act had occurred and a police report was made. They stated the regional director of operations told them you need to know the person who committed the crime was no longer in the facility. Family Member #2 stated at 7 o'clock at night [07/25/25], that's the first time we were told [Resident #2] was gone. They stated the only reason the regional director of operations was answering them was because they were asking the questions and the regional director of operations started covering it up. They stated that was the first time the facility staff had told family member #2 the police were involved. Family Member #2 stated they already knew the police were involved because they talked with the police already. On 07/30/25 at 1:45 p.m., family member #3 stated the lieutenant called and spoke with them about the event. They told family member #2 there was a person arrested at the facility for an alleged assault in the first degree, rape. Family Member #3 stated what the lieutenant did not know was Resident #4 was in the room when it happened. Family Member #3 stated the facility never told the police that Resident #4 was in the room. They stated the facility was acting like their staff was who discovered the incident. On 07/30/25 at 1:52 p.m., family member #3 stated the detective only told them it was first degree rape. They stated no one from the facility would talk to them or give them information for three days which was why they went to the news station. They stated they believed the facility was trying to cover it up and it needed to be investigated. They stated on 07/29/25, a reporter from the news station came to them and read them the police report. They stated that was the only way they knew exactly what occurred because the facility still had not communicated the information to them. On 07/30/25 at 1:58 p.m., family member #3 stated when they found out (Resident #2) was in the room raping (Resident #1), (Resident #4) was also in the room, and went and got staff, and the police report omits that (Resident #4) was who discovered it because they were not told was concerning. Family Member #3 stated, then (Resident #2) got into a wheelchair, unassisted from the bed of (Resident #1), left the room, and told staff (Resident #2) was going to go outside and smoke while they were giving aide to (Resident #1). Meanwhile the police came to the facility and (Resident #2) was nowhere to be found. The police located (Resident #2) two blocks away from the facility and arrested them in a mobile wheelchair. Family Member #3 stated the facility can't detain someone who committed rape? Family Member #3 stated, Where's the protection for the residents in the facility? Family Member #3 stated, Where's the accountability for this place? Family Member #2 stated, They need to be shut down. On 07/30/25 at 2:03 p.m., family member #2 stated, At night [Resident #4] can't sleep. Family Member #2 stated Resident #4 was scared and their eyes were black from lack of sleep. Family Member #2 stated Resident #4 reported they were going to climb out the window today. Family Member #2 stated, [Resident #4] is just scared! On 07/30/25 at 2:04 p.m., family member #2 stated the facility had not addressed their concerns at all. Family Member #2 stated no one had come back to talk to Resident #4 or family member #2. Family Member #2 stated Resident #4 reported They are all scared in there. Family Member #2 stated (Surveyor 1) was the only person who had come into Resident #4's room to talk with the resident. On 07/30/25 at 2:33 p.m., family member #4 stated the first call they received from the facility was on 07/25/25 at 5:57 a.m. Family Member #4 stated the regional director of operations informed family member #4 Resident #1 had been sexually assaulted. Family Member #4 stated no details were provided from the facility at the time. Family Member #4 stated the next call they received was from the hospital to obtain consent for a rape kit. Family Member #4 stated they were with Resident #1 at the hospital all day and returned with the resident to the facility around 3:00 p.m. Family Member #4 stated the facility informed them (Resident #2) was found in (Resident #1's) room and they did not have pants on. Family Member #4 stated they did not know the details until they saw the story come across their social media page. On 07/30/25 at 2:36 p.m., family member #4 stated, at this time, Resident #1 does not even know who family member #4 was when they visit. Family Member #4 stated Resident #1 could not consent for anything. Family Member #4 stated Resident #1 was able to speak, but just can't speak up for [themselves]. On 07/30/25 at 2:42 p.m., family member #4 stated staff had reported they were going to move Resident #1 by the nurses' station, but they did not. Family Member #4 stated Resident #1's room was halfway down the hallway. Family Member #4 stated they informed the facility of the concern with the new room and they responded It might not be today, but [Resident #1] would be moved closer. Family Member #4 stated the regional director of operations told family member #4 We can't protect the residents from everything that is going to happen to them. The regional director of operations reported the facility was making new trainings and strategies to make it not happen again. On 07/30/25 at 2:44 p.m., family member #4 stated the facility mentioned trying to get Resident #1 a (same sex) therapist, but other than that and training the staff, there is nothing else they are doing. Family Member #4 stated they did not feel Resident #1 was safe in the facility. Family Member #4 stated, If [Resident #1] was safe, it wouldn't have happened. On 07/30/25 at 3:52 p.m., CNA #2 stated if they saw abuse, they would tell the administrator and DON right away. They stated the administrator was responsible for investigating abuse. On 07/30/25 at 3:55 p.m. CNA #2 stated they did not know the details about the abuse allegation between Resident #1 and Resident #2. They stated on 07/25/25, they had asked CNA #1 (who was working another hall) to assist with a two person transfer on their hall. They stated this was during the time the alleged incident occurred. CNA #1 had left the hall the incident occurred on to help CNA #2 on their hall. CNA #2 stated they were informed by staff that while CNA #1 was assisting them, (Resident #2) had raped (Resident #1). They stated they believed the supervisor (RN #1) went in the room to separate the residents and called the administrator. CNA #2 stated the DON, administrator, and people higher up in the company came in. They stated a police report was filed, and Resident #1 went to the hospital during their shift. CNA #2 stated Resident #2 somehow ended up leaving the building, and the police found Resident #2 outside. CNA #2 stated they did not know where Resident #2 had gone. CNA #2 stated when the police arrived at the facility, Resident #2 was not around the building, but the police ended up finding them. CNA #2 stated they believed the police took Resident #2 away before their shift ended. On 07/30/25 at 4:04 p.m., CNA #2 stated in response to the event, the facility just made sure everyone was on the hall. If someone had to leave the hall, they were to make sure another staff member was on the hall. On 07/30/25 at 4:41 p.m., an attempt was made to call and speak with RN #1. RN #1's phone was not accepting calls at the time and did not return the state agency's call. On 07/31/25 at 12:00 a.m., CNA #1 stated if they saw any abuse or neglect, they would report it. They stated they would reach out to the administrator. On 07/31/25 at 12:01 a.m., CNA #1 stated they believed the administrator and DON were responsible for investigating abuse. On 07/31/25 at 12:05 a.m., CNA #1 stated on 07/25/25 when the allegation between Resident #1 and Resident #2 occurred, they were assisting CNA #2 with a resident on another hall. CNA #2 stated they saw Resident #4 come out of their room and go to the nurses' station. CNA #1 stated, [Resident #4] was never up that early in the morning. CNA #1 stated it was between 3:00 a.m. and 3:30 a.m. They stated Resident #4 was with RN #1 wearing a knit sweater type covering. CNA #1 stated they asked RN #1 to check Resident #4 because they usually slept with no clothes on. On 07/31/25 at 12:14 a.m., CNA #1 stated when they finished helping CNA #2, LPN #1 was sitting in the hall at a bedside table, and wanted CNA #1 to get Resident #4 (who was sitting in the living room on hall 300) dressed. CNA #1 stated Resident #4 also requested to have their purse. On 07/31/25 at 12:16 a.m., CNA #1 stated they had gone down to Resident #4's room to get clothes for the resident to put on 07/25/25. They stated when they walked in the room they saw Resident #2 in Resident #1's bed. They stated Resident #1 was in the bed too. They stated no one else was in the room at the time. They stated it had to be around 3:00 a.m. to 3:30 a.m. CNA #1 stated Resident #1's brief was ripped off and their gown was off. They stated Resident #2 was in the bed with their shorts pulled down to their knees. CNA #1 reported saying What are you doing? CNA #1 reported saying Did you just rape [Resident #1]? CNA #1 stated Resident #2 said, No, [Resident #1] invited me in. CNA #1 told Resident #2 that Resident #1 could not have invited them in the room because the resident was unable to speak like that. CNA #1 stated, You need to get out of her bed. CNA #1 stated they were so upset when they saw what happened. They stated they observed a wet towel next to Resident #1 in the bed. They stated Resident #2 was prepared to wipe themselves off afterwards. CNA #1 stated there was nothing in the bed besides the blankets and the resident when they previously left Resident #1's room after providing care. On 07/31/25 at 12:21 a.m., CNA #1 stated Resident #2 started to get out of Resident #1's bed and sat in their wheelchair. They stated Resident #2 transferred themselves to their electric wheelchair and started rubbing Resident #1's leg saying, I saw your [family member] at the store. CNA #1 told Resident #2 You don't even know [Resident #1's] family. CNA #1 told Resident #2 stop rubbing on [Resident #1's] leg. CNA #1 stated if they did not take Resident #2 to jail, they were not going to work for the facility anymore. They stated, I'm not working at a place that allows someone to rape a resident. CNA #1 stated after Resident #2 left the room, CNA #1 proceeded to get clothes and dress Resident #4. They stated Resident #4 stated [Resident #2] had told [them] when [they] walked out the room to close the door. CNA #1 stated that was the point when police, the DON, and everyone came to the facility. On 07/31/25 at 12:24 a.m., CNA #1 stated before the police arrived at the facility, Resident #2 told CNA #1 and RN #1 they were going to smoke outside. CNA #1 stated from what they understood when the police arrived, Resident #2 was not outside the facility. CNA #1 stated the police did find Resident #2 and took them to jail. CNA #1 stated before they had left Resident #1's room to assist in dressing Resident #4, [Resident #1] was just laying there lifeless. CNA #1 stated, [Resident #1] couldn't defend [themselves]. On 07/31/25 at 12:29 a.m., CNA #1 stated Resident #1 was pretty much mute. They stated the resident would sometimes say thank you after care. CNA #1 stated when they returned to work the 11:00 p.m. to 7:00 a.m. shift (07/25/25 into the morning of 07/26/25), they went and checked on Resident #1 who had been moved to a different hall. CNA #1 stated Resident #1 was usually asleep during their whole shift, but the night following the rape incident, Resident #1 was awake. CNA #1 also checked on Resident #4 who was asleep with a gown on. On 07/31/25 at 12:32 a.m., CNA #1 stated they were not aware of anything the facility did in response to the abuse allegation. On 07/31/25 at 12:33 a.m., CNA #1 stated they reported the abuse to the DON and administrator who came up to the facility that night. CNA #1 stated they had not received any new instructions related to the plan of care of Resident #1 or Resident #4 since the abuse incident. On 07/31/25 at 12:36 a.m., CNA #1 stated no additional staff came to work when the abuse occurred on 07/25/25. CNA #1 stated no 1:1 supervision was provided to any resident during the night shift on the day the abuse occurred (07/25/25). CNA #1 stated when Resident #2 went down to their room after the rape occurred, no staff went with the resident. CNA #1 stated RN #1 did not come to them at all regarding the incident. CNA #1 stated they did not know about the rape incident until they walked into Resident #1 and Resident #4's room and discovered Resident #2 in the room with their pants down with Resident #1 completely naked. CNA #1 began to cry while recalling the events. On 07/31/25 at 12:45 a.m., LPN #1 stated if abuse was observed or reported to them, they were to report it immediately. They stated they would call the abuse hotline number and call the administrator right away. On 07/31/25 at 12:46 a.m., LPN #1 stated the administrator was responsible for investigating abuse. On 07/31/25 at 12:47 a.m., LPN #1 stated Resident #1 did not talk. They stated the resident speaks very minimal words. On 07/31/25 at 12:49 a.m., LPN #1 stated Resident #1 was unable to make decisions on their own. LPN #1 stated they did not witness anything regarding the abuse allegation on 07/25/25 for Resident #1 and #2. LPN #1 stated they saw Resident #4 speaking to RN #1 on the night shift that morning. They stated Resident #4 was wearing a Sleep jacket with no other clothes on. They stated they did not know the reason Resident #4 was talking to RN #1 that day, but LPN #1 had Resident #4 sit in the television room on hall 300 and instructed CNA #1 to get the resident dressed. On 07/31/25 at 12:52 a.m., LPN #1 stated RN #1 came to them and said they had CNA #1 in Resident #1's room (who shares a room with Resident #4) and reported [Resident #2] was in [Resident #1's] room. They stated RN #1 had to call the DON because they saw Resident #2 in the room with Resident #1. They stated RN #1 was visibly upset saying [Explicit], [explicit] and banging on the nurses' station. LPN #1 stated they later saw the DON fly in the facility with the police. On 07/31/25 at 12:57 a.m., LPN #1 stated they asked what was going on and RN #1 stated Resident #2 was in bed with Resident #1. On 07/31/25 at 1:00 a.m., LPN #1 stated they received an in-service that night informing staff if they saw any resident in another resident's room in an inappropriate way, staff were to stay and not leave the resident. LPN #1 stated staff were to make sure the residents were safe. On 07/31/25 at 1:04 a.m., LPN #1 stated Resident #1 was moved to LPN #1's hall after the event. LPN #1 stated they were not instructed on any new interventions for the care of Resident #1 since the abuse allegation. LPN #1 stated they just would just go in Resident #1's room during their shift and Makes sure [they] are fine. On 07/31/25 at 5:50 a.m., the DON stated if staff reported abuse, they would investigate it. They stated they would send a report to the state agency, APS, notify police, complete an investigation, and have it finalized in five days. On 07/31/25 at 5:52 a.m., the DON stated the administrator and DON were responsible for investigating abuse. They stated if there was a resident to resident abuse, they would make sure the abuser had no contact with the other residents and would try to get the abuser out of the facility. On 07/31/25 at 6:01 a.m., the DON stated Resident #1 was a total assist with all ADLs. They stated the resident could not engage in conversation, but could say yes. They stated the resident was incontinent of bowel and bladder. The DON stated Resident #1's cognition was impaired and they did not have the ability to consent. On 07/31/25 at 6:02 a.m., the DON stated they had received a call from RN #1 on 07/25/25 around 3:40 to 3:45 a.m. who reported Resident #2 was found in Resident #1's room and both residents' clothes were off. The DON stated Resident #2's cognition was very much intact. The DON instructed RN #1 to separate the residents, monitor them, put Resident #2 on 1:1, and call the police. On 07/31/25 at 6:04 a.m., the DON stated they were who called the police because when they were in route to the facility, RN #1 still had not called the police. They stated RN #1 was instructed to call EMSA. The DON stated they pulled up to the facility at the same time the police arrived. They stated the police informed them the room was a crime scene and they could not touch anything. They stated law enforcement took all of the bedding and the gown Resident #1 was wearing. They stated Resident #1 was sent to the hospital for a SANE rape kit. The DON stated Resident #1 received a prophylactic antibiotic for STDs at the hospital. The DON stated Resident #2 was arrested. On 07/31/25 at 6:07 a.m., the DON stated the facility was able to review video footage and identified Resident #2 entered Resident #1's room at 2:49 a.m. and Resident #4 came out of the room and told CNA #1 there was a person (Resident #2) in their room who got RN #1. They stated at 3:09 a.m., RN #1 entered Resident #1's room and saw Resident #2 with their pants down. They stated RN #1 called them at 3:34 a.m. because that was when they could no longer see them on the video footage. The DON stated RN #1 leaving the room did not follow the facility abuse policy. The DON stated the policy showed once residents were observed in abusive behavior, staff were supposed to separate the residents. The DON stated RN #1 missed separating the residents. The DON stated the abuse policy was not followed. The DON stated when CNA #1 entered the room, Resident #2 was still in bed with Resident #1. The DON stated CNA #1 separated the residents and stayed in the room with Resident #1. The DON stated when Resident #2 came out of Resident #1's room, RN #1 and Resident #2 were observed on the video footage in the hallway together by Resident #2's room. On 07/31/25 at 6:09 a.m., The DON stated MDS coordinator #1 spoke with Resident #4 and wrote down their statement after the abuse allegation on 07/25/25. On 07/31/25 at 6:54 a.m., the DON stated CNA #1 was the staff member who completed1:1 supervision with Resident #1 after the incident until Resident #1 left for the hospital. The DON stated RN #1 completed 1:1 supervision with Resident #2 until the resident left the building. The DON stated there were no other staff members called in to help when the 1:1 was in place because it was only an hour and a half before they left. The DON stated CNA #1 did not document the 1:1 and just stayed with Resident #1. The DON stated there was no documentation to put in the chart. On 07/31/25 at 7:04 a.m., the DON asked MDS coordinator #1 where the statement from Resident #4 was (for the allegation of abuse investigation). MDS Coordinator #1 stated, I didn't write anything down on it. On 07/31/25 at 8:22 a.m., the COO was identified as the person who would answer questions for the administrator who was on vacation. The COO

Based on observation, record review, and interview, the facility failed to complete a thorough investigation after an allegation of abuse for 3 (#1, 2, and #4) of 6 sampled residents reviewed for abuse. The BOM identified 78 residents resided in the facility.Findings: On 07/30/25 at 9:13 a.m., Resident #4 was observed seated on the bed in their room with family member #1 present in the room. On 07/30/25 at 9:28 a.m., the room with Resident #2's name on it was observed. Resident #2's side of the room was free from any personal items from a resident and did not have a resident on that side of the room. On 07/30/25 at 10:10 a.m., Resident #1's name was observed outside the fourth room down from the nurse's station on the right side of hall 300. Resident #1 was not observed inside the room. On 07/30/25 at 10:14 a.m., Resident #1 was observed seated in a standard wheelchair at the beginning of hall 300. Resident #1 was observed wearing a light green shirt with a flower on it, blue/grey pants, and tan skid proof socks on. Resident #1 was able to identify their first name, but was unable to provide any additional information to the surveyor. An abuse, neglect, exploitation or misappropriation policy, revised 04/2021, read in part, All reports of resident abuse (including injuries of unknown origin), 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. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator.Witness statements are obtained in writing, signed, and dated.A significant change resident assessment, dated 04/28/25, showed Resident #7's cognition was intact (BIMS 13).An abuse and neglect policy, dated 05/02/25, read in part, It is the Policy of any [name withheld] Long Term Care managed facility that no resident shall be subject to abuse and/or neglect.All incidents to include suspected resident abuse will be reported to the Administrator and Director of Nursing.Any occurrence of abuse/neglect will be evaluated at the time for removal of a resident to a more appropriate facility.Following the initial verbal investigation, the Administrator will take written statements from all employees, residents, any witness if any, and will determine action to be taken.Administration will evaluate and analyze any occurrence and make any necessary changes that would prevent the situation from recurring in the future. An admission resident assessment, dated 06/04/25, showed Resident #2's cognition was intact (BIMS 15). The assessment showed the resident exhibited verbal behavioral symptoms directed toward others that significantly disrupted care or the living environment. The assessment showed the resident required supervision or touching assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, sitting to standing, and chair/bed-to-chair transfer. An annual resident assessment, dated 06/16/25, showed Resident #1's cognitive skills for daily decision making were severely impaired per staff assessment for mental status. The assessment showed the resident required substantial/maximum assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, and was dependent on staff for chair to bed transfers. A quarterly resident assessment, dated 06/29/25, showed Resident #4's cognition was severely impaired (BIMS 04). The assessment showed the resident was independent for rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfers, and walking 10 feet. A nurse progress note, dated 07/25/25 at 3:30 a.m., showed at approximately 3:25 a.m., RN #1 was alerted by another resident (Resident #4) to a situation occurring in their room. Upon entering the room, RN #1 observed concerning behavior between (Resident #1 and Resident #2). RN #1 instructed Resident #2 to stop and leave the area. A CNA (CNA #1) was directed to supervise and escort Resident #2 out of the room while RN #1 contacted the DON for further guidance. The note showed Resident #1 was briefly assessed with no visible injuries noted at the time. The note showed Resident #2 was placed on 1:1 supervision for close monitoring. The note showed the provider on call and facility administration were notified and appropriate reporting procedures were initiated per protocol. An initial facility reported incident, dated 07/25/25, showed the DON and administrator were notified Resident #2 was in Resident #1's room. The initial report showed the residents were immediately separated and Resident #2 left the property. The initial report showed Resident #1 was sent to the emergency room for precautionary evaluation. The initial report showed the police, family, physician, resident's legal representative, and APS were notified. The initial report was received by the state agency on 07/25/25 at 7:14 a.m. The final facility reported incident, dated 07/25/25, was received by the state agency on 07/30/25 at 12:12 p.m. The final report contained additional information in the description of the incident. The final report showed at 3:42 a.m., (RN #1) contacted the DON regarding (Resident #2) in (Resident #1's) room and in (Resident #1's) bed. The final report showed staff reported (Resident #2) was in (Resident #1's) room with (Resident #2's) pants halfway pulled down. The final report showed (Resident #2) was on the bed with (Resident #1). The DON notified (RN #1) to immediately separate the residents. (Resident #2) was to be placed on 1:1. (Resident #2) then exited the facility while staff was attempting to talk with them. Police were notified and (Resident #1) was sent to the emergency room for precautionary evaluation. The final report showed staff stayed with (Resident #1) until they left to the emergency room. The final report showed (Resident #1) was transported via ambulance and report was given. When police arrived, (Resident #2) was taken into custody by the police department. The DON notified the administrator at 3:48 a.m. The final report showed (Resident #1's) most recent BIMS was 0/15, required total assistance with ADLs, and had diagnoses which included dementia. The final report showed investigation of the incident revealed staff was present on the hall at 2:42 a.m. giving medication to (Resident #2). At 2:49 a.m., (Resident #2) entered (Resident #1's) room. At 2:52 a.m., (Resident #2) shut (Resident #1's) door. At 3:06 a.m. (Resident #4) heard (Resident #2) enter, got up, and reported to staff (name not provided) that (Resident #2) was in their room. At 3:09 a.m., (RN #1) went down to the room and when they entered, (RN #1) saw (Resident #2) in the bed with (Resident #1) appearing to be engaged in sex. (RN #1) reported they told (Resident #2) to stop and exit the room and (Resident #2) was getting up and attempting to explain what (Resident #2) was doing when (RN #1) exited the room to call the DON. At 3:12 a.m., (CNA #1) walked into (Resident #1's) room and (Resident #2) was still in the bed with (Resident #1). (CNA #1) separated (Resident #2 and #1) and (Resident #2) was placed on 1:1. The police department was contacted by the DON along with the facility administrator. (Resident #2) exited the building while staff was attempting 1:1 supervision with (Resident #2) until the police arrived. The police department escorted (Resident #2) back into the building and took them into custody. (Resident #1's) family was notified of the incident and of the resident being transported to the emergency room. (Resident #1) was sent to the emergency room for evaluation and treatment. A SANE exam was completed. (Resident #1) returned to the facility and was moved to a room closer to the nurse's station for family comfort. Psych NP to see (Resident #1) upon return from the hospital to evaluate and treat as needed. Safe surveys for all resident's completed with each resident. No concerns for safety or incidents of abuse reported. In-service with staff completed, small roundtables completed with staff over abuse types, appropriate interventions related and who to report abuse to. In house counselor made available for staff and residents as needed. Immediate QAPI completed and ongoing QAPI review. (RN #1) suspended indefinitely. The immediate QAPI provided for this abuse investigation, dated 07/25/25, showed the COO was called, the administrator was notified, and the DON, ADON, and the SSD were present for the QAPI. The immediate QAPI showed Resident #1 and #2 were placed on 1:1 on 07/25/25 and an in-service was held for all types of abuse. The immediate QAPI showed the physician, nursing board, police, OSDH, and APS were notified of the event and Resident #1 was went to the emergency room for an evaluation. There was no documentation of the 1:1 for the residents provided to the surveyors. There was no documentation of any monitoring component the facility completed to ensure the ongoing safety of the residents in the facility for this immediate QAPI. There was documentation the facility had interviewed Resident #4 and obtained a statement for this abuse investigation. Resident #1's hospital records, dated 07/25/25, showed final diagnosis of sexual assault of adult, initial encounter. The hospital records showed a staff member had gone into Resident #1's room on 07/25/25 and found another resident (Resident #2) vaginally penetrating Resident #1. The hospital records showed Resident #1 was nonverbal. The hospital records showed Resident #1 had diagnoses which included anxiety, brain tumor, dementia with behavioral disturbance, and traumatic brain injury. On 07/30/25 at 9:24 a.m., Resident #7 (who was Resident #2's roommate the day of the incident) stated they had not been a roommate with (Resident #2) for long. Resident #7 stated Resident #2 Went to jail. Resident #7 stated the reason Resident #2 went to jail was because they were a sexual predator. Resident #7 stated Resident #2 had shared stories with them parenting children at the age of eight. On 07/30/25 at 10:10 a.m., CNA #8 stated Resident #1 had just moved to hall 300 because there was an incident on hall 100. CNA #8 stated they did not know the details of the incident, but if something traumatic did occur, [they] wouldn't want [Resident #1] returned to the same room. On 07/30/25 at 10:34 a.m., Resident #4 stated they reported, [Resident #2's] laying on top of [Resident #1]. Family Member #1 stated (Resident #1) had been moved out of Resident #4's room. Family Member #1 stated the incident was on the news on 07/29/25. Resident #4 stated when they saw the two residents, Resident #2 told Resident #4 to shut the door, so they did. Resident #4 stated Resident #1 had to be sexually assaulted because [Resident #2] was on top of [Resident #1]. Resident #4 stated once facility staff came in to get Resident #1 and #2, Resident #4 walked out because they did not want any part of it. On 07/30/25 at 10:46 a.m., family member #1 stated family member #2 (who could be reached by phone) would be the best person to talk to about the incident. Family Member #1 stated they only knew what was on the news and what was in the police report. Family Member #1 stated they were alarmed by the information and came up to the facility. Resident #4 stated, It was very scary. On 07/30/25 at 10:52 a.m., Resident #4 stated, Yeah, it was very scary. Resident #4 stated they reported it when they heard someone coming. Resident #4 reported seeing a firetruck at the facility. On 07/30/25 at 1:19 p.m., family member #2 and family member #3 reported there was a rape that occurred in Resident #4's room on 07/25/25. Family Member #2 stated Resident #4 was woke up and went to the door to their room that was closed. Family Member #2 stated as Resident #4 was going to open the door, they noticed (Resident #2) in bed on top of (Resident #1). Family Member #2 stated Resident #4 left to go to the nurse's station and report (Resident #2) in the room. Family Member #2 stated the facility would not give family member #2 any information on anything and family member #2 was Resident #4's legal representative. On 07/30/25 at 1:28 p.m., family member #2 stated they still had not received any phone calls from the facility about the incident. On 07/30/25 at 1:30 p.m., family member #3 stated all the facility would tell them was there was an incident. Family Member #3 stated, If [Resident #4] was in the room where the incident started, don't you think we should have been notified? They stated the facility went into HIPAA. Family Member #3 stated they were not asking about the other resident, they wanted to know the incident that involved Resident #4 and (an opposite sex individual) being in their room. On 07/30/25 at 1:32 p.m., family member #3 stated, But is [Resident #4] safe? On 07/30/25 at 1:43 p.m., family member #2 stated after 5:00 p.m. that day (07/25/25), they spoke with the regional director of operations. Family Member #2 stated that was when the regional director of operations informed them a criminal act had occurred and a police report was made. They stated the regional director of operations told them you need to know the person who committed the crime was no longer in the facility. Family Member #2 stated at 7 o'clock at night [07/25/25], that's the first time we were told [Resident #2] was gone. They stated the only reason the regional director of operations was answering them was because they were asking the questions and the regional director of operations started covering it up. They stated that was the first time the facility staff had told family member #2 the police were involved. Family Member #2 stated they already knew the police were involved because they talked with the police already. On 07/30/25 at 1:45 p.m., family member #3 stated the lieutenant called and spoke with them about the event. They told family member #2 there was a person arrested at the facility for an alleged assault in the first degree, rape. Family Member #3 stated what the lieutenant did not know was Resident #4 was in the room when it happened. Family Member #3 stated the facility never told the police that Resident #4 was in the room. They stated the facility was acting like their staff was who discovered the incident. On 07/30/25 at 1:52 p.m., family member #3 stated the detective only told them it was first degree rape. They stated no one from the facility would talk to them or give them information for three days which was why they went to the news station. They stated they believed the facility was trying to cover it up and it needed to be investigated. They stated on 07/29/25, a reporter from the news station came to them and read them the police report. They stated that was the only way they knew exactly what occurred because the facility still had not communicated the information to them. On 07/30/25 at 1:58 p.m., family member #3 stated when they found out (Resident #2) was in the room raping (Resident #1), (Resident #4) was also in the room, and went and got staff, and the police report omits that (Resident #4) was who discovered it because they were not told was concerning. Family Member #3 stated, then (Resident #2) got into a wheelchair, unassisted from the bed of (Resident #1), left the room, and told staff (Resident #2) was going to go outside and smoke while they were giving aide to (Resident #1). Meanwhile the police came to the facility and (Resident #2) was nowhere to be found. The police located (Resident #2) two blocks away from the facility and arrested them in a mobile wheelchair. Family Member #3 stated the facility can't detain someone who committed rape? Family Member #3 stated, Where's the protection for the residents in the facility? Family Member #3 stated, Where's the accountability for this place? Family Member #2 stated, They need to be shut down. On 07/30/25 at 2:03 p.m., family member #2 stated, At night [Resident #4] can't sleep. Family Member #2 stated Resident #4 was scared and their eyes were black from lack of sleep. Family Member #2 stated Resident #4 reported they were going to climb out the window today. Family Member #2 stated, [Resident #4] is just scared! On 07/30/25 at 2:04 p.m., family member #2 stated the facility had not addressed their concerns at all. Family Member #2 stated no one had come back to talk to Resident #4 or family member #2. Family Member #2 stated Resident #4 reported They are all scared in there. Family Member #2 stated (Surveyor 1) was the only person who had come into Resident #4's room to talk with the resident. On 07/30/25 at 2:33 p.m., family member #4 stated the first call they received from the facility was on 07/25/25 at 5:57 a.m. Family Member #4 stated the regional director of operations informed family member #4 Resident #1 had been sexually assaulted. Family Member #4 stated no details were provided from the facility at the time. Family Member #4 stated the next call they received was from the hospital to obtain consent for a rape kit. Family Member #4 stated they were with Resident #1 at the hospital all day and returned with the resident to the facility around 3:00 p.m. Family Member #4 stated the facility informed them (Resident #2) was found in (Resident #1's) room and they did not have pants on. Family Member #4 stated they did not know the details until they saw the story come across their social media page. On 07/30/25 at 2:36 p.m., family member #4 stated, at this time, Resident #1 does not even know who family member #4 was when they visit. Family Member #4 stated Resident #1 could not consent for anything. Family Member #4 stated Resident #1 was able to speak, but just can't speak up for [themselves]. On 07/30/25 at 2:42 p.m., family member #4 stated staff had reported they were going to move Resident #1 by the nurses' station, but they did not. Family Member #4 stated Resident #1's room was halfway down the hallway. Family Member #4 stated they informed the facility of the concern with the new room and they responded It might not be today, but [Resident #1] would be moved closer. Family Member #4 stated the regional director of operations told family member #4 We can't protect the residents from everything that is going to happen to them. The regional director of operations reported the facility was making new trainings and strategies to make it not happen again. On 07/30/25 at 2:44 p.m., family member #4 stated the facility mentioned trying to get Resident #1 a (same sex) therapist, but other than that and training the staff, there is nothing else they are doing. Family Member #4 stated they did not feel Resident #1 was safe in the facility. Family Member #4 stated, If [Resident #1] was safe, it wouldn't have happened. On 07/30/25 at 3:52 p.m., CNA #2 stated if they saw abuse, they would tell the administrator and DON right away. They stated the administrator was responsible for investigating abuse. On 07/30/25 at 3:55 p.m. CNA #2 stated they did not know the details about the abuse allegation between Resident #1 and Resident #2. They stated on 07/25/25, they had asked CNA #1 (who was working another hall) to assist with a two person transfer on their hall. They stated this was during the time the alleged incident occurred. CNA #1 had left the hall the incident occurred on to help CNA #2 on their hall. CNA #2 stated they were informed by staff that while CNA #1 was assisting them, (Resident #2) had raped (Resident #1). They stated they believed the supervisor (RN #1) went in the room to separate the residents and called the administrator. CNA #2 stated the DON, administrator, and people higher up in the company came in. They stated a police report was filed, and Resident #1 went to the hospital during their shift. CNA #2 stated Resident #2 somehow ended up leaving the building, and the police found Resident #2 outside. CNA #2 stated they did not know where Resident #2 had gone. CNA #2 stated when the police arrived at the facility, Resident #2 was not around the building, but the police ended up finding them. CNA #2 stated they believed the police took Resident #2 away before their shift ended. On 07/30/25 at 4:04 p.m., CNA #2 stated in response to the event, the facility just made sure everyone was on the hall. If someone had to leave the hall, they were to make sure another staff member was on the hall. On 07/30/25 at 4:41 p.m., an attempt was made to call and speak with RN #1. RN #1's phone was not accepting calls at the time and did not return the state agency's call. On 07/31/25 at 12:00 a.m., CNA #1 stated if they saw any abuse or neglect, they would report it. They stated they would reach out to the administrator. On 07/31/25 at 12:01 a.m., CNA #1 stated they believed the administrator and DON were responsible for investigating abuse. On 07/31/25 at 12:05 a.m., CNA #1 stated on 07/25/25 when the allegation between Resident #1 and Resident #2 occurred, they were assisting CNA #2 with a resident on another hall. CNA #2 stated they saw Resident #4 come out of their room and go to the nurses' station. CNA #1 stated, [Resident #4] was never up that early in the morning. CNA #1 stated it was between 3:00 a.m. and 3:30 a.m. They stated Resident #4 was with RN #1 wearing a knit sweater type covering. CNA #1 stated they asked RN #1 to check Resident #4 because they usually slept with no clothes on. On 07/31/25 at 12:14 a.m., CNA #1 stated when they finished helping CNA #2, LPN #1 was sitting in the hall at a bedside table, and wanted CNA #1 to get Resident #4 (who was sitting in the living room on hall 300) dressed. CNA #1 stated Resident #4 also requested to have their purse. On 07/31/25 at 12:16 a.m., CNA #1 stated they had gone down to Resident #4's room to get clothes for the resident to put on 07/25/25. They stated when they walked in the room they saw Resident #2 in Resident #1's bed. They stated Resident #1 was in the bed too. They stated no one else was in the room at the time. They stated it had to be around 3:00 a.m. to 3:30 a.m. CNA #1 stated Resident #1's brief was ripped off and their gown was off. They stated Resident #2 was in the bed with their shorts pulled down to their knees. CNA #1 reported saying What are you doing? CNA #1 reported saying Did you just rape [Resident #1]? CNA #1 stated Resident #2 said, No, [Resident #1] invited me in. CNA #1 told Resident #2 that Resident #1 could not have invited them in the room because the resident was unable to speak like that. CNA #1 stated, You need to get out of her bed. CNA #1 stated they were so upset when they saw what happened. They stated they observed a wet towel next to Resident #1 in the bed. They stated Resident #2 was prepared to wipe themselves off afterwards. CNA #1 stated there was nothing in the bed besides the blankets and the resident when they previously left Resident #1's room after providing care. On 07/31/25 at 12:21 a.m., CNA #1 stated Resident #2 started to get out of Resident #1's bed and sat in their wheelchair. They stated Resident #2 transferred themselves to their electric wheelchair and started rubbing Resident #1's leg saying, I saw your [family member] at the store. CNA #1 told Resident #2 You don't even know [Resident #1's] family. CNA #1 told Resident #2 stop rubbing on [Resident #1's] leg. CNA #1 stated if they did not take Resident #2 to jail, they were not going to work for the facility anymore. They stated, I'm not working at a place that allows someone to rape a resident. CNA #1 stated after Resident #2 left the room, CNA #1 proceeded to get clothes and dress Resident #4. They stated Resident #4 stated [Resident #2] had told [them] when [they] walked out the room to close the door. CNA #1 stated that was the point when police, the DON, and everyone came to the facility. On 07/31/25 at 12:24 a.m., CNA #1 stated before the police arrived at the facility, Resident #2 told CNA #1 and RN #1 they were going to smoke outside. CNA #1 stated from what they understood when the police arrived, Resident #2 was not outside the facility. CNA #1 stated the police did find Resident #2 and took them to jail. CNA #1 stated before they had left Resident #1's room to assist in dressing Resident #4, [Resident #1] was just laying there lifeless. CNA #1 stated, [Resident #1] couldn't defend [themselves]. On 07/31/25 at 12:29 a.m., CNA #1 stated Resident #1 was pretty much mute. They stated the resident would sometimes say thank you after care. CNA #1 stated when they returned to work the 11:00 p.m. to 7:00 a.m. shift (07/25/25 into the morning of 07/26/25), they went and checked on Resident #1 who had been moved to a different hall. CNA #1 stated Resident #1 was usually asleep during their whole shift, but the night following the rape incident, Resident #1 was awake. CNA #1 also checked on Resident #4 who was asleep with a gown on. On 07/31/25 at 12:32 a.m., CNA #1 stated they were not aware of anything the facility did in response to the abuse allegation. On 07/31/25 at 12:33 a.m., CNA #1 stated they reported the abuse to the DON and administrator who came up to the facility that night. CNA #1 stated they had not received any new instructions related to the plan of care of Resident #1 or Resident #4 since the abuse incident. On 07/31/25 at 12:36 a.m., CNA #1 stated no additional staff came to work when the abuse occurred on 07/25/25. CNA #1 stated no 1:1 supervision was provided to any resident during the night shift on the day the abuse occurred (07/25/25). CNA #1 stated when Resident #2 went down to their room after the rape occurred, no staff went with the resident. CNA #1 stated RN #1 did not come to them at all regarding the incident. CNA #1 stated they did not know about the rape incident until they walked into Resident #1 and Resident #4's room and discovered Resident #2 in the room with their pants down with Resident #1 completely naked. CNA #1 began to cry while recalling the events. On 07/31/25 at 12:45 a.m., LPN #1 stated if abuse was observed or reported to them, they were to report it immediately. They stated they would call the abuse hotline number and call the administrator right away. On 07/31/25 at 12:46 a.m., LPN #1 stated the administrator was responsible for investigating abuse. On 07/31/25 at 12:47 a.m., LPN #1 stated Resident #1 did not talk. They stated the resident speaks very minimal words. On 07/31/25 at 12:49 a.m., LPN #1 stated Resident #1 was unable to make decisions on their own. LPN #1 stated they did not witness anything regarding the abuse allegation on 07/25/25 for Resident #1 and #2. LPN #1 stated they saw Resident #4 speaking to RN #1 on the night shift that morning. They stated Resident #4 was wearing a Sleep jacket with no other clothes on. They stated they did not know the reason Resident #4 was talking to RN #1 that day, but LPN #1 had Resident #4 sit in the television room on hall 300 and instructed CNA #1 to get the resident dressed. On 07/31/25 at 12:52 a.m., LPN #1 stated RN #1 came to them and said they had CNA #1 in Resident #1's room (who shares a room with Resident #4) and reported [Resident #2] was in [Resident #1's] room. They stated RN #1 had to call the DON because they saw Resident #2 in the room with Resident #1. They stated RN #1 was visibly upset saying [Explicit], [explicit] and banging on the nurses' station. LPN #1 stated they later saw the DON fly in the facility with the police. On 07/31/25 at 12:57 a.m., LPN #1 stated they asked what was going on and RN #1 stated Resident #2 was in bed with Resident #1. On 07/31/25 at 1:00 a.m., LPN #1 stated they received an in-service that night informing staff if they saw any resident in another resident's room in an inappropriate way, staff were to stay and not leave the resident. LPN #1 stated staff were to make sure the residents were safe. On 07/31/25 at 1:04 a.m., LPN #1 stated Resident #1 was moved to LPN #1's hall after the event. LPN #1 stated they were not instructed on any new interventions for the care of Resident #1 since the abuse allegation. LPN #1 stated they just would just go in Resident #1's room during their shift and Makes sure [they] are fine. On 07/31/25 at 5:50 a.m., the DON stated if staff reported abuse, they would investigate it. They stated they would send a report to the state agency, APS, notify police, complete an investigation, and have it finalized in five days. On 07/31/25 at 5:52 a.m., the DON stated the administrator and DON were responsible for investigating abuse. They stated if there was a resident to resident abuse, they would make sure the abuser had no contact with the other residents and would try to get the abuser out of the facility. On 07/31/25 at 6:01 a.m., the DON stated Resident #1 was a total assist with all ADLs. They stated the resident could not engage in conversation, but could say yes. They stated the resident was incontinent of bowel and bladder. The DON stated Resident #1's cognition was impaired and they did not have the ability to consent. On 07/31/25 at 6:02 a.m., the DON stated they had received a call from RN #1 on 07/25/25 around 3:40 to 3:45 a.m. who reported Resident #2 was found in Resident #1's room and both residents' clothes were off. The DON stated Resident #2's cognition was very much intact. The DON instructed RN #1 to separate the residents, monitor them, put Resident #2 on 1:1, and call the police. On 07/31/25 at 6:04 a.m., the DON stated they were who called the police because when they were in route to the facility, RN #1 still had not called the police. They stated RN #1 was instructed to call EMSA. The DON stated they pulled up to the facility at the same time the police arrived. They stated the police informed them the room was a crime scene and they could not touch anything. They stated law enforcement took all of the bedding and the gown Resident #1 was wearing. They stated Resident #1 was sent to the hospital for a SANE rape kit. The DON stated Resident #1 received a prophylactic antibiotic for STDs at the hospital. The DON stated Resident #2 was arrested. On 07/31/25 at 6:07 a.m., the DON stated the facility was able to review video footage and identified Resident #2 entered Resident #1's room at 2:49 a.m. and Resident #4 came out of the room and told CNA #1 there was a person (Resident #2) in their room who got RN #1. They stated at 3:09 a.m., RN #1 entered Resident #1's room and saw Resident #2 with their pants down. They stated RN #1 called them at 3:34 a.m. because that was when they could no longer see them on the video footage. The DON stated RN #1 leaving the room did not follow the facility abuse policy. The DON stated the policy showed once residents were observed in abusive behavior, staff were supposed to separate the residents. The DON stated RN #1 missed separating the residents. The DON stated the abuse policy was not followed. The DON stated when CNA #1 entered the room, Resident #2 was still in bed with Resident #1. The DON stated CNA #1 separated the residents and stayed in the room with Resident #1. The DON stated when Resident #2 came out of Resident #1's room, RN #1 and Resident #2 were observed on the video footage in the hallway together by Resident #2's room. On 07/31/25 at 6:09 a.m., The DON stated MDS coordinator #1 spoke with Resident #4 and wrote down their statement after the abuse allegation on 07/25/25. On 07/31/25 at 6:54 a.m., the DON stated CNA #1 was the staff member who completed1:1 supervision with Resident #1 after the incident until Resident #1 left for the hospital. The DON stated RN #1 completed 1:1 supervision with Resident #2 until the resident left the building. The DON stated there were no other staff members called in to help when the 1:1 was in place because it was only an hour and a half before they left. The DON stated CNA #1 did not document the 1:1 and just stayed with Resident #1. The DON stated there was no documentation to put in the chart. On 07/31/25 at 7:04 a.m., the DON asked MDS coordinator #1 where the statement from Resident #4 was (for the allegation of abuse investigation). MDS Coordinator #1 stated, I didn't write anything down on it. On 07/31/25 at 8:22 a.m., the COO was identified as the person who would answer questions for the admini[TRUNCATED]

Based on record review and interview, the facility failed to ensure an initial facility reported incident regarding an allegation of abuse was sent within two hours to the state agency for 3 (#1, 2, and #4) of 6 sampled residents reviewed for abuse. The BOM identified 78 residents resided in the facility. Findings: An abuse, neglect, exploitation or misappropriation policy, revised 04/2021, read in part, All reports of resident abuse (including injuries of unknown origin), 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.If resident abuse .is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.Immediately is defined as .within two hours of an allegation involving abuse. An admission resident assessment, dated 06/04/25, showed Resident #2's cognition was intact (BIMS 15). The assessment showed the resident exhibited verbal behavioral symptoms directed toward others that significantly disrupted care or the living environment. The assessment showed the resident required supervision or touching assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, sitting to standing, and chair/bed-to-chair transfer. An annual resident assessment, dated 06/16/25, showed Resident #1's cognitive skills for daily decision making were severely impaired per staff assessment for mental status. The assessment showed the resident required substantial/maximum assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, and was dependent on staff for chair to bed transfers. A quarterly resident assessment, dated 06/29/25, showed Resident #4's cognition was severely impaired (BIMS 04). The assessment showed the resident was independent for rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfers, and walking 10 feet. A nurse progress note, dated 07/25/25 at 3:30 a.m., showed at approximately 3:25 a.m. RN #1 was alerted by another resident (Resident #4) to a situation occurring in their room. Upon entering the room, RN #1 observed concerning behavior between (Resident #1 and Resident #2). RN #1 instructed Resident #2 to stop and leave the area. A CNA (CNA #1) was directed to supervise and escort Resident #2 out of the room while RN #1 contacted the DON for further guidance. The note showed Resident #1 was briefly assessed with no visible injuries noted at the time. The note showed Resident #2 was placed on 1:1 supervision for close monitoring. The note showed the provider on call and facility administration were notified and appropriate reporting procedures were initiated per protocol. An initial facility reported incident, dated 07/25/25, showed the DON and administrator were notified Resident #2 was in Resident #1's room. The reported incident showed the residents were immediately separated and Resident #2 left the property. The reported incident showed Resident #1 was sent to the emergency room for precautionary evaluation. The reported incident showed the police, family, physician, resident's legal representative, and APS were notified. The initial report was received by the state agency on 07/25/25 at 7:14 a.m. Resident #1's hospital records, dated 07/25/25, showed final diagnoses of sexual assault of adult, initial encounter. The hospital records showed a staff member had gone into Resident #1's room on 07/25/25 and found another resident (Resident #2) vaginally penetrating Resident #1. The hospital records showed Resident #1 was nonverbal. The hospital records showed Resident #1 had diagnoses which included anxiety, brain tumor, dementia with behavioral disturbance, and traumatic brain injury. On 07/30/25 at 10:34 a.m., Resident #4 stated they reported, [Resident #2's] laying on top of [Resident #1]. Resident #4 stated when they saw the two residents, Resident #2 told Resident #4 to shut the door, so they did. Resident #4 stated Resident #1 had to be sexually assaulted because [Resident #2] was on top of [Resident #1]. On 07/30/25 at 2:33 p.m., family member #4 stated the first call they received from the facility was on 07/25/25 at 5:57 a.m. Family member #4 stated the regional director of operations informed family member #4 Resident #1 had been sexually assaulted. Family member #4 stated no details were provided from the facility at the time. Family member #4 stated the next call they received was from the hospital to obtain consent for a rape kit. On 07/30/25 at 4:41 p.m., an attempt was made to call and speak with RN #1. RN #1's phone was not accepting calls at the time and did not return the state agency's call. On 07/31/25 at 12:00 a.m., CNA #1 stated if they saw any abuse or neglect, they would report it. They stated they would reach out to the administrator. On 07/31/25 at 12:01 a.m., CNA #1 stated they believed the administrator and DON were responsible for investigating abuse. On 07/31/25 at 12:16 a.m., CNA #1 stated they had gone down to Resident #4's room to get clothes for the resident to put on 07/25/25. They stated when they walked in the room they saw Resident #2 in Resident #1's bed. They stated Resident #1 was in the bed too. They stated no one else was in the room at the time. They stated it had to be around 3:00 a.m. to 3:30 a.m. CNA #1 stated Resident #1's brief was ripped off and their gown was off. They stated Resident #2 was in the bed with their shorts pulled down to their knees. CNA #1 reported saying What are you doing? CNA #1 reported saying Did you just rape [Resident #1]? CNA #1 stated Resident #2 said, No, [Resident #1] invited me in. CNA #1 told Resident #2 that Resident #1 could not have invited them in the room because the resident was unable to speak like that. CNA #1 stated, You need to get out of her bed. CNA #1 stated they were so upset when they saw what happened. They stated they observed a wet towel next to Resident #1 in the bed. They stated Resident #2 was prepared to wipe themselves off afterwards. CNA #1 stated there was nothing in the bed besides the blankets and the resident when they previously left Resident #1's room after providing care. On 07/31/25 at 12:21 a.m., CNA #1 stated Resident #2 started to get out of Resident #1's bed and sat in their wheelchair. They stated Resident #2 transferred themselves to their electric wheelchair and started rubbing Resident #1's leg saying, I saw your [family member] at the store. CNA #1 told Resident #2 You don't even know [Resident #1's] family. CNA #1 told Resident #2 stop rubbing on [Resident #1's] leg. CNA #1 stated if they did not take Resident #2 to jail, they were not going to work for the facility anymore. They stated, I'm not working at a place that allows someone to rape a resident. CNA #1 stated after Resident #2 left the room, CNA #1 proceeded to get clothes and dress Resident #4. They stated Resident #4 stated [Resident #2] had told [them] when [they] walked out the room to close the door. CNA #1 stated that was the point when police, the DON, and everyone came to the facility. On 07/31/25 at 12:45 a.m., LPN #1 stated if abuse was observed or reported to them, they were to report it immediately. They stated they would call the abuse hotline number and call the administrator right away. On 07/31/25 at 12:46 a.m., LPN #1 stated the administrator was responsible for investigating abuse. On 07/31/25 at 12:47 a.m., LPN #1 stated Resident #1 did not talk. They stated the resident speaks very minimal words. On 07/31/25 at 12:49 a.m., LPN #1 stated Resident #1 was unable to make decisions on their own. LPN #1 stated they did not witness anything regarding the abuse allegation on 07/25/25 for Resident #1 and #2. LPN #1 stated they saw Resident #4 speaking to RN #1 on the night shift that morning. They stated Resident #4 was wearing a Sleep jacket with no other clothes on. They stated they did not know the reason Resident #4 was talking to RN #1 that day, but LPN #1 had Resident #4 sit in the television room on hall 300 and instructed CNA #1 to get the resident dressed. On 07/31/25 at 12:52 a.m., LPN #1 stated RN #1 came to them and said they had CNA #1 in Resident #1's room (who shares a room with Resident #4) and reported [Resident #2] was in [Resident #1's] room. They stated RN #1 had to call the DON because they saw Resident #2 in the room with Resident #1. They stated RN #1 was visibly upset saying [Explicit], [explicit] and banging on the nurses' station. LPN #1 stated they later saw the DON fly in the facility with the police. On 07/31/25 at 12:57 a.m., LPN #1 stated they asked what was going on and RN #1 said Resident #2 was in bed with Resident #1. On 07/31/25 at 12:58 a.m., LPN #1 stated the ADON, the DON, the administrator, and the cops came to the facility. LPN #1 stated they started interviewing RN #1 with the door closed. On 07/31/25 at 5:50 a.m., the DON stated if staff reported abuse, they would investigate it. They stated they would send a report to the state agency, APS, notify police, complete an investigation, and have it finalized in five days. They stated the initial reporting for abuse had to be completed within two hours. They stated the timeline for reported a criminal act was also two hours. On 07/31/25 at 5:52 a.m., the DON stated the administrator and DON were responsible for investigating abuse. On 07/31/25 at 6:02 a.m., the DON stated they had received a call from RN #1 on 07/25/25 around 3:40 to 3:45 a.m. who reported Resident #2 was found in Resident #1's room and both residents' clothes were off. The DON instructed RN #1 to separate the residents, monitor them, put Resident #2 on 1:1, and call the police. On 07/31/25 at 6:04 a.m., the DON stated they were who called the police because when they were in route to the facility, RN #1 still had not called the police. They stated RN #1 was instructed to call EMSA. The DON stated they pulled up to the facility at the same time the police arrived. They stated the police informed them it was a crime scene and they could not touch anything. They stated law enforcement took all of the bedding and the gown Resident #1 was wearing. They stated Resident #1 was sent to the hospital for a SANE rape kit. The DON stated Resident #1 received a prophylactic antibiotic for STDs at the hospital. On 07/31/25 at 6:07 a.m., the DON stated the facility was able to review video footage and identified Resident #2 entered Resident #1's room at 2:49 a.m. and Resident #4 came out of the room and told CNA #1 there was a person (Resident #2) in their room who got RN #1. They stated at 3:09 a.m., RN #1 entered Resident #1's room and saw Resident #2 with their pants down. They stated RN #1 called them at 3:34 a.m. because that was when they could no longer see them on the video footage. On 07/31/25 at 6:15 a.m., the DON stated once they arrived to the facility, they started the investigation. The DON reviewed the initial state reportable sent on 07/25/25 at 7:14 a.m. and stated they thought it was sent before then.On 07/31/25 at 8:22 a.m., the COO was identified as the person who would answer questions for the administrator who was on vacation. The COO stated the facility operated on state and federal regulations and met the abuse and neglect training requirements for new hires as well as ongoing education throughout the year. On 07/31/25 at 8:24 a.m., the COO stated the facility abuse and neglect policy met the state and federal guidelines. On 07/31/25 at 8:25 a.m., the COO stated they could not tell the surveyor what they did if they witnessed abuse or neglect because they had not witnessed it and it would be speculation. They stated they could tell the surveyor speculation was they would protect the residents. They stated if it was reported to them, they would need to follow state and federal regulation and follow policy and regulation. On 07/31/25 at 8:26 a.m., the COO stated the administrator was the abuse coordinator and responsible for investigating abuse. They stated in their absence, the DON, COO or regional nursing staff would be responsible. On 07/31/25 at 8:33 a.m., the COO stated they received a call there was an incident between Resident #1 and Resident #2 on 07/25/25. They stated by the time the COO was notified, the administration, DON, and leadership were aware and the police were on site. They stated they were aware one resident was detained by police, and one resident was sent to the hospital for evaluation. They stated at the time of the initial call they did not know the reason for the detainment. On 07/31/25 at 8:34 a.m., the COO stated they had seen online Resident #2 had been charged for first degree rape after further investigation on Friday (07/25/25) because those details began to come to light pretty quickly. On 07/31/25 at 8:57 a.m., the COO stated the facility had a two-hour timeline to submit the initial allegation of abuse to the state agency. They stated the initial report to the state agency for a criminal act was two hours. The COO stated the first note from RN #1 regarding this incident of abuse was dated 07/25/25 at 3:30 a.m. The COO stated 07/25/25 at 7:14 a.m. was when the state agency received the initial allegation of abuse.

Based on observation, record review, and interview, the facility failed to place a call light within reach of a resident for 1 (#1) of 1 sampled resident who was observed for call lights.Administrator #1 identified 80 residents resided in the facility.Findings:On 07/23/25 at 2:35 p.m., Resident #1's call light was observed nearest the head of bed laying on top of a pillow. Resident #1 was observed in their Geri-chair approximately two feet away from the bed.An Answering the Call Light policy and procedure, revised 03/2021, read in part, The purpose of this procedure is to ensure timely response to the resident's request and needs.When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.A quarterly resident assessment, dated 05/17/25, showed Resident #2 was cognitively intact.An undated care plan for Resident #1 showed the resident had diagnoses which included post traumatic disorder and quadriplegia.On 07/23/25 at 2:38 p.m., Resident #1 stated they could use the call light if it was clipped to their shirt and placed under their chin so they could use their chin to activate it.On 07/23/25 at 2:50 p.m., CNA #1 stated the call light was on the bed and yes Resident #1 was able to use it. On 07/23/25 at 2:53 p.m., CNA #1 stated the policy for call lights was it was to be within reach of the resident and to make sure the call light was in working order. On 07/23/25 at 3:02 p.m., the director of clinical services stated the expectation was to have call lights within reach of the residents.

Based on record review and interview, the facility failed to complete and submit a final report of findings of an investigation after an allegation of verbal abuse for 1 (#3) of 3 sampled residents reviewed for abuse.Administrator #1 identified 80 residents resided in the facility.Findings:An Abuse Investigation and Reporting policy, revised 07/2017, read in part, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ('abuse').The administrator. or his/her designee, will provide the appropriate agencies or individuals.a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. An undated care plan for Resident #3's showed the resident had diagnoses which included hypertension and diabetes mellitus type 2.An Initial Incident Report Form, dated 03/06/25, read in part, [Resident #3] was very upset because [they] could not find [their] remote control to [their] TV [television], [CNA #5] (employee) told [Resident #3] that [they] needed to calm down and stop yelling. [CNA #5] spoke to [Resident #3] in a tone/manner that they are used to speaking but [CNA #5] did have to raise [their] volume due to [Resident #3] yelling. The resident did not seem to be offended by [CNA #5] tone/manner and [CNA #5] ordered a replacement remote for the resident.Administrator was notified, [CNA #5] was suspended immediately upon notification.There was no documentation of the results of an abuse/mistreatment investigation or documentation of final results being reported.On 07/23/25 at 3:22 p.m., the DON stated they could not find the follow up and the final 5-day investigation.

Based on record review and interview, the facility failed to conduct a thorough investigation after an allegation of abuse/mistreatment for 1 (#2) of 3 sampled residents reviewed for abuse.Administrator #1 identified 80 residents resided in the facility.Findings:An Abuse Investigation and Reporting policy, revised 07/2017, read in part, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ('abuse') shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management.interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident.Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it.An undated facesheet for Resident #2 showed diagnoses of dehiscence of wound of abdominal wall and acute kidney failure.A Final State Reportable Incident form, dated 07/16/25, read in part, [Family member] stated they arrived at the facility at about 2pm on Sunday 07/13/25 and noted [Resident #2] to be throwing up, and they had bowel movement on them. [Family member] said [Resident #2] had IV fluids running. [They] [were] upset that no one had called them to inform them that there had been changes or that [Resident #2] was on IV fluids or new medications. [They] stated they requested the nurse to clean [Resident #2] up and [the nurse] said [they] would get a CNA to assist. [Family member] also stated they asked for the nurse to come and check [Resident #2] and [they] did not come in a timely manner.[They] had waited for about 15 minutes total when they decided they just wanted [Resident #2] sent to the ER [emergency room].There was no documentation of employee witness statements being conducted.On 07/23/25 at 1:48 p.m., the DON stated they had spoken with registered nurse #1, licensed practical nurse #1, and CNA #1.On 07/23/25 at 1:52 p.m., the assistant director of nursing stated they had not been told to do interviews with staff.On 07/23/25 at 1:54 p.m., the DON stated they had spoken with staff, but they had not written it down. The DON stated, I usually just talk with them.

Based on record review and interview, the facility failed to ensure residents who received dialysis had pre and post monitoring for 2 (#1 and #3) of 3 sampled residents reviewed for dialysis. The DON identified four residents who received dialysis services resided in the facility. Findings: An undated facility policy titled Dialysis Care/Arterial-Venous Fistula, read in part, All residents receiving dialysis will have monitoring before and after their dialysis treatment to ensure condition is stable after treatment. 1. Resident #1's physician's order, dated 03/31/25, showed scheduled visits to the dialysis center every Tuesday, Thursday, and Saturdays with a chair time of 6:15 a.m. to 10:15 a.m., but to be present at the site at 6:00 a.m. to coordinate care accordingly. Resident #1's admission resident assessment, dated 04/03/25, showed the resident had moderate cognitive impairment with a brief interview for mental status score of 11. A review of 04/2025 dialysis communication forms showed Resident #1 had one completed pre and post monitoring dialysis communication form dated 04/17/25. A review of 04/2025 dialysis communication forms showed there were no pre and post monitoring dialysis communication forms for the dates of 04/01/25, 04/03/25, 04/05/25, 04/08/25, 04/10/25, 04/12/25, 04/15/25, 04/19/25, 04/22/25, 04/24/25, 04/26/25, and 04/29/25. Resident #1's order summary report, dated 05/2025, showed the resident had a diagnosis of end stage renal disease. On 05/02/25 at 7:58 a.m., Resident #1 stated staff did not assess them before or after dialysis. They stated they went to dialysis on Tuesday, Thursday, and Saturdays. On 05/02/25 at 10:47 a.m., the DON stated they could only locate one pre and post monitoring dialysis communication form for Resident #1. They stated the resident does not bring back the communication form. The DON stated they instructed the nurses to call the dialysis center for the form. On 05/02/25 at 10:50 a.m., the DON stated the process for pre and post dialysis monitoring was for the nurses to fill out the pre dialysis communication form and give the form to the resident to take to the dialysis center. They stated the dialysis center would fill out the form and would include any new orders or changes. The DON stated the nurse at the facility would complete the post dialysis on the form when the resident returned to the facility. 2. Resident #3's physician's order, dated 03/25/25, showed scheduled visits to the dialysis center every Tuesday, Thursday, and Saturdays with a chair time of 12:00 p.m., but to be present at site at 11:40 a.m. to coordinate care accordingly. A review of 04/2025 dialysis communication forms showed there were no post monitoring dialysis communication forms for the dates of 04/08/25, 04/15/25, 04/17/25, 04/22/25, and 04/24/25. Resident #3's order summary report, dated 05/2025, showed the resident had a diagnosis of end stage renal disease. On 05/02/25 at 12:57 p.m., license practical nurse #1 stated the pre and post dialysis monitoring included obtaining vitals, weights, and assessing dialysis site. On 05/02/25 at 2:41 p.m., the DON stated the post dialysis forms were not completed for the dates above.

On 03/21/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to assess, intervene, and evaluate a resident in accordance with physician's orders and professional standards of practice for Resident #2. On 03/21/25 at 10:21 a.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On 03/21/25 at 1:45 p.m., the administrator, DON, and the director of clinical services were notified of the IJ situation and the IJ template was provided. On 3/24/25 at 1:55 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, [NAME] healthcare Center Plan of Removal Immediate Jeopardy 03/21/25. The facility's response to the IJ called for the facility to implement a plan of removal to ensure there is a system in place to assess, intervene and evaluate to receive appropriate care and treatment. The facility will be in compliance on 3/21/25 by 10:00 p.m. 1. All staff are educated on reviewing and following physician orders for a change of condition on hire and annually, as well as periodically as a reminder. 2. In-service will be completed with all core nursing staff by 10:00 p.m. on 03/21/25 over the following: A. Acute Change of Condition Policy to include the following interventions to prevent a decline in condition and/or a lack of treatment/care: a. Any resident who is determined to have a change of condition during a nurse's shift will be assessed and a progress note will be placed describing the event and the interventions that were done to prevent further decline. b. Resident will be monitored every shift with documentation on residents condition until stable. c. The resident's provider will be notified in a timely manner as well as the resident's family if applicable, and any orders implemented as required. B. Following physicians orders as required. 3. The Administrator and DON have been in-serviced over events requiring investigations and reports to OSDH [Oklahoma State Department of Health] and presenting related education to the staff following the event or situation to prevent recurrence. 3. Agency will be provided with in-service materials as well. 4. Any staff on vacation or unable to reach will be in-serviced before working their next shift. The IJ was lifted, effective 03/21/25 at 10:00 p.m., when all components of the plan of removal had been completed. Multiple staff on all shifts were interviewed on the in-service received and the acute change in condition and physician notification policies were reviewed. The deficiency remained at an isolated level with the potential for more than minimal harm. Based on record review and interview, the facility failed to complete a resident assessment, intervene, and evaluate the resident in accordance to physician's orders and professional standards of practice for 1 (#2) of 3 sampled residents reviewed for timely care and treatment. The administrator identified 72 residents resided in the facility. Findings: The Resident Rights policy, revised 12/2016, read in part, Employees shall treat all residents with kindness, respect, and dignity. The Administering Medications policy, revised 04/2019, read in part, Medications are administered in a safe and timely manner, and as prescribed. Resident #2 had diagnoses which included altered mental status, quadriplegia, contracture of left hand, depression, schizoaffective disorder, bipolar type, and anxiety disorder. A physician's order, dated 05/08/24, showed Zofran (anti-nausea) 4 milligrams, give one tablet by mouth every four hours as needed for nausea and vomiting. Resident #2's quarterly resident assessment, dated 02/14/25, showed the resident had moderate cognitive impairment (BIMS 09) and they were dependent on staff for activities of daily living. An Initial INCIDENT REPORT FORM, dated 03/03/25, showed an allegation of abuse/mistreatment. It report showed Resident #2 told LPN #1 that they were sick. The report showed Resident #2 vomited on themselves, and LPN #1 refused to clean them up and left them covered in their vomit until the aide on the next shift came in to clean them up. The report showed the appropriate licensing board had been notified. There was no documentation in the nurses note regarding the incident or the resident was cleaned during the time of the incident as of 03/21/25. There was no documentation the resident received Zofran on 03/03/25 as of 03/21/25. On 03/20/25 at 8:35 a.m., Resident #2 stated they never threw up in the facility. On 03/20/25 at 9:51 a.m., Resident #2's representative stated the resident called them at around 3:00 a.m. on 03/03/25, because they threw up on themselves and wanted to be cleaned up. They stated they called the facility to inform them and the nurse in charge told them they knew and when the new shift came in, they would clean the resident. They stated they reviewed the camera in the room and the nurse had told the resident they had to wait. On 03/20/25 at 12:36 p.m., the administrator stated they reviewed the video of the 03/03/25 incident and terminated the nurse the same day. They stated there was nothing to investigate because it was clear in the video. On 03/20/25 at 12:37 p.m., the administrator stated the resident had told the nurse they were sick and the nurse left the room. They stated the nurse later came back and told the resident they would have to wait to be cleaned. They stated they could not tell how long the resident was left in their vomit because the video did not have a time stamp. On 03/20/25 at 12:40 p.m., the administrator stated they did not do an in-service related to Resident #2's incident, but they had done a staff in-service on resident rights and dignity on 02/27/25. On 03/20/25 at 12:41 p.m., the administrator and DON stated the nurse was terminated for leaving the resident in their own vomit, not taking care of the resident, and poor bedside manners. On 03/20/25 at 12:45 p.m., the director of clinical services stated Resident #2 did not receive the Zofran on 03/03/25 when they complained of being sick. On 03/20/25 at 12:48 p.m., the administrator and DON stated it was not acceptable for the resident to be left in their vomit. On 03/20/25 at 12:50 p.m., CNA #1 stated they told the nurse around 1:30 a.m. on 03/03/25, Resident #2 reported they felt sick. They stated around 2:00 a.m. on 03/03/25, Resident #2 complained of being sick again and they informed the nurse. CNA #1 stated around 6:00 a.m. on 03/03/25, they walked by the resident's room and saw the vomit on the resident and they cleaned them up. They stated they were not scheduled to work on that hall. On 03/21/25 at 8:36 a.m., Resident #2's representative stated the resident was upset when they called them on 03/03/25 and had used a few curse words. The resident told them it was not right that the staff did not clean them. They stated the resident's memory was not good, but complained sometimes the facility did not care about them.

On 03/18/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to supervise a resident with a known history of suicide attempt from access to a box cutter for Resident #4. On 03/18/25 at 5:23 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On 03/18/25 at 5:28 p.m., the administrator and the chief nursing officer were notified of the IJ situation and the IJ template was provided. On 3/20/25 at 9:37 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, [NAME] healthcare Center Plan of Removal Immediate Jeopardy 03/18/25. The facility's response to the IJ called for the facility to implement a plan of removal to ensure there is a system in place to protect residents. 1. In-service will be completed with all staff by 10:00 p.m. on 3/18/25 over the following: a. Suicide Precautions Policy b. Supervision of residents exhibiting signs of suicidal ideations to prevent access to sharps, chemicals, and other hazardous objects or materials and if any noted staff are to remove objects of concern and notify the DON or Administrator immediately. c. Agency staff will be provided with in-service as well. d. Any staff on vacation or unable to reach will be in-serviced before working their next shift. 2. All residents were audited for history or diagnosis of Suicidal Ideations 3/12/25 and: a. Psych [psychiatric] Consult and Counseling orders were received for one resident identified as having a history of suicidal ideations. b. Behavior Monitoring will be implemented on admission for any resident with history of suicidal ideations until resident has been cleared by psychiatric evaluation. c. Frequent monitoring will be immediately implemented for any resident identified as verbalizing having suicidal ideations to include 1:1 monitoring. d. Care Plans will be updated to include Suicidal Ideations and interventions for protection and prevention of self-harm or harm to others. 3. Trauma Informed Care Assessment will be completed for all residents on admission and if any suicidal ideations are noted Suicide Precautions will be implemented. 4. Physician will be notified of any resident noted with immediate concerns of suicidal ideations and they will be placed on 1:1 monitoring until resident can be transferred to a higher level of care. The IJ was lifted, effective 03/18/25 at 10:00 p.m., when all components of the plan of removal had been completed. Multiple staff on different shifts were interviewed regarding the in-service they received, resident audits were reviewed and the care plan and physician orders for the identified resident were reviewed. The suicide precaution policy and trauma care informed assessment completion plan was reviewed. The deficiency remained at an isolated level with the potential for more than minimal harm. Based on record review and interview, the facility failed to supervise a resident with a known history of suicide attempt from access to a box cutter for 1 (#4) of 3 sampled residents reviewed for accident hazards. The administrator identified 72 residents resided in the facility and 37 residents received mental health services. Findings: The Safety and Supervision of Residents policy, revised 07/2017, read in part, Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents .The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents .Resident supervision is a core component of the systems approach to safety. An undated facility SUICIDE PRECAUTION policy, read in part, To provide staff with guidelines by which to plan, intervene, to control and prevent harmful behavior .The interdisciplinary team should evaluate residents who exhibit suicidal tendencies and a plan put into place to manage their psychological needs. Definition of suicidal ideation: A history of attempted suicide. Resident #4 had diagnoses which included suicidal ideation, unspecified lack of coordination, and abnormalities of gait and mobility. A physician progress note, dated 08/27/24, read in part, Patient reported to the ER [emergency room ] staff that they was attempting to kill themselves after being evicted from housing which caused them distressed. A physician's order, dated 09/09/24, showed community pathways to eval and treat. An eye institute After Visit Summary, dated 10/03/24, showed secondary optic atrophy of both eyes and ischemic optic neuropathy of both eyes. A care plan, initiated, 09/05/24, showed Resident #4 had impaired visual function related to secondary optic atrophy of both eyes and ischemic optic neuropathy of both eyes. The care plan showed the resident was able to see silhouettes and shades of gray and able to ambulate using a cane. A care plan, initiated, 11/04/24, showed Resident #4 was often manipulative, had a recent history of attempting suicide, became very angry and yelled at staff. The care plan showed to have two staff members present for all resident interactions if possible. Resident #4's quarterly resident assessment, dated 03/02/25, showed the resident's cognition was intact (BIMS 15). A 30-Day Involuntary Transfer/Discharge Notice, dated 02/10/25, showed the resident had failed after reasonable notice, to pay for their stay at the facility. The discharge date was set for 03/11/25 to a shelter. A social service note, dated 03/05/25, read in part, Resident discharging to [shelter name withheld] on Tuesday. [name withheld] will transport. No DME [durable medical equipment] or home health needed for resident. Medication will be called in to [pharmacy name withheld] on Monday. A nursing note, dated 03/11/25 at 12:30 p.m., read in part, Staff alerted me that resident was in their bathroom and had cut both wrists and left side of their neck, upon arrival observed resident with boxcutter in their right hand and blood running down both wrist and right side of their neck, resident was waving the boxcutter in anger manner telling staff to move away or they will cut them, that they want to die because they don't want to go back to homeless shelter and dying was their best outlet, continue to talk to resident to get them to calm down and to remove the boxcutter out of their hand, they at this time allowed me to remove boxcutter and apply pressure to bilateral wrist and right side of neck area, resident started yelling and crying saying they just wanted to die, continue with pressure applied to the areas of concern until EMS [emergency medical services] arrive to take over and transport resident to [hospital name withheld]. A nursing note, dated 03/11/25 at 12:55 p.m., read in part, While resident was being transported asked resident where they get the boxcutter from they stated they purchased it while they went out on self initiated trip to [name withheld] and placed in their pocket and kept it there until today when attempted to cut bilateral wrists and right side of neck, stated they kept it there to keep away from staff. An Initial INCIDENT REPORT FORM, dated 03/11/25, showed physical harm. The report showed the resident had cut both wrists and left side of their neck. The report showed the resident was observed with a boxcutter in their right hand. The report showed the resident had a planned discharge for today. There was no documentation Resident #4 was on behavior monitoring as of 03/17/25. On 03/17/25 at 2:30 p.m., CNA #2 stated Resident #4 had their moments of behavior. They stated they never witnessed it, but was informed the resident did yell and got upset sometimes. On 03/17/25 at 2:32 p.m., CNA #2 stated Resident #4 used a cane for ambulation. They were told the resident was legally blind, but they believed the resident could see. On 03/17/25 at 2:34 p.m., CNA #2 stated they were not familiar with the facility neighborhood, but the shopping center was not within walking distance of the facility. They stated the facility had shopping center trips. CNA #2 stated they were not sure when those trips were held. On 03/17/25 at 2:36 p.m., CNA #2 stated they were not aware Resident #4 had a box cutter. On 03/17/25 at 2:46 p.m., CNA #3 stated Resident #4 liked attention and proving a point. They stated the resident had manipulative behaviors. On 03/17/25 at 2:47 p.m., CNA #3 stated they were not aware Resident #4 had a box cutter. On 03/17/25 at 2:55 p.m., LPN #2 stated Resident #4 complained a lot, but did not have behaviors. On 03/17/25 at 2:56 p.m., LPN #2 stated Resident #4 used a cane for ambulation. They stated there was no shopping center within walking distance of the facility. On 03/17/25 at 2:57 p.m., LPN #2 stated they were the nurse for Resident #4 on 03/11/25. They stated they were informed to call 911 upon returning from a 15 minute break. They stated they went into the resident's room and found the assistant director of nursing and DON assisting the resident to stop the bleeding prior to emergency services arrival. On 03/17/25 at 3:00 p.m., LPN #2 stated they were not aware the resident received medication for behaviors. On 03/17/25 at 3:02 p.m., LPN #2 stated Resident #4 was not on behavior monitoring. On 03/17/25 at 3:03 p.m., LPN #2 stated they were not aware Resident #4 had a box cutter. On 03/17/25 at 3:12 p.m., the social services director stated they first initiated talks about discharge on 01/14/25. They stated they gave Resident #4's 30 day involuntary discharge notice on 02/10/25. On 03/17/25 at 3:23 p.m., the social services director stated they had spoken to Resident #4 on 03/11/25 about making payments and the resident refused to pay. They stated they had informed the resident their ride was about 10 minutes away. The social services director stated housekeeping had helped the resident pack their belongings and took them to the front. The social services director stated the resident asked to use the bathroom due to having diarrhea, so they took the rest of the resident's belongings to the front. They stated they returned to the room to wait for the resident. They stated a CNA had stopped by to say [NAME] to the resident. They stated the resident remained in the bathroom so they asked the CNA to open the door and check on the resident. They stated the CNA observed blood on the floor, the resident had cut both wrists and side of their neck. The social services director stated they notified the DON. On 03/17/25 at 3:28 p.m., the social services director stated they were not aware the resident had a history of attempting suicide with eviction. On 3/17/25 at 3:34 p.m., the activity director stated Resident #4 required supervised shopping due to their selective blindness. They stated the transport personnel assisted the resident during their shopping center outing. The activity director stated they could not confirm nor deny the resident bought a box cutter from the shopping center trip. On 03/17/25 at 3:40 p.m., the activity director stated Resident #4 last went to the shopping center on 02/11/25 at 9:30 a.m. On 03/18/25 at 10:56 a.m., the DON stated they were notified the resident was in the bathroom with blood. They stated the resident had cut both wrists and side of their neck. They stated they were not sure how deep the cuts were, but there was a lot of blood on the floor. They stated the resident remained conscious. The DON stated they called the police and emergency services should the resident refuse to go out for treatment. They stated they applied pressure to stop the bleeding. They stated the resident initially refused to give them the box cutter, but they eventually did. They stated once the resident was calmed, they told the DON they had gone to the shopping center and purchased the box cutter and hid it. The DON stated the resident stated they attempted suicide because they did not want to go to the homeless shelter. On 03/18/25 at 11:02 a.m., the DON stated Resident #4 had counseling services. They stated the resident was not totally blind and they were independent for all activities of daily living except bathing. They stated the resident would not let staff touch their clothing. The DON stated the resident was allowed to check out and go out. On 03/18/25 at 11:11 a.m., the DON stated they started employment at the facility in January 2025. They stated they were not aware the resident had a history of attempting suicide with eviction. On 03/18/25 at 11:32 a.m., the activity director stated they would assist with checkout for residents who required supervision and the residents who were independent would checkout on their own. They stated they did not keep receipts to verify purchases. On 3/18/25 at 12:58 p.m., the administrator was asked what the facility did after the incident. They stated they did a sweep of the facility and resident rooms to identify any safety concerns. They stated they obtained statements from everyone involved and cleaned Resident #4's bathroom. They stated they sent a report to the State Agency. On 3/18/25 at 1:00 p.m., the administrator stated the transport personnel was in the facility on 03/11/25. They stated the transport personnel stated they could not remember the resident purchasing a box cutter. The administrator stated Resident #4 did online shopping center deliveries and food deliveries. They stated online deliveries were new and they could not impede resident rights. They stated they did not have a process in place for online deliveries. On 3/18/25 at 4:53 p.m., the transport personnel stated they did not normally assist residents with shopping. They stated they assisted Resident #4 because the activity director requested assistance. They stated they helped the resident retrieve a pair a pants and they accompanied the resident back to CNA #4. They stated the resident had some cookies, beauty products, and a pair of pants. The transport personnel stated they did not remember what the beauty products were. On 3/18/25 at 4:59 p.m., the transport personnel stated, I misremember. They stated they assisted Resident #4 with checkout prior to handing the Resident to CNA #4. On 3/18/25 at 5:00 p.m., the transport personnel stated they did not see Resident #4 purchase a box cutter. On 3/18/25 at 5:03 p.m., the transport personnel stated they no longer worked for the company as of yesterday.

Based on record review and interview, the facility failed to ensure a resident's legal representative was notified of a resident's refusal to use a c-pap for 1 (#3) of 3 sampled residents reviewed for respiratory care. The administrator identified 72 residents resided in the facility. Findings: Resident #3 had diagnoses which included chronic respiratory failure with hypoxia, bipolar disorder, generalized anxiety, and major depressive disorder. A court ORDER APPOINTING GUARDIAN, dated 04/07/21, showed the Resident #3 had a court appointed guardian. The court appointed guardian was listed on Resident #3's electronic health record as the guardian, power of attorney, and emergency contact. Resident #3's quarterly resident assessment, dated 11/21/24, showed the resident's cognition was intact with a BIMS of 15. A care plan, initiated, 07/12/24, showed Resident #3 often will remove the c-pap once staff has left the room, staff has found it under their bed before where they had tossed/tried to hide it. Staff to encourage them to keep it in place and not remove it. A physician's order, dated 07/19/24, read in part, the resident was to wear c-pap due to sleep apnea. Oxygen to bleed [oxygen going through the tube] in at 3 LPM [liters per minute], c-pap setting: 6 cmH20 to 14 cmH20. The Resident may remove at their discretion every evening and night shift related to chronic respiratory failure with hypoxia. Document when the resident refuses to wear c-pap. The January 2025 TAR showed refused for Resident #3's evening shift c-pap administration on the 3rd, 4th, 5th, 6th, 7th, 8th, 9th, 10th, 11th, 12th, 13th, 18th, 19th, and 25th. The January 2025 TAR showed refused for Resident #3's night shift c-pap administration on the 1st, 2nd, 3rd, 7th, 8th, 9th, 10th, 11th, 12th, 14th, 15th, 16th, 17th, 20th, 21st, 22nd, and 23rd. A nursing note, dated 01/16/25 at 10:09 a.m., read in part, Resident's representative [name withheld], expressed concerns to me regarding Resident #3's condition reporting they were experiencing low oxygen saturation. Resident was refusing to wear their c-pap at night due to discomfort. I let [name withheld] know we were going to send a new pulmonologist referral and have the c-pap company come evaluate their c-pap and pressure setting. [name withheld] requested to be updated when we have updates. I assured them I would. No additional questions or concerns at this time. There was no documentation prior to 01/16/25 Resident #3's legal guardian was aware of their refusal to use the c-pap. On 03/19/25 at 4:14 p.m., CNA #4 stated Resident #3 was non-compliant with care and diet including the use of the c-pap machine. They stated the resident's memory was intact. On 03/19/25 at 4:16 p.m., CNA #4 stated Resident #3 mostly needed assistance with transfers. On 03/19/25 at 4:21 p.m., LPN #3 stated they were familiar with Resident #3. They stated the resident was non-complaint with oxygen and c-pap use. On 03/19/25 at 4:25 p.m., LPN #3 stated Resident #3's cognition was intact. On 03/19/25 at 4:27 p.m., LPN #3 stated nurses were responsible for administering c-pap for residents. On 03/19/25 at 4:28 p.m., LPN #3 stated if a resident refuses care, the first emergency contact was notified and if unable to reach, call the second emergency contact, notify the doctor and document notification. On 03/19/25 at 4:30 p.m., LPN #3 stated if there was a pattern of refusal to use a c-pap, they would notify the resident's representative. They stated Resident #3's family had a camera in the resident's room and were able to see everything. On 03/19/25 at 4:32 p.m., LPN #3 stated they did not notify Resident #3's legal guardian of the resident's refusal to use the c-pap. On 03/19/25 at 4:36 p.m., the DON stated staff were to notify the physician and family of refusal of treatment unless the resident is their own representative. They stated when they started working at the facility in January 2025, they identified staff were not notifying family so they did a performance improvement plan and staff in-service. On 03/19/25 at 4:38 p.m., the DON stated refusal to use a c-pap required family/guardian notification. On 03/19/25 at 4:47 p.m., the DON stated there was no documentation Resident #3's legal guardian was notified of refusals to use c-pap prior to 01/16/25.

Based on record review and interview, the facility failed to ensure: a. the results of an abuse/mistreatment investigation were reported to the State Agency within 10 business days for 1 (#2); and b. an allegation of abuse/mistreatment was reported to the appropriate licensing board in a timely manner for 1 (#2) of 3 sampled residents reviewed for timely care and treatment. The administrator identified 72 residents resided in the facility. Findings: The Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, revised 04/2021, read in part, Findings of all investigations are documented and reported. Resident #2 had diagnoses which included altered mental status and quadriplegia. An Initial INCIDENT REPORT FORM, dated 03/03/25, showed an allegation of abuse/mistreatment. The report showed Resident #2 told LPN #1 that they were sick. The report showed Resident #2 vomited on themselves, and LPN #1 refused to clean them up and left them covered in their vomit until the aide on the next shift came in to clean them up. The report showed the appropriate licensing board had been notified. The final investigation report was not sent to the State Agency within 10 business days after the incident on 03/03/25. There was no documentation to show the appropriate licensing board was notified on 03/03/25. On 03/20/25 at 12:34 p.m., the administrator stated the process was to send a final report of an investigation to the State Agency within five days. They stated their fax machine had issues so the final report was sent in today. On 03/20/25 at 12:35 p.m., the administrator stated the report was not successfully sent in a timely manner to the State Agency. On 03/20/25 at 12:44 p.m., the administrator stated they did not notify the appropriate licensing board in a timely manner. They stated they sent the notification today.

Based on record review and interview, the facility failed to provide ADL care for a dependent resident for one (#3) of three sampled residents reviewed for ADL care. The DON identified 76 residents resided in the facility. Findings: The facility's Bath, Shower/Tub policy, revised 02/2018, read in part, Documentation 1. The date and time the shower/tub was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 3. All assessment data obtained during the bath. 4. How the resident tolerated the shower/tub bath. 5. If the resident refused the shower/tub bath, the reason(s). The facility's Activities of Daily Living (ADL), Supporting policy, revised 03/2018, read in part, Appropriate care services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care.) Resident #3 was admitted on [DATE] with diagnoses which included cerebral infarction, contracture of the right hand, conversion disorder, and dysphagia. Resident #3's annual assessment, dated 01/01/25, documented their cognition was impaired and they required substantial/maximal assistance with showers/baths. Resident #3's care plan, dated 01/01/25, documented the resident had an ADL self-care performance deficit. It documented the resident was totally dependent for bathing. Task sheets for bathing, reviewed 11/01/24 through 12/31/24, documented the resident was not bathed 13 out of 26 opportunities on the following dates, a. 11/01/24, b. 11/04/24, c. 11/06/24, d. 11/15/24, e. 11/18/24, f. 11/20/24, g. 11/22/24, h. 12/04/24, i. 12/09/24, j. 12/13/24, k. 12/20/24, l. 12/23/24, and m. 12/27/24. On 01/08/25 at 10:35 a.m., CNA #1 was asked to discuss Resident #3's baths. They stated the resident took showers on the 3-11 shift and had a bath about a month ago and had not been getting showers. The CNA stated they had bath sheets and residents should sign a refusal, but they did not think the resident had refused showers because they did not think the resident was offered a shower. On 01/08/25 at 11:30 a.m., corporate nurse #1 was asked about showers on the above mentioned dates. They stated there was no documented refusal or showers given for the above dates. Corporate Nurse #1 was asked what the policy was for bathing dependent residents. They stated baths were logged in task and if the resident refused, the refusal should be documented. Corporate Nurse #1 was asked if their policies were followed regarding the above dates. They stated,No, they did not document refusals, notify the nurse of the refusal, and did not fill out shower sheets.

Based on observation, interview and record review, the facility failed to provide protection from abuse for three (#1, #2 and #3) of five sampled residents who were reviewed for allegations of abuse. The facility identified 62 residents who resided in the facility. Findings: The facility failed to report and investigate allegations of abuse including suspension of an alleged perpetrator during an investigation. The facility allowed the alleged perpetrator to continue to provide care to the residents who had allegations against him for a period of at least one to two months, which resulted in psychosocial harm. 1. Resident #1 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 07/01/20, documented the resident was independent in cognitive skills for daily decision making. Review of the state reports dated 07/20 through 09/20 did not include any investigations of allegations of abuse. On 09/09/20 at 4:10 p.m., the resident was asked how the staff treated him. He stated they were really rough sometimes. He was asked which staff was rough. He named CNA #1. He stated CNA #1 had poked his fingers in his face and had mocked the noises he made when his legs jerked. He was asked when the last time CNA #1 had treated him this way. He stated it had been three days ago. Resident #1 was asked if he had reported to the staff about the incidents. He stated he had reported to the administrator about a week ago and it had been better since then. He stated he had also reported it to the ADON several times and she had told him she had talked to the staff until she was blue in the face. He was asked if CNA #1 was intentional in the way he treated him. He stated yes. He stated CNA #1 would enter his room when he knew he was asleep and get in his face and scream to wake him up. He stated, He laughs and thinks it's funny. He stated he had told CNA #1 he did not like it and to quit putting his nasty hands in his face. He stated, He just grunts at me like I do. The resident stated he had cried a few times over the way he had been treated. He was asked how it made him feel. He stated, I get intimidated. He stated he wanted to hit CNA #1. He stated he was tired of it. He stated, He degrades me. I feel embarrassed and ashamed about it. At 4:45 p.m. an anonomous employee stated CNA #1 was asked for assistance with resident #4 in the past. CNA #1 had stated he could do the transfer by himself. CNA #1 was rough with resident #4 during the transfer. The anonomous employee stated they had reported the situation to staff, but nothing was done. At 5: 25 p.m. CNA #1 was observed on-duty. He stated no one at the facility had ever spoken to him about employee to resident abuse. At 6:00 p.m., the DON was asked if any residents had complained about CNA #1. She stated resident #1 had reported he thought CNA #1 was rough with resident #2. The DON did not mention any allegations of abuse which involved resident #1. At 6:25 p.m., the administrator was asked if any residents had reported to her related to staff being rough during care. She stated, No. The administrator did not mention any allegations of abuse which involved resident #1. On 09/10/20 at 10:20 a.m., the ADON was asked if she had received any allegations of abuse from a resident or staff in the last three months. She stated, No. The ADON did not mention any allegations of abuse which involved resident #1. On 09/11/20 at 9:18 a.m., the DON and the administrator were asked if they had recieved any allegations of abuse which involved resident #1. They both stated no. They were informed of the allegation of abuse resident #1 had reported related to CNA #1. They stated they had suspended CNA #1 on 09/09/20 after the surveyors' arrival pending an investigation of allegations of abuse. 2. Resident #2 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 07/20/20, documented the resident was moderately impaired in cognitive skills for daily decision making. Review of the state reports dated 07/20 through 09/20 did not include any investigations of allegations of abuse. On 09/09/20 at 4:10 p.m., during an interview related to abuse, resident #1 stated he thought CNA #1 was rough on his roommate (resident #2). He was asked what he meant by rough. He stated he could hear resident #2 make noises each time CNA #1 provided care to him and it sounded like the resident would hit his head on the wall. At 4:45 p.m. an anonomous employee stated CNA #1 was asked for assistance with resident #4 in the past. CNA #1 had stated he could do the transfer by himself. CNA #1 was rough with resident #4 during the transfer. The anonomous employee stated they had reported the situation to staff, but nothing was done. At 5: 25 p.m. CNA #1 was observed on-duty. He stated no one at the facility had ever spoken to him about employee to resident abuse. At 6:00 p.m., the DON was asked what she did if someone reported an allegation of abuse to her or her staff. She stated they had issues on another shift. She was asked what she meant by issues. She stated the staff had been bickering and accusing each other trying to get each other fired. The DON stated if she received an allegation of abuse she investigated it. She stated if it was accurate she reported it to the state. She was asked what she did if she substantiated abuse. She stated she suspended the alleged perpetrator during an investigation and she terminated them if it was substantiated. The DON was asked when she had started in the DON position. She stated the end of July. She was asked if she had received any allegations of abuse. She stated one of the aides thought CNA #1 had been rough with resident #2. She was asked what she had done related to the allegation. She stated she stood back and observed CNA #1 from a distance and had not observed any concerns. She stated she had asked resident #2 if any staff had been rough with him and the resident stated no. She was asked if she had talked to CNA #1 related to the allegation. She stated, I told him to be sure he is being gentle. The DON was asked if she had interviewed any other residents related to the allegation of abuse. She stated no. The DON was asked how she documented her investigation. She stated she had not documented the investigation. The DON was asked if she had reported the allegation of abuse to anyone. She stated no. She stated she did not see it as abuse because the report was about CNA #1 being rough. She stated the staff who reported the allegation had been complaining about CNA #1 and not wanting to work with him. She stated, They just want to get him fired, I should have documented it. The DON was asked if any residents had complained about CNA #1. She stated resident #1 had reported he thought CNA #1 was rough with resident #2 because he could hear resident #2 when CNA #1 repositioned the resident. She stated she had assessed resident #2 and had not observed any signs of abuse. She was asked when resident #1 had reported the allegation. She stated about an hour after the aide had reported to her, the aide pushed resident #1 into the DON's office and stated, He has something to tell you. She stated she had mentioned it to the administrator. At 6:25 p.m., the administrator was asked what their procedure was if they received an allegation of abuse. She stated the DON checked it out. She stated they would talk to the residents and turn it in. She stated they would suspend the alleged perpetrator during the investigation and if it was substantiated they would terminate the employee. She was asked if she was aware of any allegations of abuse in the last three months. She stated the DON had just notified her of an allegation today which involved resident #2. She was asked if any allegations of abuse had been reported to her before today. She stated, No. She was asked if CNA #1 should have been suspended during the investigation of an allegation of abuse with resident #2. She stated, Yes. She was asked how they documented an allegation of abuse. She stated, On paper and keep it in a file. She was asked if an allegation of abuse was required to be reported to the OSDH. She stated, Yes. The administrator was informed the DON had not interviewed other residents during the investigation of the allegation of abuse for resident #2. She was asked how they knew if CNA #1 had abused other residents. She stated, We don't. She was asked if they had continued to allow CNA #1 to provide care to the residents without interviewing the residents related to being abused by CNA #1. She stated, Yes. On 09/10/20 at 9:30 a.m., the DON was asked for their policy and procedure related to abuse. She provided the policy and stated she had not followed their policy in regards to the allegation of abuse which involved CNA #1. 3. Resident #3 had [DIAGNOSES REDACTED]. An annual assessment, dated 07/17/20, documented the resident was independent in cognitive skills for daily decision making. A written statement, dated 09/10/20, documented, .clarification of above statement 9/10/2020 @ 11:00 am .(resident #3 name deleted) had stated that he had gotten his breast pinched by and (sic) employee. He said this to me in the shower rm a few months ago. I went & reported the alligation (sic) to the charge nurse .the employee is name (CNA #1 name deleted) . Review of the state reports dated 07/20 through 09/20 did not include any investigations of allegations of abuse. On 09/10/20 at 10:07 a.m., CNA #2 was asked what she would do if a staff was abusive to a resident. She stated she would report it to the nurse. She was asked if she had observed or heard of any staff being abusive to a resident. She stated resident #3 had reported to her about two months ago that CNA #1 had pinched him on his breasts. She stated she had reported it to a nurse that no longer worked at the facility. She was asked what the facility had done about it. She stated she did not know because she was off work for awhile after that, but when she returned CNA #1 had been moved from first shift to second shift. She stated she had told the staff on second shift to keep an eye on CNA #1. At 10:28 a.m., resident #3 was asked how the staff treated him. He stated CNA #1 had pinched his titties. He stated he could not recall the last time this had occurred, but it had been awhile. He was asked who he had reported the incidents to. He stated he could not recall who he had reported it to. He was asked how it made him feel when CNA #1 pinched him. He stated, I didn't like it. At 10:33 a.m., the DON was asked if she was aware of allegations of abuse with resident #3. She stated she had just received a written report from staff related to resident #3 and she had not completed reading it. She showed the report to the surveyor and stated it documented CNA #1 had pinched resident #3's breast. She stated she needed to clarify some information and start the investigation. She stated the allegation of abuse had not been reported to her.

Based on observation, interview and record review, it was determined the facility failed to implement the abuse policy as follows ~ the ADON and the administrator failed to report allegations of abuse to the DON for one (#1), ~ the DON failed to perform a thorough investigation of abuse, which included suspension of an employee during the investigation and reporting/documenting the allegation of abuse to the OSDH for one (#2), and ~ the charge nurse failed to notify the DON and the administrator of allegations of abuse for one (#3) of five sampled residents who were reviewed for allegations of abuse. The facility identified 62 residents who resided in the facility. Findings: The facility failed to report and investigate allegations of abuse including suspension of an alleged perpetrator during an investigation. The facility allowed the alleged perpetrator to continue to provide care to the residents who had allegations against him for a period of at least one to two months, which resulted in psychosocial harm. A policy, titled Investigation of Abuse Guidelines, documented, .must develop and implement policies and procedures that include the seven components . .Investigation: ensuring that as much knowledge as possible has been generated, allowing for a preliminary determination of the allegation . .Protection: ensuring that any resident alleging abuse, be protected until the investigation is completed and determination is made . .Reporting/Response: reporting and responding to State Entities and individuals in a specific time frame per State and Federal Regulations . A policy, titled Reporting and Responseing to Alleged Abuse, documented, .if the events that cause the allegation involved abuse or results in serious bodily injury the allegation will be reported within 2 hours or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . .completion of the investigation will be sent to appropriate reporting agencies, within 5 working days of the incident, with the findings of the investigation .Every staff member must immediately report any observed or suspected abuse of a resident by another staff member .Supervisors will report all allegations to the Director of Nursing and the Administrator . .The Director of Nursing will immediately initiate and abuse incident report and begin investigation of the alleged abuse .To protect the residents during the abuse investigation, the Director of Nursing and/or Administrator will suspend the involved employee . .the Director of Nursing will inform the state survey, certification, and licensing agencies of .Evidence that all alleged violations are thoroughly investigated, and that further potential abuse has been prevented while the investigation is in progress .The results of all investigations within 5 working days of the incidents, and if the alleged violation is verified, appropriate corrective action was taken . 1. Resident #1 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 07/01/20, documented the resident was independent in cognitive skills for daily decision making. At 4:50 p.m., the DON was asked for the state reportable documentation from 07/20 to current. She provided four state reports. No reports were documented related to allegations of abuse. On 09/09/20 at 4:10 p.m., the resident was asked how the staff treated him. He stated they were really rough sometimes. He was asked which staff was rough. He named CNA #1. He stated CNA #1 had poked his fingers in his face and had mocked the noises he made when his legs jerked. He was asked when the last time CNA #1 had treated him this way. He stated it had been three days ago. Resident #1 was asked if he had reported to the staff about the incidents. He stated he had reported to the administrator about a week ago and it had been better since then. He stated he had also reported it to the ADON several times and she had told him she had talked to the staff until she was blue in the face. He was asked if CNA #1 was intentional in the way he treated him. He stated yes. He stated CNA #1 would enter his room when he knew he was asleep and get in his face and scream to wake him up. He stated, He laughs and thinks it's funny. He stated he had told CNA #1 he did not like it and to quit putting his nasty hands in his face. He stated, He just grunts at me like I do. The resident stated he had cried a few times over the way he had been treated. He was asked how it made him feel. He stated, I get intimidated. He stated he wanted to hit CNA #1. He stated he was tired of it. He stated, He degrades me. I feel embarrassed and ashamed about it. At 4:45 p.m. an anonomous employee stated CNA #1 was asked for assistance with resident #4 in the past. CNA #1 had stated he could do the transfer by himself. CNA #1 was rough with resident #4 during the transfer. The anonomous employee stated they had reported the situation to staff, but nothing was done. At 5: 25 p.m. CNA #1 was observed on-duty. He stated no one at the facility had ever spoken to him about employee to resident abuse. At 6:00 p.m., the DON was asked if any residents had complained about CNA #1. She stated resident #1 had reported he thought CNA #1 was rough with resident #2. The DON did not mention any allegations of abuse which involved resident #1. At 6:25 p.m., the administrator was asked if any residents had reported to her related to staff being rough during care. She stated, No. The administrator did not mention any allegations of abuse which involved resident #1. On 09/10/20 at 10:20 a.m., the ADON was asked if she had received any allegations of abuse from a resident or staff in the last three months. She stated, No. The ADON did not mention any allegations of abuse which involved resident #1. On 09/11/20 at 9:18 a.m., the DON and the administrator were asked if they had received any allegations of abuse which involved resident #1. They both stated no. They were informed of the allegation of abuse resident #1 had reported related to CNA #1. They stated they had suspended CNA #1 on 09/09/20 after the surveyors' arrival pending an investigation of allegations of abuse. 2. Resident #2 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 07/20/20, documented the resident was moderately impaired in cognitive skills for daily decision making. Review of the state reports dated 07/20 through 09/20 did not include any investigations of allegations of abuse. On 09/09/20 at 4:10 p.m., during an interview related to abuse, resident #1 stated he thought CNA #1 was rough on his roommate (resident #2). He was asked what he meant by rough. He stated he could hear resident #2 make noises each time CNA #1 provided care to him and it sounded like the resident would hit his head on the wall. At 4:45 p.m. an anonomous employee stated CNA #1 was asked for assistance with resident #4 in the past. CNA #1 had stated he could do the transfer by himself. CNA #1 was rough with resident #4 during the transfer. The anonomous employee stated they had reported the situation to staff, but nothing was done. At 5: 25 p.m. CNA #1 was observed on-duty. He stated no one at the facility had ever spoken to him about employee to resident abuse. At 6:00 p.m., the DON was asked what she did if someone reported an allegation of abuse to her or her staff. She stated they had issues on another shift. She was asked what she meant by issues. She stated the staff had been bickering and accusing each other trying to get each other fired. She stated if she received an allegation of abuse she investigated it. She stated if it was accurate she reported it to the state. She was asked what she did if she substantiated abuse. She stated she suspended the perpetrator during an investigation and she terminated them if it was substantiated. The DON was asked when she had started in the DON position. She stated the end of July. She was asked if she had received any allegations of abuse. She stated one of the aides thought CNA #1 had been rough with resident #2. She was asked what she had done related to the allegation. She stated she stood back and observed CNA #1 from a distance and had not observed any concerns. She stated she had asked resident #2 if any staff had been rough with him and the resident stated no. She was asked if she had talked to CNA #1 related to the allegation. She stated, I told him to be sure he is being gentle. The DON was asked if she had interviewed any other residents related to the allegation of abuse. She stated no. The DON was asked how she documented her investigation. She stated she had not documented the investigation. The DON was asked if she had reported the allegation of abuse to anyone. She stated no. She stated she did not see it as abuse because the report was about CNA #1 being rough. She stated the staff who reported the allegation had been complaining about CNA #1 and not wanting to work with him. She stated, They just want to get him fired, I should have documented it. The DON was asked if any residents had complained about CNA #1. She stated resident #1 had reported he thought CNA #1 was rough with resident #2 because he could hear resident #2 when CNA #1 repositioned the resident. She stated she had assessed resident #2 and had not observed any signs of abuse. She was asked when resident #1 had reported the allegation. She stated about an hour after the aide had reported to her, the aide pushed resident #1 into the DON's office and stated, He has something to tell you. She stated she had mentioned it to the administrator. At 6:25 p.m., the administrator was asked what their procedure was if they received an allegation of abuse. She stated the DON checked it out. She stated they would talk to the residents and turn it in. She stated they would suspend the alleged perpetrator during the investigation and if it was substantiated they would terminate the employee. She was asked if she was aware of any allegations of abuse in the last three months. She stated the DON had just notified her of an allegation today which involved resident #2. She was asked if any allegations of abuse had been reported to her before today. She stated, No. She was asked if CNA #1 should have been suspended during the investigation of an allegation of abuse with resident #2. She stated, Yes. She was asked how they documented an allegation of abuse. She stated, On paper and keep it in a file. She was asked if an allegation of abuse was required to be reported to OSDH. She stated, Yes. The administrator was informed the DON had not interviewed other residents during the investigation of the allegation of abuse for resident #2. She was asked how they knew if CNA #1 had abused other residents. She stated, We don't. She was asked if they had continued to allow CNA #1 to provide care to the residents without interviewing the residents related to being abused by CNA #1. She stated, Yes. On 09/10/20 at 9:30 a.m., the DON was asked for their policy and procedure related to abuse. She provided the policy and stated she had not followed their policy in regards to the allegation of abuse involving CNA #1. 3. Resident #3 had [DIAGNOSES REDACTED]. An annual assessment, dated 07/17/20, documented the resident was independent in cognitive skills for daily decision making. A written statement, dated 09/10/20, documented, .clarification of above statement 9/10/2020 @ 11:00 am .(resident #3 name deleted) had stated that he had gotten his breast pinched by and (sic) employee. He said this to me in the shower rm a few months ago. I went & reported the alligation (sic) to the charge nurse .the employee is name (CNA #1 name deleted) . Review of the state reports dated 07/20 through 09/20 did not include any investigations of allegations of abuse. On 09/10/20 at 10:07 a.m., CNA #2 was asked what she would do if a staff was abusive to a resident. She stated she would report it to the nurse. She was asked if she had observed or heard of any staff being abusive to a resident. She stated resident #3 had reported to her about two months ago that CNA #1 had pinched him on his breasts. She stated she had reported it to a nurse that no longer worked at the facility. She was asked what the facility had done about it. She stated she did not know because she was off work for awhile after that, but when she returned CNA #1 had been moved from first shift to second shift. She stated she had told the staff on second shift to keep an eye on CNA #1. At 10:28 a.m., resident #3 was asked how the staff treated him. He stated CNA #1 had pinched his titties. He stated he could not recall the last time this had occurred, but it had been awhile. He was asked who he had reported the incidents to. He stated he could not recall who he had reported it to. He was asked how it made him feel when CNA #1 pinched him. He stated, I didn't like it. At 10:33 a.m., the DON was asked if she was aware of allegations of abuse with resident #3. She stated she had just received a written report from staff related to resident #3 and she had not completed reading it. She showed the report to the surveyor and stated it documented CNA #1 had pinched resident #3's breast. She stated she needed to clarify some information and start the investigation. She stated the allegation of abuse had not been reported to her.

Based on observation, interview and record review, the facility failed to complete a thorough investigation related to an allegation of abuse for one (#2) of five sampled residents who were reviewed for allegations of abuse. The facility identified 62 residents who resided in the facility. Findings: The facility failed to report and investigate allegations of abuse including suspension of a perpetrator during an investigation. The facility allowed the perpetrator to continue to provide care to the residents who had allegations against him for a period of at least one to two months, which resulted in psychosocial harm. A policy, titled Investigation of Abuse Guidelines, documented, .Investigation: ensuring that as much knowledge as possible has been generated, allowing for a preliminary determination of the allegation . .Protection: ensuring that any resident alleging abuse, be protected until the investigation is completed and determination is made . A policy, titled Reporting and Responseing to Alleged Abuse, documented, .The Director of Nursing will immediately initiate and abuse incident report and begin investigation of the alleged abuse .To protect the residents during the abuse investigation, the Director of Nursing and/or Administrator will suspend the involved employee . .the Director of Nursing will inform the state survey, certification, and licensing agencies of .Evidence that all alleged violations are thoroughly investigated, and that further potential abuse has been prevented while the investigation is in progress .The results of all investigations within 5 working days of the incidents, and if the alleged violation is verified, appropriate corrective action was taken . Resident #2 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 07/20/20, documented the resident was moderately impaired in cognitive skills for daily decision making. On 09/09/20 at 4:10 p.m., during an interview related to abuse, resident #1 stated he thought CNA #1 was rough on his roommate (resident #2). He was asked what he meant by rough. He stated he could hear resident #2 make noises each time CNA #1 provided care to him and it sounded like the resident would hit his head on the wall. At 4:45 p.m. an anonomous employee stated CNA #1 was asked for assistance with resident #4 in the past. CNA #1 had stated he could do the transfer by himself. CNA #1 was rough with resident #4 during the transfer. The anonomous employee stated they had reported the situation to staff, but nothing was done. At 4:50 p.m., the DON was asked for the state reportable documentation from 07/20 to current. She provided four state reports. No reports were documented related to allegations of abuse. At 5: 25 p.m. CNA #1 was observed on-duty. He stated no one at the facility had ever spoken to him about employee to resident abuse. At 6:00 p.m., the DON was asked what she did if someone reported an allegation of abuse to her or her staff. She stated they had issues on another shift. She was asked what she meant by issues. She stated the staff had been bickering and accusing each other trying to get each other fired. The DON stated if she received an allegation of abuse she investigated it. She stated if it was accurate she reported it to the state. She was asked what she did if she substantiated abuse. She stated she suspended the alleged perpetrator during an investigation and she terminated them if it was substantiated. The DON was asked when she had started in the DON position. She stated the end of July. She was asked if she had received any allegations of abuse. She stated one of the aides thought CNA #1 had been rough with resident #2. She was asked what she had done related to the allegation. She stated she stood back and observed CNA #1 from a distance and had not observed any concerns. She stated she had asked resident #2 if any staff had been rough with him and the resident stated no. She was asked if she had talked to CNA #1 related to the allegation. She stated, I told him to be sure he is being gentle. The DON was asked if she had interviewed any other residents related to the allegation of abuse. She stated no. The DON was asked how she documented her investigation. She stated she had not documented the investigation. The DON was asked if she had reported the allegation of abuse to anyone. She stated no. She stated she did not see it as abuse because the report was about CNA #1 being rough. She stated the staff who reported the allegation had been complaining about CNA #1 and not wanting to work with him. She stated, They just want to get him fired, I should have documented it. The DON was asked if any residents had complained about CNA #1. She stated resident #1 had reported he thought CNA #1 was rough with resident #2 because he could hear resident #2 when CNA #1 repositioned the resident. She stated she had assessed resident #2 and had not observed any signs of abuse. She was asked when resident #1 had reported the allegation. She stated about an hour after the aide had reported to her, the aide pushed resident #1 into the DON's office and stated, He has something to tell you. She stated she had mentioned it to the administrator. At 6:25 p.m., the administrator was asked what their procedure was if they received an allegation of abuse. She stated the DON checked it out. She stated they would talk to the residents and turn it in. She stated they would suspend the alleged perpetrator during the investigation and if it was substantiated they would terminate the employee. She was asked if she was aware of any allegations of abuse in the last three months. She stated the DON had just notified her of an allegation today which involved resident #2. She was asked if any allegations of abuse had been reported to her before today. She stated, No. She was asked if CNA #1 should have been suspended during the investigation of an allegation of abuse with resident #2. She stated, Yes. She was asked how they documented an allegation of abuse. She stated, On paper and keep it in a file. She was asked if an allegation of abuse was required to be reported to OSDH. She stated, Yes. The administrator was informed the DON had not interviewed other residents during the investigation of the allegation of abuse for resident #2. She was asked how they knew if CNA #1 had abused other residents. She stated, We don't. She was asked if they had continued to allow CNA #1 to provide care to the residents without interviewing the residents related to being abused by CNA #1. She stated, Yes. On 09/10/20 at 9:30 a.m., the DON was asked for their policy and procedure related to abuse. She provided the policy and stated she had not followed their policy in regards to the allegation of abuse which involved CNA #1.

Based on observations, interviews, and record reviews, it was determined the facility failed to obtain accurate weights and intervene for a severe weight loss for one (#75) of four sampled residents reviewed for weight loss. The DON (director of nurses) identified three residents who had experienced a severe weight loss of 7.5 percent or greater in the last 90 days. Findings: A facility policy titled,Weight assessment and intervention, documented: .team will strive to prevent, monitor and intervene for undesirable weight loss for our residents .Weight assessment .nursing staff will measure resident weight on admission, the next day and weekly for 4 (four) weeks .any weight change of 5% (five percent) or more .will be retaken the next day for confirmation .nursing will immediately notify the dietician in writing .threshold for significant .weight loss will be .greater than 5 % is severe .the physician and .team will identify conditions .that may be causing .weight loss . Resident #75 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. According to the physician's orders [REDACTED]. A nutrition assessment, dated 06/11/19, documented the resident weighed 185 pounds. He was on a regular diet with low concentrated sweets (LCS). A Restorative care TAR (treatment administration record), dated 06/11/19, documented an admission weight of 185.20 lbs (pounds). A Restorative care TAR comment, dated 06/18/19, documented a standing weight of 174.10 lbs which indicated the resident had experienced a 11.1 lb/5.9 % weight loss in one week. An admission assessment, dated 06/23/19, documented the resident was severely impaired in cognitive skills for daily decision making but could understand and make needs known. He required supervision of one staff member with eating. He weighed 185 pounds, and was on a therapeutic diet during the seven day look back period. A care plan, dated 06/24/19, documented, .Resident's nutrition .status is at risk r/t (related to) low BMI (body mass index), dx (diagnosed ) on admission with severe protein- calorie malnutrition .weigh monthly and record in chart .monitor/document/report PRN (as needed) .weight loss .serve diet as ordered: Regular LCS .RD (registered dietician) to evaluate and make diet change recommendations . if refused or less than 50% of meal is consumed offer an alternate meal or supplement . A Restorative care TAR, dated 06/25/19, documented a standing weight of 166.10 lbs. The TAR further documented, .1st week down 11 lbs, 2nd week down 8 lbs. Nurse is advised about wt (weight) loss . A TAR, dated 06/11/19 through 06/30/19 was reviewed. It documented the resident refused 11 of 58 meal opportunities and had refused a supplement in lieu of the refused meals. A Nursing TAR entry, dated 07/02/19, documented a weight of 195.75 lbs. The nursing TAR did not document if the resident's weight was obtained standing or seated in a wheelchair. There was no documentation the resident was reweighed to confirm if the 195.75 lb weight was accurate, per their policy. On 07/15/19 at 10:00 a.m., the resident's clinical record was reviewed. The record did not contain any documentation the resident's weight loss, which had trended downward since admission, had been identified and interventions had been developed and implemented to prevent further weight loss. At 2:55 p.m., the resident was lying in bed. The resident was asked if he refused meals. He stated he did not like the food. On 07/16/19 at 7:45 a.m., the resident was observed lying in bed. No meal service tray was at the bedside. The hall tray service cart had been rolled off of the hallway. The resident was asked if he had been offered a meal tray. He stated he had not. At 8:50 a.m., CNA #1 was asked how often did the resident refuse meals. He stated, If the plate is not in front of the resident he will leave the dining room. He refuses every day, but if I take him back to the dining room he will eat something. He was asked if the resident received restorative services. He stated,Restorative weighs the resident. The first week he might have lost weight, but he is maintaining now. At 9:00 a.m., CNA #3 was asked if the resident refused to eat. She stated he did on occasion. She was asked if the resident had any had weight loss. She stated I've not noticed a weight loss. At 11:40 a.m., the DON was asked to review the resident's weights and comment notations on the TAR. She was asked if the resident had experienced a severe weight loss. She stated she was not aware he had any weight loss. She further stated the staff did not follow procedure. They were supposed to notify me when a resident has any weight loss. She was unsure if the resident's weights had been taken sitting or standing with the wheelchair (w/c) weight subtracted. She was unsure if staff had been consistent and accurate when weighing the resident. She acknowledged there were discrepancies with the resident's weights since admission. At 11:45 a.m., LPN #5 provided Nursing TARs, dated (MONTH) and (MONTH) 2019, which documented the resident weight of 200 pounds on 06/18/19, 198 pounds on 06/25/19, and 195 pounds on 07/02/19 and on 07/09/19. No weight was documented for 06/11/19. LPN#5 stated he had not been notified of any weight loss by the restorative aide. LPN #5 was asked to reweigh the resident while standing, without a w/c. At 3:00 p.m., the DON stated they had reweighed the resident. His current weight was 163 pounds standing without a wheelchair. She stated she was not sure if the resident's admission weight was standing or sitting with a wheelchair. She acknowledged the resident had a severe weight loss since his admission to the facility which had not been identified. She confirmed the facility failed to identify interventions to prevent further weight loss.

Based on record reviews and interviews, it was determined the facility failed to ensure: ~ allegations of sexual abuse were investigated or thoroughly investigated for eight (#1, 7, 8, 10, 11, 14, 15, and #16) of 11 sampled residents reviewed with allegations of sexual abuse; ~ investigate an allegation of misappropriation of property for one (#1) of one sampled resident reviewed with an allegation of misappropriation of property; and ~ residents were protected from potential abuse for six (#1, 7, 10, 11, 15 and #16) of 11 sampled residents reviewed with allegations of abuse. The DON (director of nurses) identified 81 residents resided in the facility Findings: A facility policy titled, Definitions, documented: .Sexual abuse includes, but not limited to fondling, exposure of the resident sexual organs, rape, engagement in sexual acts without the resident's informed consent . A facility policy titled, Prevention And Purpsoe (sic), documented: .(Named facility) will take precautionary steps in attempts to intervene prior to suspected abuse happening .(Named facility) will identify, correct and intervene in situation in which abuse, neglect and/or misappropriation of resident property is likely to have occurred .(Named facility) will utilize care plans for residents that have a history of sexual inappropriateness, history of falsifying allegations . A facility policy titled, Abuse Investigation And Reporting, documented: .all reports of abuse .misappropriation of resident property .shall be promptly reported to local, state and federal agencies .and thoroughly investigated by (Named facility) management. Findings of abuse investigation will also be reported . Role of administrator .The administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation .The administrator will ensure that any further potential abuse .is prevented . Role of the investigator .The individual conducting the investigation will, as a minimum .interview the person (s) reporting the incident .Interview any witnesses to the incident .Interview the resident (as medically appropriate) .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident . If the investigation reveals that the allegation (s) of abuse are unfounded, the employee (s) will be reinstated to his/her/their former position with back pay . A facility policy titled, Abuse Investigation Procedure, documented: .The individual conducted the investigation will, as needed, maintain confidentiality of all information, to extent of allowing for a thorough investigation .Interview with the accuser/victim will be conducted and documented .Interviews withy staff members, family members or visitors who had contact with the resident during the last 24 hour period, prior to the time of the reported incident/allegation, if the resident or staff cannot describe or identify who the aggressor was .Interviews with the resident's roommate (if physically/cognitively appropriate) a d (sic, and) documented .Interviews with co-workers to determine if they had witnessed any other incidents that they felt were inappropriate involving the person accused and documented .Interviews with other residents to determine if they have any complaints against the accused and document .While the investigation is being conducted, visitors/family accused of abuse will be denied access to individual/individuals without supervision All documentation and records of the investigation will be kept in report file . A facility policy titled, Protedtion (sic) During The Investigation, documented: .During an abuse investigation, the resident/residents will be protected from harm by the following measures .Employee accused of participating in the alleged abuse of a resident will be suspended until the findings of the investigation have been reviewed by the Administrator .The employee will not be allowed to visit the resident/residents or make contact with them during the suspension .If the alleged abuse involves another resident, the accused resident's representative ad (sic, and) attending physician will be informed of the alleged abuse incident and that the accused individual will not be permitted to make visits to other resident rooms unattended. If necessary, the accused resident's family members may be requires to provide assistance in meeting this requirement . 1. Resident #1 had [DIAGNOSES REDACTED]. A nurse's note, dated [DATE] at 9:30 a.m., documented, .States her husband was here earlier and took money and things from her . A nurse's note, dated [DATE] at 6:00 p.m., documented, .Talks of her things being taken from out of her room, thinks her husband took money . An admission assessment, dated [DATE], documented the resident was severely impaired in cognitive skills for daily decision making. She did not exhibit behaviors. A care plan, dated [DATE] and last updated on [DATE], did not document any problem areas related to resident having a history of sexual allegations or acting out in a sexual manner. A nurse's note, dated [DATE] at 9:45 p.m., documented the resident fell in the front lobby and struck the left side of her head. The physician was notified and emergency services was contacted for transport. A physician's orders [REDACTED]. A nurse's note, dated [DATE] at 11:40 p.m., documented, .(Named registered nurse #1 from the hospital emergency room ) called to give an update on resident. Stated resident had a subdural hematoma on the affected site and that resident will be transferred to (Named hospital, main campus) for further evaluation. Also while attempting to obtain urine for UA (urinalysis) .the nurse observed bleeding ulcer at the end of the vagina. This nurse inguire (sic) from the (Named registered nurse #1) if the resident sustained [REDACTED]. The (Named registered nurse #1) stated 'No', resident is observed to have had the bleeding that it was seen while she is being cleaned up at start of the procedure. Nurse on duty notified (signed licensed practical nurse #1). This nurse's note documented the first time the facility was notified of a suspicious finding during a procedure which indicated possible abuse may have occurred. A hospital nurse's note, dated [DATE] at 11:41 p.m., documented, Report called to (Named facility) to advise nursing sataff (sic) that pt (patient) will be transferred to (Named hospital, main campus) for further TX (treatment). Also included information regarding (sic, regarding) [MEDICATION NAME] (sic) ulcer for follow up Tx when she returns to the facility . A hospital nurse's note, dated [DATE] at 7:19 a.m., documented, .Received report and assumed care .UA attempted with straight cath (catheter) with (Named RN (registered nurse) #2), red inflammed (sic), bleeding and swollen with tear at the bottom of the vaginal oriface (sic). Grimaced and cried with attempt .(signed RN #3). A hospital nurse's note, dated [DATE] at 7:27 a.m., documented, .This nurse assisted with an attempt to straight cath patient with (Named RN #3). Patient very sore, raw in peri area, and a tear was noted to vaginal opening Unable to straight cath patient d/t (due to) c/o (complaint of) pain .(signed RN #2). A hospital gynecology consult report, dated [DATE] at 10:36 a.m., documented, .Chief complaint .vaginal laceration .History of present illness .Her RN was attempting to place a Foley to obtain a UA when she noticed a vaginal laceration with bleeding present. The patient denies any trauma or pain at the location of the laceration. She is postmenopausal and does report using soap/moisturizers on the area at home, no hx (history) of vaginal [MEDICATION NAME] use. She denies noticing any lesion or injury prior to admission . Past medical history .Dementia .Depression/anxiety .Pt states she has 5 children, previous records report 3 children . GU ([MEDICAL CONDITION]) Vagina markedly atrophic (inflammation of the vagina due to thinning and shrinking of the tissues) 0.5 cm (centimeters) at posterior fourchette, no bleeding or purulence . Recommendations/Plan .superficial laceration at perineum, no longer bleeding at time of gyn (gynecology) exam .likely due to minor trauma related to vaginal atrophy . A local police report, dated [DATE], documented the description of the incident under investigation was rape. A rape kit was obtained on [DATE]. The local police report, dated [DATE], documented, .On [DATE] at (11:30 a.m.) I spoke with (Named DON) .in reference to a possible rape. (Named DON) told me .on [DATE] at (9:45 p.m.) one of her residents (Named resident) fell in the front lobby and struck her head .her staff .called for an Ambulance .(Named resident) was transported to (Named hospital) and at (10:05 p.m.) the staff of (Named hospital) was notified that there was a bleeding ulcer at the end of (Named resident's) vagina that was noticed when they were cleaning her and preparing for her a Catheter. (Named resident) was transported .to (hospital, main campus) and their staff notified the staff of (Named hospital) that (Named resident's) vagina was red, swollen, and bleeding. (Named DON) said one of her employees is watching the video to try and determine if anyone was in (Named resident's) room before her fall and looking for any suspicious activity. (Named DON) said (Named resident) suffers from Alzheimer's and lives in the past and does not comprehend anything that is going on currently and (Named resident) female roommate has severe Dementia and is confined to a geriatric chair .I spoke with (Named resident's family member) and she said she has Power of Attorney over (Named resident) and she has requested a Rape Exam be done on (Named resident) while she is at (Named hospital, main campus) and will let us known if one is done . The local police department report documented the second time the facility was notified of an incident of potential sexual abuse was on [DATE] at 11:30 a.m. A facsimile transmission report, dated [DATE] at 2:41 p.m., documented an incident report was transmitted to the OSDH (Oklahoma State Department of Health). The report documented the incident date was [DATE]. The incident type was documented as Certain Injuries. This was over three hours from the time the second notification of an allegation of sexual abuse was made known to the facility. The description of the incident was documented as follows: Received call from (Named hospital, main campus) from nurse. Reported to this nurse that upon (Named resident's) arrival to the ER (emergency room ) on [DATE] it was noted that her peri-area was red, swollen and bleeding .She reported that upon attempting to In-Out catheterization (Named resident) it was noted that (Named resident) was res (sic, red) inflamed (sic), bleeding and swollen with a tear at the bottom of the vaginal oriface (sic). Stated it was painful. This nurse answered all questions to the best of this nurse ability. Asked if raped test had been done and was informed no but that she would speak with their team .All residents are being interviewed as well as staff. Video cameras are being reviewed at this time . A nurse's note, dated [DATE] at 6:00 p.m., documented the resident was readmitted to the nursing facility. A facsimile report, dated [DATE] at 12:22 p.m., documented a request for additional information from the OSDH. The report documented, Incident of allegation of physical/sexual abuse of (Named resident) nurse from (Named hospital) called facility advising there is evidence of possible physical/sexual abuse of Resident. Please submit documentation of corrective (and) protective measures: including investigative details and final determinations . A facsimile report, dated [DATE] at 11:00 a.m., documented the final incident report was submitted to the OSDH for the allegation of abuse for the resident. The report documented the incident occurred on [DATE]. The reported incident was marked as certain injuries instead of allegations of abuse/mistreatment. The report documented, in the section marked for five day and final reports, the following information: An investigation was initiated and the local police had been notified. All residents and staff were being interviewed. The camera was being viewed. The report documented the video showed the resident was not observed in her room with a male. When the resident had been incontinent a female staff member took her to her room and provided care. The video was only observed from the morning of [DATE] to the time the resident left for the hospital. The report included the gynecology consult findings from the hospital and her recommendations. The reported documented, (Named facility) investigation did not indicate injury occurred at the facility. (Named resident) was not alone with a male. She cleans herself in the bathroom when incontinent, not wanting staff to touch her. She was observed the morning of the alleged incident when gotten up by female CNA (certified nurse assistant). She had used the toilet and had wiped herself and CNAA (sic) reported that she not notice anything left on her paper after wiping nor on her brief .Video did not show her being alone with male CNA ad (sic, and) only briefly, couple of minutes with female. She was observed ambulating normally except during periods when brief was wet. Female CNA took her to her room and bathroom to be changed. She was sitting and standing in her normal manner. Staff has been instructed that male CNAs need to have female CNA with them when provide care to female residents. Only female CNAs are to attend to (Named resident) . The report further documented the facility was notified of the incident on [DATE] at approximately 10:45 a.m. Eleven residents were interviewed during the investigation and asked, Has anyone touched you inappropriately or have you seen anyone touching anyone inappropriately. The interview responses were included in the five day/final report. Nine residents interviewed reported they had been touched inappropriately or had observed another resident touch resident(s) inappropriately. Only one of the nine was reported to OSDH and had an investigation completed. There was no documentation for the remaining eight residents' allegations. The following two staff statements were attached to the five day/final OSDH report: A statement report, dated [DATE] at 11:00 a.m., documented, .I worked ,[DATE] (6:00 a.m. to 2:00 p.m.). I got the resident up while changing her I didn't see any type of bleeding from her private area. (Signed CNA #1). CNA #1 worked the 6:00 a.m. to 2:00 p.m. shift on [DATE]. A statement report, dated [DATE] at 11:00 a.m., documented, On taking over the shift, the above named resident observed ambulating without any sign of pain or distress .She was holding her stuffed animal with her and talking about her going to her parents to help them; and this is her normal way she converse. She ate dinner in the big dining without any problem. After dinner she came to sit in the small dining watching TV (television) with the rest of the resident. After while she got up and she was moving around without any distress and did not voice any pain complaints. She was assisted as per hygiene and still with her stuffed animal with her up to the time of her fall. There was no changes in her movement nor mental status. (signed LPN #1). LPN #1 worked the 2:00 p.m. to 10:00 p.m. shift on [DATE]. On [DATE] at 3:17 p.m., CNA #2, who worked the 6:00 a.m. to 2:00 p.m. shift on [DATE], was asked if she had ever provided peri care for the resident. She stated she had. She was asked if she had ever observed the resident's peri area to be red, swollen, inflamed or bleeding. She stated she had not. At 3:24 p.m., CNAs #3, #4, and #5 were asked if they had provided peri care for the resident. They all stated they had. They were asked if they had ever observed the resident's peri area to be red, swollen, inflamed or bleeding. All stated they had not. At 3:50 p.m., the DON was asked what her findings had been for the investigation she conducted related to the allegation of possible sexual abuse for the resident. She said, No one did it cause the video was watched from the time she fell until the am (morning). She stated the nurse at the acute care hospital emergency room stated the vaginal injury was fresh because there was fresh bleeding. She stated the video was watched and the resident was observed up and down and moving about the facility. She stated she had her usual gait unless she was in need of incontinent care. She stated she was then transferred to her room by a female CNA and care was provided. She further stated she based most of her findings on reading the hospital reports which included the gynecology consult report. She stated the gynecology report documented she had a minor trauma to her vagina due to vaginal atrophy. She was asked if she had consulted with the gynecologist or other hospital staff regarding what could have caused the minor vaginal trauma. She said, No. She then stated the first nurse at the hospital emergency room stated the resident had a small vaginal ulcer and then the second hospital staff member stated she had a vaginal laceration. On [DATE] at 9:56 a.m., the DON was shown the nurse's notes from [DATE] when the resident alleged her husband took money and other items from her room. She reviewed the OSDH incident reports for the resident and was unable to locate a completed report and investigation for the allegation of misappropriation of the resident's property. She said, I wasn't doing them then. I wasn't aware of it. She was then asked if this should have been investigated. She said, Yes ma'am. She was then asked to review the initial and five day/final report for the OSDH incident report dated [DATE] for the allegation of abuse. She was asked if the incident report was submitted for the correct type of incident since it was marked as certain injuries. She stated she probably should have marked certain injuries and abuse. She was then asked why she only interviewed one staff member from the day shift and one from the evening shift on [DATE]. She was asked if she had only conducted the two interviews with staff during her investigation. She said, I did interview others probably, but it's not documented. She acknowledged the two documented interviews did not indicate a thorough investigation was conducted. She was then asked if she had considered the possibility of a female perpetrator in the allegation of sexual abuse for the resident. She stated she had not. She further stated she did not suspend any staff members during the investigation. 2. Resident #7 had [DIAGNOSES REDACTED]. A quarterly assessment, dated [DATE], documented the resident was severely cognitively impaired for daily decision making skills. An OSDH final incident report, submitted on [DATE], documented the incident date was [DATE]. The incident report documented the resident involved was resident #1. The description of the incident included information related to an allegation of sexual abuse for resident #1. The investigation included an interview with resident #7. The resident was asked if anyone had touched her inappropriately. She said, Yes, a white male (Named male). It happened recently not sure when. A facility investigation of the allegation, undated, documented, .(Named resident) has Dementia and is confused and disoriented most of the time. She can be oriented to person and place at times. She is known to response to questions at times, how she believes you want her to response. We have not had an employee by the name of (Named male) On [DATE] at 3:50 p.m., the DON was asked if the resident's allegation had been investigated including staff and resident interviews and an assessment of the resident. She stated there was no employee working in the facility by the name the resident provided and she's confused. She was asked if she required the exact name of a staff member employed at the facility in order to conduct an investigation for allegations of abuse. She said, No. An OSDH incident report, dated [DATE], documented the report was a combined initial and final report. The incident date was documented as [DATE]. The incident type was identified as allegations of abuse/mistreatment. The incident report included the resident's interview results obtained during the investigation of resident #1's allegation of abuse. The incident report documented the following investigation, .(Named resident) could not give any other information when this nurse visited with her. (Named facility) has not had any white males working for them, let alone one name (Named male). (Named psychiatric services) was notified . 3. Resident #8 had [DIAGNOSES REDACTED]. An annual assessment, dated [DATE], documented the resident was cognitively intact for daily decision making skills. She experienced fluctuating disorganized thinking with no documented behaviors. An OSDH final incident report, submitted on [DATE], documented the incident date was [DATE]. The incident report documented the resident involved was resident #1. The description of the incident included information related to an allegation of sexual abuse for resident #1. The investigation included an interview with resident #8 which stated, Yes, (Named resident #14) has tried to touch my private parts several times since I've been here. The investigation further documented this was the first time that this had been reported by the resident since her admission. When she was questioned again she stated, Well he has come up to me and he has come in my room. She was asked if he had actually touched her and she stated he had not, but she thought he had wanted to. A facility investigation of the allegation, undated, documented, .(Named resident) has visual and auditory Hallucinations. She does require redirection sometimes due to the hallucinations She was unable to give any more details. She stated that he tried to touch her but had not . On [DATE] at 3:50 p.m., the DON was asked if the resident's allegation had been investigated including staff and resident interviews and an assessment of the resident. She stated they had placed a red chain across the door as a barrier but no investigation had been completed. An OSDH incident report, dated [DATE], documented the report was a combined initial and final report. The incident date was documented as [DATE]. The incident type was identified as allegations of abuse/mistreatment. The description of the incident included the resident's interview alleging that resident #14 had tried to touch her private areas several times. The investigation of the allegation documented the resident had never mentioned this before this time and she was informed she should have mentioned it before so we could have stopped him. A chain was painted red and placed in the resident's doorway with a sign saying STOP in both English and Spanish to discourage the alleged perpetrator from wandering in. 4. Resident #10 had [DIAGNOSES REDACTED]. An OSDH final incident report, submitted on [DATE], documented the incident date was [DATE]. The incident report documented the resident involved was resident #1. The description of the incident included information related to an allegation of sexual abuse for resident #1. The investigation included a resident interview with resident #10. The resident was asked if any one had touched her inappropriately. She stated, Yes, one time (Named male) did. The report further documented, No one by that name (Named male) has worked at (Named facility). (Named resident) is known to hallucinate and be delusional. A facility investigation of the allegation, undated, documented, .(Named resident) lives in her own world most of the time. She gets fixated on things that staff has no idea where it can (came) from. Have no idea where the name (Named male) came from. No one knows of anyone ever working here by that name . On [DATE] at 3:50 p.m., the DON was asked if the resident's allegation had been investigated including staff and resident interviews and an assessment of the resident. She stated the resident was confused. She stated she did not know the person the resident had named. She stated she did not suspend staff because there was no one by that name working in the facility or residing in the facility. An OSDH incident report, dated [DATE], documented the report was a combined initial and final report. The incident date was documented as [DATE]. The incident type was an allegation of abuse. The report included the resident's interview results obtained when resident #1's abuse allegation was investigated. The investigation of the allegation submitted to the OSDH documented there was no one by the name the resident had provided at the facility and the resident was unable to provide additional information. 5. Resident #11 had [DIAGNOSES REDACTED]. A care plan, dated [DATE] and last updated on [DATE], documented the resident had impaired visual function due to [MEDICATION NAME] degeneration. She had a history of [REDACTED]. A quarterly assessment, dated [DATE], documented the resident was moderately impaired in cognitive skills for daily decision making. She did not exhibit behaviors. An OSDH final incident report, submitted on [DATE], documented the incident date was [DATE]. The incident report documented the resident involved was resident #1. The description of the incident included information related to an allegation of sexual abuse for resident #1. The investigation included a resident interview with resident #11. The resident was asked if any one had touched her inappropriately. She stated, Yes, about 1 (to) 2 months ago someone came in my room at night and had a sling shot with cheese and put it in my vagina. I don't know who, I was asleep. The report further documented, (Named resident) has [MEDICAL CONDITION] and is known to be delusional. This was the first time anything had been reported of this nature. A facility investigation of the allegation, undated, documented, .(Named resident) lives in her own little world. She has been fixated on religion for some time. She does her own things. Her stories are not usually real has stated her husband has visited her and he is deceased . Her family is highly involved and visits frequently and takes her out often. On [DATE] at 3:50 p.m., the DON was asked if the resident's allegation had been investigated including staff and resident interviews and an assessment of the resident. She said, Well, I didn't know how to go further. An OSDH incident report, dated [DATE], documented the report was a combined initial and final report. The incident date was documented as [DATE]. The incident type was identified as allegations of abuse/mistreatment. The incident report included the resident's interview results obtained when resident #1's abuse allegation was investigated. The incident report documented the following investigation, (Named resident) was unable to provide any other information, stating 'I was asleep, I don't know what they looked like or what time it was.' .(Named psych physician assistant) notified. Son .was notified today [DATE] at 11:25 AM and stated 'Oh my God, I hope you didn't investigate that one.' This nurse explained that all allegations have to be investigated and turned in to the State of Oklahoma and contacts notified . At 9:26 a.m., the administrator was shown the combined initial/final report for the resident which the DON had submitted as a completed investigation. She stated each allegation must be treated seriously. She stated the investigation was not thorough. 6. Resident #14 had [DIAGNOSES REDACTED]. A care plan, dated [DATE], documented the resident needed supervision and or assistance with decision making related to poor impulse control and decreased safety awareness. The care plan documented intervene as necessary to protect the rights and safety of others. Redirect off hall 300 if wandering/pacing in that direction. The care plan documented the resident exhibited atypical sexual behaviors. A quarterly assessment, dated [DATE], documented the resident was severely impaired in cognitive skills for daily decision making. He did not exhibit any behaviors. He required supervision with ambulation and utilized a walker and/or wheelchair. An OSDH final incident report, submitted on [DATE], documented the incident date was [DATE]. The incident report documented the resident involved was resident #1. The description of the incident included information related to an allegation of sexual abuse for resident #1. The investigation included a resident interview with residents #21 and #22. The residents were asked if any one had touched them inappropriately of if they had observed anyone touching anyone inappropriately. Resident #21 stated, Yes, I saw another resident (Named resident #14) kiss (Named resident #15) and touch her breast. It's happened a couple of times. (Named resident #15) was kissing (Named resident #14) back. Resident #22 stated, Yes, I saw same thing (Named resident #21) saw with the same resident. A facility investigation of the allegation, undated, documented, .(Named resident #14) has been seen kissing (named resident #15) and (Named resident #15) was allowing. They had been separated and staff kept them separated. Staff was instructed and it was care planned to redirect (Named resident #14) away from hall 300 (the hall resident #15 resides on). (Named resident #15) does have dementia and is disoriented. No one had seem (sic) him touching her breast. This occurred probably 6 months to a year ago . (Named resident #14) has a history of wandering into others room. He especially wandered into 315 due to having been assigned that room in the past. Staff was instructed and it was care planned for them to redirect him away from hall 300 when he would start wandering in that direction. His wandering into other rooms has been decreasing in frequency. Part of the difficulty with (Named resident #14) is the fact he does not speak English. A nurse's note, dated [DATE], documented, Resident was observed yelling in Spanish and grabbing a female resident. Female resident was observed trying to move away from him but he wouldn't let her. Nurse removed female and assisted her to room. Resident was seen trying to follow and enter her room. Assisted resident to his room where he became combative. Yelling and attempting to leave room . On [DATE] at 10:23 a.m., residents #21 and #22 were interviewed in their room. They reported (Named resident #14) wandered the halls at night and

Based on record reviews and interviews, it was determined the facility failed to implement their abuse policy for: ~ allegations of sexual abuse for eight (#1, 7, 8, 10, 11,14, 15, and 16) of 11 sampled residents reviewed with allegations of abuse. This included the failure to; report/report timely any allegations of abuse, investigate or thoroughly investigate allegations of abuse and protect residents from further abuse; and ~ an allegation of misappropriation of property for one (#1) of one sampled resident reviewed with an allegation of misappropriation of property. The DON (director of nurses) identified 81 residents resided in the facility. Findings: A facility policy titled, Reporting And Responses To Alleged Abuse, documented: (Named facility) will ensure that all alleged violations involving any form of abuse .misappropriation of resident's property .if the events that cause the allegation involved abuse or result in serious bodily injury the allegation will be reported within 2 hours .Completion of the investigation will be sent to appropriate reporting agencies, within 5 working days of the incident, with the findings of the investigation .In the event that the investigation is still in progress on the 5th day, an addendum will be sent to the reporting agencies as necessary to inform them of the continued investigation . A facility policy titled, Definitions, documented: .Sexual abuse includes, but not limited to fondling, exposure of the resident sexual organs, rape, engagement in sexual acts without the resident's informed consent . A facility policy titled, Prevention And Purpsoe (sic), documented: .(Named facility) will take precautionary steps in attempts to intervene prior to suspected abuse happening .(Named facility) will identify, correct and intervene in situation in which abuse, neglect and/or misappropriation of resident property is likely to have occurred .(Named facility) will utilize care plans for residents that have a history of sexual inappropriateness, history of falsifying allegations . A facility policy titled, Abuse Investigation And Reporting, documented: .all reports of abuse .misappropriation of resident property .shall be promptly reported to local, state and federal agencies .and thoroughly investigated by (Named facility) management. Findings of abuse investigation will also be reported . Role of administrator .The administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation .The administrator will ensure that any further potential abuse .is prevented . Role of the investigator .The individual conducting the investigation will, as a minimum .interview the person (s) reporting the incident .Interview any witnesses to the incident .Interview the resident (as medically appropriate) .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident . If the investigation reveals that the allegation (s) of abuse are unfounded, the employee (s) will be reinstated to his/her/their former position . A facility policy titled, Abuse Investigation Procedure, documented: .The individual conducted the investigation will, as needed, maintain confidentiality of all information, to extent of allowing for a thorough investigation .Interview with the accuser/victim will be conducted and documented .Interviews with staff members, family members or visitors who had contact with the resident during the last 24 hour period, prior to the time of the reported incident/allegation, if the resident or staff cannot describe or identify who the aggressor was .Interviews with the resident's roommate (if physically/cognitively appropriate) a d (sic, and) documented .Interviews with co-workers to determine if they had witnessed any other incidents that they felt were inappropriate involving the person accused and documented .Interviews with other residents to determine if they have any complaints against the accused and document .While the investigation is being conducted, visitors/family accused of abuse will be denied access to individual/individuals without supervision All documentation and records of the investigation will be kept in report file . 1. Resident #1 had [DIAGNOSES REDACTED]. A nurse's note, dated [DATE] at 9:30 a.m., documented, .States her husband was here earlier and took money and things from her . A nurse's note, dated [DATE] at 6:00 p.m., documented, .Talks of her things being taken from out of her room, thinks her husband took money . An admission assessment, dated [DATE], documented the resident was severely impaired in cognitive skills for daily decision making. She did not exhibit behaviors. A care plan, dated [DATE] and last updated on [DATE], did not document any problem areas related to resident having a history of sexual allegations or acting out in a sexual manner. A nurse's note, dated [DATE] at 9:45 p.m., documented the resident fell in the front lobby and struck the left side of her head. The physician was notified and emergency services was contacted for transport. A physician's orders [REDACTED]. A nurse's note, dated [DATE] at 11:40 p.m., documented, .(Named registered nurse #1 from the hospital emergency room ) called to give an update on resident. Stated resident had a subdural hematoma on the affected site and that resident will be transferred to (Named hospital, main campus) for further evaluation. Also while attempting to obtain urine for UA (urinalysis) .the nurse observed bleeding ulcer at the end of the vagina. This nurse inguire (sic) from the (Named registered nurse #1) if the resident sustained [REDACTED]. The (Named registered nurse #1) stated 'No', resident is observed to have had the bleeding that it was seen while she is being cleaned up at start of the procedure. Nurse on duty notified (signed licensed practical nurse #1). This nurse's note documented the first time the facility was notified of a suspicious finding during a procedure which indicated possible abuse may have occurred. A hospital nurse's note, dated [DATE] at 11:41 p.m., documented, Report called to (Named facility) to advise nursing sataff (sic) that pt (patient) will be transferred to (Named hospital, main campus) for further TX (treatment). Also included information regarding (sic, regarding) [MEDICATION NAME] (sic) ulcer for follow up Tx when she returns to the facility . A hospital nurse's note, dated [DATE] at 7:19 a.m., documented, .Received report and assumed care .UA attempted with straight cath (catheter) with (Named RN (registered nurse) #2), red inflammed (sic), bleeding and swollen with tear at the bottom of the vaginal oriface (sic). Grimaced and cried with attempt .(signed RN #3). A hospital nurse's note, dated [DATE] at 7:27 a.m., documented, .This nurse assisted with an attempt to straight cath patient with (Named RN #3). Patient very sore, raw in peri area, and a tear was noted to vaginal opening Unable to straight cath patient d/t (due to) c/o (complaint of) pain .(signed RN #2). A hospital gynecology consult report, dated [DATE] at 10:36 a.m., documented, .Chief complaint .vaginal laceration .History of present illness .Her RN was attempting to place a Foley to obtain a UA when she noticed a vaginal laceration with bleeding present. The patient denies any trauma or pain at the location of the laceration. She is postmenopausal and does report using soap/moisturizers on the area at home, no hx (history) of vaginal [MEDICATION NAME] use. She denies noticing any lesion or injury prior to admission . Past medical history .Dementia .Depression/anxiety .Pt states she has 5 children, previous records report 3 children . GU ([MEDICAL CONDITION]) Vagina markedly atrophic (inflammation of the vagina due to thinning and shrinking of the tissues) 0.5 cm (centimeters) at posterior fourchette, no bleeding or purulence . Recommendations/Plan .superficial laceration at perineum, no longer bleeding at time of gyn (gynecology) exam .likely due to minor trauma related to vaginal atrophy . A local police report, dated [DATE], documented the description of the incident under investigation was rape. A rape kit was obtained on [DATE]. The local police report, dated [DATE], documented, .On [DATE] at (11:30 a.m.) I spoke with (Named DON) .in reference to a possible rape. (Named DON) told me .on [DATE] at (9:45 p.m.) one of her residents (Named resident) fell in the front lobby and struck her head .her staff .called for an Ambulance .(Named resident) was transported to (Named hospital) and at (10:05 p.m.) the staff of (Named hospital) was notified that there was a bleeding ulcer at the end of (Named resident's) vagina that was noticed when they were cleaning her and preparing for her a Catheter. (Named resident) was transported .to (Named hospital, main campus) and their staff notified the staff of (Named hospital) that (Named resident's) vagina was red, swollen, and bleeding. (Named DON) said one of her employees is watching the video to try and determine if anyone was in (Named resident's) room before her fall and looking for any suspicious activity. (Named DON) said (Named resident) suffers from Alzheimer's and lives in the past and does not comprehend anything that is going on currently and (Named resident) female roommate has severe Dementia and is confined to a geriatric chair .I spoke with (Named resident's family member) and she said she has Power of Attorney over (Named resident) and she has requested a Rape Exam be done on (Named resident) while she is at (Named hospital, main campus) and will let us known if one is done . The local police department report documented the second time the facility was notified of an incident of potential sexual abuse was on [DATE] at 11:30 a.m. A facsimile transmission report, dated [DATE] at 2:41 p.m., documented an incident report was transmitted to the OSDH (Oklahoma State Department of Health). This was over three hours from the time the second notification of an allegation of sexual abuse was made known to the facility. The report documented the incident date was [DATE]. The incident type was documented as Certain Injuries. The description of the incident was documented as follows: Received call from (Named hospital, main campus) from nurse. Reported to this nurse that upon (Named resident's) arrival to the ER (emergency room ) on [DATE] it was noted that her peri-area was red, swollen and bleeding .She reported that upon attempting to In-Out catheterization (Named resident) it was noted that (Named resident) was res (sic, red) inflamed (sic), bleeding and swollen with a tear at the bottom of the vaginal oriface (sic). Stated it was painful. This nurse answered all questions to the best of this nurse ability. Asked if raped test had been done and was informed no but that she would speak with their team .All residents are being interviewed as well as staff. Video cameras are being reviewed at this time . A nurse's note, dated [DATE] at 6:00 p.m., documented the resident was readmitted to the nursing facility. A facsimile report, dated [DATE] at 12:22 p.m., documented a request for additional information from OSDH. The report documented, Incident of allegation of physical/sexual abuse of (Named resident) nurse from (Named hospital) called facility advising there is evidence of possible physical/sexual abuse of Resident. Please submit documentation of corrective (and) protective measures: including investigative details and final determinations . A facsimile report, dated [DATE] at 11:00 a.m., documented the final incident report was submitted to the OSDH for the allegation of abuse for the resident. The report documented the incident occurred on [DATE]. The reported incident was marked as certain injuries instead of allegations of abuse/mistreatment. The report documented, in the section marked for five day and final reports, the following information: An investigation was initiated and the local police had been notified. All residents and staff were being interviewed. The camera was being viewed. The report documented the video showed the resident was not observed in her room with a male. When the resident had been incontinent a female staff member took her to her room and provided care. The video was only observed from the morning of [DATE] to the time the resident left for the hospital. The report included the gynecology consult findings from the hospital and her recommendations. The report documented, (Named facility) investigation did not indicate injury occurred at the facility. (Named resident) was not alone with a male. She cleans herself in the bathroom when incontinent, not wanting staff to touch her. She was observed the morning of the alleged incident when gotten up by female CNA (certified nurse assistant). She had used the toilet and had wiped herself and CNAA (sic) reported that she did not notice anything left on her paper after wiping nor on her brief .Video did not show her being alone with male CNA ad (sic, and) only briefly, couple of minutes with female. She was observed ambulating normally except during periods when brief was wet. Female CNA took her to her room and bathroom to be changed. She was sitting and standing in her normal manner. Staff has been instructed that male CNAs need to have female CNA with them when provide care to female residents. Only female CNAs are to attend to (Named resident) . The report further documented the facility was notified of the incident on [DATE] at approximately 10:45 a.m. Eleven residents were interviewed during the investigation and asked, Has anyone touched you inappropriately or have you seen anyone touching anyone inappropriately. The interview responses were included in the five day/final report. Nine residents interviewed reported they had been touched inappropriately or had observed another resident touch resident(s) inappropriately. Only one of the nine was reported to OSDH and had an investigation completed. There was no documentation for the remaining eight residents' allegations. The following two staff statements were attached to the five day/final OSDH report: A statement report, dated [DATE] at 11:00 a.m., documented, .I worked ,[DATE] (6:00 a.m. to 2:00 p.m.). I got the resident up while changing her I didn't see any type of bleeding from her private area. (Signed CNA #1). CNA #1 worked the 6:00 a.m. to 2:00 p.m. shift on [DATE]. A statement report, dated [DATE] at 11:00 a.m., documented, On taking over the shift, the above named resident observed ambulating without any sign of pain or distress .After dinner she came to sit in the small dining watching TV (television) with the rest of the resident. After while she got up and she was moving around without any distress and did not voice any pain complaints. She was assisted as per hygiene and still with her stuffed animal with her up to the time of her fall. There was no changes in her movement nor mental status. (signed LPN #1). LPN #1 worked the 2:00 p.m. to 10:00 p.m. shift on [DATE]. On [DATE] at 3:17 p.m., CNA #2, who worked the 6:00 a.m. to 2:00 p.m. shift on [DATE], was asked if she had ever provided peri (perineum) care for the resident. She stated she had. She was asked if she had ever observed the resident's peri area to be red, swollen, inflamed, or bleeding. She stated she had not. At 3:24 p.m., CNAs #3, #4, and #5 were asked if they had provided peri care for the resident. They all stated they had. They were asked if they had ever observed the resident's peri area to be red, swollen, inflamed, or bleeding. All stated they had not. At 3:50 p.m., the DON was asked what her findings had been for the investigation she conducted related to the allegation of possible sexual abuse for the resident. She said, No one did it cause the video was watched from the time she fell until the am (morning). She stated the nurse at the acute care hospital emergency room stated the vaginal injury was fresh because of fresh bleeding. She stated the video was watched and the resident was observed up and down and moving about the facility. She stated she had her usual gait unless she was in need of incontinent care. She stated she was then transferred to her room by a female and care was provided. She further stated she based most of her findings on reading the hospital reports which included the gynecology consult report. She stated the gynecology report documented she had a minor trauma to her vagina due to vaginal atrophy. She was asked if she had consulted with the gynecologist or other hospital staff regarding what could have caused the minor vaginal trauma. She said, No. She then stated the first nurse at the hospital emergency room stated the resident had a small vaginal ulcer and then the second hospital staff member stated she had a vaginal laceration. On [DATE] at 9:56 a.m., the DON was shown the nurses' notes from [DATE] when the resident alleged her husband took money and other items from her room. She reviewed the OSDH incident reports for the resident and was unable to locate a completed report and investigation for the allegation of misappropriation of the resident's property. She said, I wasn't doing them then. I wasn't aware of it. She was then asked if this should have been reported and investigated. She said, Yes ma'am. She was asked to review the initial and five day/final report for the OSDH incident reports dated [DATE] for allegations of abuse. She was asked if the incident report was submitted for the correct type of incident since it was marked as certain injuries. She stated she probably should have marked certain injuries and abuse. She was then asked why she only interviewed one staff member from the day shift and one from the evening shift on [DATE]. She was asked if she had only conducted the two interviews with staff during her investigation. She said, I did interview others probably, but it's not documented. She acknowledged the two documented interviews did not indicate a thorough investigation was conducted and the facility policy was not followed. She was then asked if she had considered the possibility of a female perpetrator in the allegation of sexual abuse for the resident. She stated she had not. She further stated she did not suspend any staff during the investigation. 2. Resident #7 had [DIAGNOSES REDACTED]. A quarterly assessment, dated [DATE], documented the resident was severely cognitively impaired for daily decision making skills. An OSDH final incident report, submitted on [DATE], documented the incident date was [DATE]. The incident report documented the resident involved was resident #1. The description of the incident included information related to an allegation of sexual abuse for resident #1. The investigation included an interview with resident #7. The resident was asked if any one had touched her inappropriately. She said, Yes, a white male (Named male). It happened recently not sure when. A facility investigation of the allegation, undated, documented, .(Named resident) has Dementia and is confused and disoriented most of the time. She can be oriented to person and place at times. She is known to response to questions at times, how she believes you want her to response. We have not had an employee by the name of (Named male) On [DATE] at 3:50 p.m., the DON was asked if the resident's allegation had been investigated including staff and resident interviews and an assessment of the resident. She stated there was no employee working in the facility by the name the resident provided and she's confused. She was asked if she required the exact name of a staff member employed at the facility in order to conduct an investigation for allegations of abuse. She said, No. An OSDH incident report, dated [DATE], documented the report was a combined initial and final report. The incident date was documented as [DATE]. The incident type was identified as allegations of abuse/mistreatment. The incident report included the resident's interview results obtained when resident #1's allegation of abuse was investigated. The incident report documented the following investigation, .(Named resident) could not give any other information when this nurse visited with her. (Named facility) has not had any white males working for them, let alone one name (Named provided). (Named psychiatric services) was notified . 3. Resident #8 had [DIAGNOSES REDACTED]. A annual assessment, dated [DATE], documented the resident was cognitively intact for daily decision making skills. She experienced fluctuating disorganized thinking with no documented behaviors. An OSDH final incident report, submitted on [DATE], documented the incident date was [DATE]. The incident report documented the resident involved was resident #1. The description of the incident included information related to an allegation of sexual abuse for resident #1. The investigation included an interview with resident #8 which stated, Yes, (Named resident #14) has tried to touch my private parts several times since I've been here. The investigation further documented this was the first time that this had been reported by the resident since her admission. When she was questioned again she stated, Well he has come up to me and he has come in my room. She was asked if he had actually touched her and she stated he had not, but she thought he had wanted to. A facility investigation of the allegation, undated, documented, .(Named resident) has visual and auditory Hallucinations. She does require redirection sometimes due to the hallucinations She was unable to give any more details. She stated that he tried to touch her but had not . On [DATE] at 3:50 p.m., the DON was asked if the resident's allegation had been investigated including staff and resident interviews and an assessment of the resident. She stated they had placed a red chain across the door as a barrier but no investigation had been completed. An OSDH incident report, dated [DATE], documented the report was a combined initial and final report. The incident date was documented as [DATE]. The incident type was identified as allegations of abuse/mistreatment. The description of the incident included the resident's interview alleging that resident #14 had tried to touch her private areas several times. The investigation of the allegation documented the resident had never mentioned this before this time and she was informed she should have mentioned it before so we could have stopped him. A chain was painted red and placed in the resident's doorway with a sign saying STOP in both English and Spanish to discourage the alleged perpetrator from wandering in. 4. Resident #10 had [DIAGNOSES REDACTED]. An OSDH final incident report, submitted on [DATE], documented the incident date was [DATE]. The incident report documented the resident involved was resident #1. The description of the incident included information related to an allegation of sexual abuse for resident #1. The investigation included a resident interview with resident #11. The resident was asked if any one had touched her inappropriately. She stated, Yes, one time (Named male) did. The report further documented, No one by that name (Named male) has worked at (Named facility). (Named resident) is known to hallucinate and be delusional. A facility investigation of the allegation, undated, documented, .(Named resident) lives in her own world most of the time. She gets fixated on things that staff has no idea where it can (came) from. Have no idea where the name (Named male) came from. No one knows of anyone ever working here by that name . On [DATE] at 3:50 p.m., the DON was asked if the resident's allegation had been investigated including staff and resident interviews and an assessment of the resident. She stated the resident was confused. She stated she did not know the person the resident had named. She stated she did not suspend staff because there was no one by that name working in the facility or residing in the facility. An OSDH incident report, dated [DATE], documented the report was a combined initial and final report. The incident date was documented as [DATE]. The incident type was an allegation of abuse. The report included the resident's interview results obtained when resident #1's abuse allegation was investigated. The investigation of the allegation submitted to the OSDH documented there was no one by the name the resident had provided at the facility and the resident was unable to provide additional information. 5. Resident #11 had [DIAGNOSES REDACTED]. A care plan, dated [DATE] and last updated on [DATE], documented the resident had impaired visual function due to [MEDICATION NAME] degeneration. She had a history of [REDACTED]. A quarterly assessment, dated [DATE], documented the resident was moderately impaired in cognitive skills for daily decision making. She did not exhibit behaviors. An OSDH final incident report, submitted on [DATE], documented the incident date was [DATE]. The incident report documented the resident involved was resident #1. The description of the incident included information related to an allegation of sexual abuse for resident #1. The investigation included a resident interview with resident #11. The resident was asked if any one had touched her inappropriately. She stated, Yes, about 1 (to) 2 months ago someone came in my room at night and had a sling shot with cheese and put it in my vagina. I don't know who, I was asleep. The report further documented, (Named resident) has [MEDICAL CONDITION] and is known to be delusional. This was the first time anything had been reported of this nature. A facility investigation of the allegation, undated, documented, .(Named resident) lives in her own little world. She has been fixated on religion for some time. She does her own things. Her stories are not usually real has stated her husband has visited her and he is deceased . Her family is highly involved and visits frequently and takes her out often. On [DATE] at 3:50 p.m., the DON was asked if the resident's allegation had been investigated including staff and resident interviews and an assessment of the resident. She said, Well, I didn't know how to go further. An OSDH incident report, dated [DATE], documented the report was a combined initial and final report. The incident date was documented as [DATE]. The incident type was identified as allegations of abuse/mistreatment. The report included the resident's interview results obtained when resident #1's abuse allegation was investigated. The incident report documented the following investigation, (Named resident) was unable to provide any other information, stating 'I was asleep, I don't know what they looked like or what time it was.' .(Named psychiatric physician assistant) notified. Son .was notified today [DATE] at 11:25 AM and stated 'Oh my God, I hope you didn't investigate that one.' This nurse explained that all allegations have to be investigated and turned in to the State of Oklahoma and contacts notified . At 9:26 a.m., the administrator was shown the combined initial/final report for the resident which the DON had submitted as a completed investigation. She stated each allegation must be treated seriously. She stated the investigation was not thorough. She stated the report was not submitted timely. She acknowledged the facility policy was not followed for the allegation of abuse. 6. Resident #14 had [DIAGNOSES REDACTED]. A care plan, dated [DATE], documented the resident needed supervision and or assistance with decision making related to poor impulse control and decreased safety awareness. The care plan documented intervene as necessary to protect the rights and safety of others. Redirect off hall 300 if wandering/pacing in that direction. The care plan documented the resident exhibited atypical sexual behaviors. A quarterly assessment, dated [DATE], documented the resident was severely impaired in cognitive skills for daily decision making. He did not exhibit any behaviors. He required supervision with ambulation and utilized a walker and/or wheelchair. An OSDH final incident report, submitted on [DATE], documented the incident date was [DATE]. The incident report documented the resident involved was resident #1. The description of the incident included information related to an allegation of sexual abuse. The investigation included a resident interview with residents #21 and #22. The residents were asked if any one had touched them inappropriately of if they had observed anyone touching anyone inappropriately. Resident #21 stated, Yes, I saw another resident (Named resident #14) kiss (Named resident #15) and touch her breast. It's happened a couple of times. (Named resident #15) was kissing (Named resident #14) back. Resident #22 stated, Yes, I saw same thing (Named resident #21) saw with the same resident. A facility investigation of the allegation, undated, documented, .(Named resident #14) has been seen kissing (named resident #15) and (Named resident #15) was allowing. They had been separated and staff kept them separated. Staff was instructed and it was care planned to redirect (Named resident #14) away from hall 300 (the hall resident #15 resided on). (Named resident #15) does have dementia and is disoriented. No one had seem (sic) him touching her breast. This occurred probably 6 months to a year ago . (Named resident #14) has a history of wandering into others room. He especially wandered into 315 due to having been assigned that room in the past. Staff was instructed and it was care planned for them to redirect him away from hall 300 when he would start wandering in that direction. His wandering into other rooms has been decreasing in frequency. Part of the difficulty with (Named resident #14) is the fact he does not speak English. A nurse's note, dated [DATE], documented, Resident was observed yelling in Spanish and grabbing a female resident. Female resident was observed trying to move away from him but he wouldn't let her. Nurse removed female and assisted her to room. Resident was seen trying to follow and enter her room. Assisted resident to his room where he became combative. Yelling and attempting to leave room . On [DATE] at 10:23 a.m., residents #21 and #22 were interviewed in their room. They reported (Named resident #14) wandered the halls at night and was loud. They stated he kissed women on the lips if staff didn't watch him. They stated they had observed the resident grab (Named resident #15's) breasts. Resident #21 said, He squeezes her breasts hard. Both residents stated they had

On [DATE], an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health (OSDH) due to the facility's failure to ensure a resident, who required the assistance of two staff members with transfers, received the necessary assistance. On [DATE] the non-weight bearing resident was stood and pivoted, by one staff member, resulting in the resident suffering multiple acute fractures. At 9:25 a.m., the administrator was notified of the existence of the IJ situation. A competency skills form titled, Checklist for Transfers was reviewed. The form included a handwritten note at the bottom of page that documented one-on-one in-services began on [DATE] with certified nurse aides (CNAs), who were working the weekend the incident took place. The in-services concluded on [DATE]. Additionally, on [DATE], registered nurses (RNs) and licensed practical nurses (LPNs) were educated on the completion of timely and complete incident reports. There were no further in-services or competency skills checks completed for the other licensed nursing staff. Only CNAs who worked the weekend of [DATE] through [DATE] participated. A new policy was developed on [DATE] titled, Transferring Residents. This policy documented; Policy: To protect residents from injury and/or harm during transfers Procedure: 1. Upon admission all residents will be considered as requiring assistance of 2. 2. No later than a week after admission all residents will be identified as to the amount of assistance thy require for safe transfers 3. Individual ADL (activities of daily living) Care Plans will identify assistance needed and the amount of assistance they require 4. Each bed will have sticker that identifies amount of and number of staff required to safely transfer resident. It will identify how many staff needed, if Hoyer lift, sit to stand, pivot, airplaned, etc. 5. All staff will be instructed on new policy and all new hires will be informed prior to starting to work on the floor 6. Stickers will be updated as needed by MDS (minimum data set)/DON (director of nurses)/Designee 7. When transferring without equipment all staff will be required to use a gait belt when transferring or ambulating residents 8. No resident is to be transferred by lifting under the arms 9. If staff is caught not using gait belt or proper lifting more than 3 times it can be grounds for immediate termination 10. Any staff member who is caught not following proper transfers/lifting methods and a resident is injured in anyway will be terminated immediately and turned in to the Oklahoma Department of Health (Certification Board) At 11:38 a.m., an acceptable plan of removal was received. The facility's plan of removal documented: (Named facility and address) [DATE] PLAN OF REMOVAL CORRECTION How (Named facility) will ensure that all nursing staff know the policy and procedure to correctly transfer residents. How they can identify the correct amount of staff needed and how they transfer. All Nursing Staff, RN (registered nurse), LPN (licensed practical nurse), CMA(certified medication aide), CAN (sic) (certified nurse aide), not already checked off on Transfer Skills, will be checked off by 2pm today [DATE]. All current nursing personnel, RN, LPN, CMA, and CAN (sic), will be in-service by 2pm today [DATE] regarding the Transferring Residents Policy and Procedure revised [DATE]. In-services will be documented on In-Service Sheet with date time and how in-service was done. Any Nursing Staff who has not had a skilled check off completed and or been in-serviced will not be allowed to work until completed. All nursing employees will be required to sign form that they have been in-serviced. This form will be placed in their personnel file. On [DATE], nursing staff were in-serviced on the new transfer policy either in person or by phone. Staff, who had not completed a one-on-one return demonstration of safe transfers including lifts, were brought to the facility to do so at that time. At 2:30 p.m., CNAs, certified medication aides (CMAs), LPNs, and RNs were interviewed in regard to their knowledge of the in-service and the new transfer policy. Staff from all shifts verbalized understanding of the in-service including the use of transfer methods consistent with individualized care plans, proper techniques for transferring residents, the location of each resident's transfer care plan, and to whom they should speak regarding questions of transferring a resident. Stickers were observed above resident beds documenting how many staff were required to transfer a resident and type of transfer that was appropriate. Three CNAs were observed safely transferring residents from wheelchairs to bed and from bed to wheelchairs using proper technique. Four staff members, including one who was out of state, did not receive the new transfer policy in-service. These staff members were told by the facility they would not be allowed to work until they had been in-serviced on the new transfer policy. At 3:45 p.m., an addendum was received to the facility's plan of removal and accepted. The addendum documented the following: (Named facility and address) ADDENDUM PLAN OF REMOVAL [DATE] at 3:45 pm Have been un able to reach the following staff, RN, LPN, CNA to in-service on the new policy and procedure regarding Transferring of Residents. They will be in-service before they are allowed to return to work at (Named facility). (Named RN #2), spoke to spouse and she is out of the state and is scheduled to work a double on [DATE] and will be in-service Saturday morning prior to working (Named LPN #7) works another job and has her phone turned off. She is scheduled to work [DATE] on the ,[DATE] (10:00 p.m. to 6:00 p.m.) shift. She will be in-serviced prior to working on Friday. (Named LPN #8) message was left, has not returned call. Schedule to work doubles [DATE], ,[DATE] (6:00 a.m. to 2:00 p.m.) and ,[DATE] (2:00 p.m. to 10:p.m.). She will be in-serviced prior to being able to work. (Named CNA #6), message was left on her phone, no returned call as of now. She is scheduled to work ,[DATE] Friday, [DATE]. She will be in-serviced prior to being allowed to work. The IJ was removed on [DATE] at 3:45 p.m., when all components of the plan of removal had been completed. The deficient practice remained at a harm that was isolated. Based on interview and record review, it was determined the facility failed to ensure a resident, who required the assistance of two staff members with transfers, received the necessary assistance for one (#1) of four sampled residents who were reviewed for transfers. The resident acquired acute fractures of the left fibula, left tibia, left ankle, and right humorous as a result of the transfer. The director of nurses (DON) identified 19 residents who required the assistance of two staff members for transfers. Findings: A facility policy titled, (Named Facility) Policy and Procedure Transfer documented; Policy .Provide proper mobility in a safe environment .Procedure .Residents will be assessed for need in transferring . A facility policy titled, (Named Facility) Po;icy (sic) and Procedure Gait Belt documented; Policy: Residents should receive safe assistance with mobility and transferring when needed . Resident #1 had [DIAGNOSES REDACTED]. An admission assessment, dated [DATE], documented, .Transfers .total assist .non-weight bearing . A quarterly assessment, dated [DATE], documented the resident was severely impaired in skills for daily decision making. She was totally dependent with all activities of daily living and required two person physical assist with all transfers. A care plan, dated [DATE], documented the resident required the assistance of two staff members when transferring. She had stroke which resulted in right side paralysis. She required total assistance from two staff members with transfers. An activities of daily living (ADL) care sheet, dated [DATE], documented transfers were to be accomplished by lifting the resident. She was nonambulatory and non weight bearing. The resident could not tolerate and refused mechanical lifts, so cradling lifts by two staff members were required. A hospice chaplain's progress note, dated [DATE] at 4:15 p.m., documented the resident asked for immediate assistance to get up for the evening meal. The note further documented the chaplain had informed the staff of the resident's request. The clinical record contained no documentation of when and how the resident was transferred to the dining room. The record further documented the resident was bedfast and rarely moved from her bed. A meal intake record, dated [DATE], documented the resident consumed 50% of her dinner meal. The resident's record documented she routinely consumed 25% or less of her meals. There was no documentation the resident exhibited signs or symptoms of discomfort during her meal. A review of the nurse's notes, dated [DATE], contained no documentation of the events surrounding the resident's injury when she was transferred back to her bed from her wheelchair. There was also no documentation of a head to toe nursing assessment or of a pain assessment having been conducted for the resident. A late entry nurse's note for [DATE], written on [DATE], documented at 6:10 p.m. certified nurse aide #1 (CNA) told LPN #1 the resident was tearful and had cried out when she had been returned to bed following dinner. This note documented the nurse found the resident in bed with her left leg crossed over her right. Her left leg was slightly swollen and misshapen. This late entry did not include details of a head to toe assessment, vital signs, or a pain assessment. The late entry nurse's note for [DATE], was written by LPN #1. LPN #1 was on duty at the time of the incident and assigned to the resident. The note further documented . At 1810 (6:10 p.m.) CNA on hall report (sic reported) to this nurse that when putting Pt (patient) back to bed she began to be tearful and cry out when positioning her legs. The CNA said that her and another CNA had put the pt back to bed using a two person assist method and had no(sic) drop(sic) her or entangled her in anything and that the pt cryed (sic) out when her legs were being positioned. At the room the pt lt (left) leg was crossed over rt (right) leg and looked slightly misshaped(sic). This nurse lifted the pt leg with both hands to assess the leg without the other leg pressing against it. The left leg was indeed sl (slightly) swollen and slightly misshaped (sic). The pt did cry out at that time until the leg was put back across the other leg . A facility incident report, dated [DATE] at 6:10 p.m., completed by LPN #1, documented, .pt was being transferred from w/c (wheelchair) to bed by two CNA (certified nurse aides) No intanglement (sic) noted during transfer . The clinical record contained documentation the physician had been notified on [DATE] at 6:25 p.m. and a new order was issued to obtain mobile x-rays of the resident's left leg and ankle. The clinical record contained documentation the mobile radiology report was received at 8:03 p.m. and documented the resident had a spiral distal tibial fracture and a transverse distal fibula fracture. The report also documented the resident had marked osteoporosis. An Oklahoma State Department of Health (OSDH) incident report, dated [DATE], documented, .(Named resident #1) .Incident Date [DATE] .Incident Type .Certain Injuries . Description of Incident .(Named resident) had been put to bed by the 2 staff members when she complained of her left foot hurting . Relevant history .She refuses to let the staff use a lift on her claiming it hurts her to (sic) much. She is lifted for transfers per her request. Her daught (sic)/POA (power of attorney) was informed and agreed . The OSDH final incident report documented that as part of the facility's investigation written statements were obtained from both CNAs involved in the incident on [DATE] and [DATE]. These statements documented that two attempts were made to transfer the resident from her wheelchair to the bed, and the second attempt was successful. On the first attempt the resident said, Ouch. She was lowered back to her wheelchair and her catheter was adjusted prior to the second attempt. CNA #2 noticed the resident had tears on her face once she was in bed. CNA #2 stayed with the resident while CNA #1 went to find a nurse. Both written statements documented the resident was stood up to transfer by CNA #1. A two person transfer was not used. The resident was transferred to a local emergency department on [DATE]. An emergency department history and physical, dated [DATE] at 9:23 p.m., documented the resident arrived by ambulance to a local emergency department. The resident presented to the emergency room with swelling, tenderness, and deformity of her left lower leg and pain in her right arm so much so that she was unable to tolerate movement of that joint. A radiology report, dated [DATE] at 10:03 p.m., documented, .Impression .acute fracture of the distal left tibial metadiaphysis .acute fractures of the proximal and distal left fibular diaphysis .probable acute fracture of the calcaneus . A radiology report, dated [DATE], documented, .Findings .Bones are osteopenic .Impression .acute, impacted fracture of the right humeral head/neck . An admission nursing facility note, dated [DATE], documented the resident was admitted to a long term care facility. She had orders to continue hospice services. She had a provisional [DIAGNOSES REDACTED]. On [DATE], interviews were conducted and documented by the facility administrative staff with both CNAs involved in the transfer of the resident. CNA #1 was asked why she stood the resident and did not lift her. She stated she did not know the resident was not to stand. CNA #1 was asked to describe how she transferred the resident. She said, .I positioned myself in front of the resident she placed her left arm over my right shoulder while the remaining arm was at her side. (Named CNA #2) was positioned to the left of the resident and the TV (television) and we assisted her back to her bed . CNA #2 stated, CNA #1 went to grab (named resident). She put one arm under right arm and told her to put her right hand on her shoulder. I (CNA#2) was standing on the left of them. She (CNA #1) began to pick her up. She started saying 'Ouch'. I went to get foley bag. CNA #1 put her back in wheelchair. I grabbed foley bag. CNA #1 clipped it on her shirt. We got her in the bed. A discharge summary, dated [DATE], documented, . Date of admission [DATE] .Diagnosis .pain of multiple fxs (fractures) .pt. (patient) was at another facility where the proper procedures for transferring .were not followed, multiple fxs (fractures) occurred, transferred to this facility .pt. while here for appx (approximately) 2 weeks, before death was on hospice comfort measures .pt. expired on [DATE] . On [DATE] at 3:32 p.m., an attempt was made to contact LPN #1. Her phone number was disconnected. At 3:35 p.m., an attempt was made to contact CNA #1. Her phone answering service stated that she was unavailable. At 3:50 p.m., LPN #2 was asked if she was the on-call nurse who received the call from LPN #1 about the incident. She stated she had received a call at 6:00 p.m. from LPN #1 at the facility. LPN #1 told her the resident had caught her foot in the side rail, was complaining of pain, and had some deformity above the ankle. LPN #2 provided LPN #1 with the doctor's phone number and the x-ray provider's phone number. At 4:02 p.m., CNA #2 was asked to describe the events surrounding the transfer of the resident back to her bed. She stated that she had never seen the resident out of bed and she knew the resident required a two person assist. She further stated she knew that she needed help, so she asked CNA #1 for assistance. She stated there were two attempts to put the resident in bed. During the first attempt, CNA #2 stood to the side and watched while CNA #1 stood in front of the resident. The resident put her left hand on CNA #1's right shoulder. When CNA #1 began to pick the resident up she said, Ouch and was quickly returned to her wheelchair. She stated they thought the resident's urinary catheter bag had caught on something, so the bag was secured and a second attempt was made to put the resident in bed. CNA #2 stated that once again she stood to the side while CNA #1 transferred the resident to the bed. CNA #2 said this time, .She (CNA#1) turned her (the resident) like a 360 motion and set her on the bed. CNA #2 stated the resident did not say she was in pain, but she could see pain in the resident's face and realized she was crying. She remained in the room with the resident while CNA #1 went to tell the nurse. On [DATE] at 8:00 a.m., the director of nurses (DON) was asked why there was a late entry nurse's note regarding the incident on [DATE]. She stated that she and the administrator came to the facility early the next morning, a Saturday. They tried to contact LPN #1 the entire weekend but were unable to reach her. They saw that no nurses' notes had been made about the event, there was no assessment, and the incident report was incomplete. When LPN #1 reported for work on Monday, [DATE], she was asked for a statement at that time. Additionally, she was terminated immediately and reported to the nursing board on [DATE]. At 4:25 p.m., the DON was asked how the resident should have been transferred. The DON stated the resident should have been lifted by two people. She stated the resident could not tolerate a mechanical lift. She stated that all nurses and CNAs had easy access to the ADL care plan which documented the transfer plan for each resident. She stated the CNAs had no excuse to be uninformed. At 4:20 p.m. The administrator stated the resident was very small and in pain a lot of the time. She stated staff had to be careful whenever they moved her, even when rolling her. On [DATE], a review of the skills check off for safe transfer competency was completed for all CNAs. The facility had not completed transfer competency training with 20 CNAs employed at the facility. At 7:50 a.m., the DON was asked to provide sign in sheets for nursing staff attendance of the new transfer policy in-service. She reported the in-service had not yet been conducted. At 10:25 a.m., LPN #2 was interviewed. LPN #2 coordinated and conducted the transfer competency training. She was asked if other staff members in the facility besides CNAs transferred residents. She stated, Yes. She identified CMAs, LPNs, and RNs also transferred residents. She then stated the only staff members who had completed transfer competency training were CNAs. She further stated the training was only conducted the weekend following the incident.

Based on interview and record review, it was determined the facility failed to ensure a resident's care plan was followed for assistance with transfers for one (#1) of four sampled residents whose care plans were reviewed for transfer assistance. The resident acquired acute fractures of the left fibula, left tibia, left ankle, and right humorous as a result of the transfer. The director of nurses (DON) identified 19 residents who required the assistance of two staff members for transfers. Findings: A facility policy titled, Care Plans documented: POLICY: to ensure the needs of the residents are met by all shifts and staff . A facility policy titled, (Named Facility) Policy and Procedure Transfer documented; Policy .Provide proper mobility in a safe environment .Procedure .Residents will be assessed for need in transferring . A facility policy titled, (Named Facility) Po;icy (sic) and Procedure Gait Belt documented; Policy: Residents should receive safe assistance with mobility and transferring when needed . Resident #1 had [DIAGNOSES REDACTED]. An admission assessment, dated [DATE], documented, .Transfers .total assist .non-weight bearing . A quarterly assessment, dated [DATE], documented the resident was severely impaired in skills for daily decision making. She was totally dependent with all activities of daily living and required two person physical assist with all transfers. A care plan, dated [DATE], documented the resident required the assistance of two staff members when transferring. She had stroke which resulted in right side paralysis. She required total assistance from two staff members with transfers. An activities of daily living (ADL) care sheet, dated [DATE], documented transfers were to be accomplished by lifting the resident. She was nonambulatory and non weight bearing. The resident could not tolerate and refused mechanical lifts, so cradling lifts by two staff members were required. A hospice chaplain's progress note, dated [DATE] at 4:15 p.m., documented the resident asked for immediate assistance to get up for the evening meal. The note further documented the chaplain had informed the staff of the resident's request. The clinical record contained no documentation of when and how the resident was transferred to the dining room. The record further documented the resident was bedfast and rarely moved from her bed. A review of the nurse's notes, dated [DATE], contained no documentation of the events surrounding the resident's injury when she was transferred back to her bed from her wheelchair. A late entry nurse's note for [DATE], written on [DATE], documented at 6:10 p.m. certified nurse aide #1 (CNA) told LPN #1 the resident was tearful and had cried out when she had been returned to bed following dinner. This note documented the nurse found the resident in bed with her left leg crossed over her right. Her left leg was slightly swollen and misshapen. The clinical record contained documentation the physician had been notified on [DATE] at 6:25 p.m. and a new order was issued to obtain mobile x-rays of the resident's left leg and ankle. The clinical record contained documentation the mobile radiology report was received at 8:03 p.m. and documented the resident had a spiral distal tibial fracture and a [MEDICATION NAME] distal fibula fracture. The report also documented the resident had marked [MEDICAL CONDITION]. An Oklahoma State Department of Health (OSDH) incident report, dated [DATE], documented, .(Named resident #1) .Incident Date [DATE] .Incident Type .Certain Injuries . Description of Incident .(Named resident) had been put to bed by the 2 staff members when she complained of her left foot hurting . Relevant history .She refuses to let the staff use a lift on her claiming it hurts her to (sic) much. She is lifted for transfers per her request. Her daught (sic)/POA (power of attorney) was informed and agreed . The OSDH final incident report documented that as part of the facility's investigation written statements were obtained from both CNAs involved in the incident on [DATE] and [DATE]. These statements documented that two attempts were made to transfer the resident from her wheelchair to the bed, and the second attempt was successful. On the first attempt the resident said, Ouch. She was lowered back to her wheelchair and her catheter was adjusted prior to the second attempt. CNA #2 noticed the resident had tears on her face once she was in bed. CNA #2 stayed with the resident while CNA #1 went to find a nurse. Both written statements documented the resident was stood up to transfer by CNA #1. A two person transfer was not used. The resident was transferred to a local emergency department on [DATE]. An emergency department history and physical, dated [DATE] at 9:23 p.m., documented the resident arrived by ambulance to a local emergency department. The resident presented to the emergency room with swelling, tenderness, and deformity of her left lower leg and pain in her right arm so much so that she was unable to tolerate movement of that joint. A radiology report, dated [DATE] at 10:03 p.m., documented, .Impression .acute [MEDICAL CONDITION] left tibial metadiaphysis .acute fractures of the proximal and distal left fibular diaphysis .probable acute [MEDICAL CONDITION] . A radiology report, dated [DATE], documented, .Findings .Bones are osteopenic .Impression .acute, impacted [MEDICAL CONDITION] humeral head/neck . An admission nursing facility note, dated [DATE], documented the resident was admitted to a long term care facility. She had orders to continue hospice services. She had a provisional [DIAGNOSES REDACTED]. On [DATE], interviews were conducted and documented by the facility administrative staff with both CNAs involved in the transfer of the resident. CNA #1 was asked why she stood the resident and did not lift her. She stated she did not know the resident was not to stand. CNA #1 was asked to describe how she transferred the resident. She said, .I positioned myself in front of the resident she placed her left arm over my right shoulder while the remaining arm was at her side. (Named CNA #2) was positioned to the left of the resident and the TV (television) and we assisted her back to her bed . CNA #2 stated, CNA #1 went to grab (named resident). She put one arm under right arm and told her to put her right hand on her shoulder. I (CNA#2) was standing on the left of them. She (CNA #1) began to pick her up. She started saying 'Ouch'. I went to get foley bag. CNA #1 put her back in wheelchair. I grabbed foley bag. CNA #1 clipped it on her shirt. We got her in the bed. A discharge summary, dated [DATE], documented, . Date of admission [DATE] .Diagnosis .pain of multiple fxs (fractures) .pt. (patient) was at another facility where the proper procedures for transferring .were not followed, multiple fxs (fractures) occurred, transferred to this facility .pt. while here for appx (approximately) 2 weeks, before death was on hospice comfort measures .pt. expired on [DATE] . At 3:35 p.m., an attempt was made to contact CNA #1. Her phone answering service stated that she was unavailable. At 4:02 p.m., CNA #2 was asked to describe the events surrounding the transfer of the resident back to her bed. She stated that she had never seen the resident out of bed and she knew the resident required a two person assist. She further stated she knew that she needed help, so she asked CNA #1 for assistance. She stated there were two attempts to put the resident in bed. During the first attempt, CNA #2 stood to the side and watched while CNA #1 stood in front of the resident. The resident put her left hand on CNA #1's right shoulder. When CNA #1 began to pick the resident up she said, Ouch and was quickly returned to her wheelchair. She stated they thought the resident's urinary catheter bag had caught on something, so the bag was secured and a second attempt was made to put the resident in bed. CNA #2 stated that once again she stood to the side while CNA #1 transferred the resident to the bed. CNA #2 said this time, .She (CNA#1) turned her (the resident) like a 360 motion and set her on the bed. CNA #2 stated the resident did not say she was in pain, but she could see pain in the resident's face and realized she was crying. She remained in the room with the resident while CNA #1 went to tell the nurse. At 4:25 p.m., the DON was asked how the resident should have been transferred. The DON stated the resident should have been lifted by two people. She stated the resident could not tolerate a mechanical lift. She stated that all nurses and CNAs had easy access to the ADL care plan which documented the transfer plan for each resident. She stated the CNAs had no excuse to be uninformed. At 4:20 p.m. The administrator stated the resident was very small and in pain a lot of the time. She stated staff had to be careful whenever they moved her, even when rolling her.

Based on observations, interviews and record reviews, it was determined the facility failed to provide the necessary supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for two (#75 and #87) of five sampled residents who had experienced falls. Resident #75 had three previous falls and then fell on [DATE] and sustained a laceration and hematoma to her head. She then fell again on 01/29/17 and sustained a hip fracture which required surgical intervention. The facility identified 16 residents who had recurring falls since 01/01/17. Findings: A facility policy titled, Falls, documented: Policy: To identify residents at risk for falls .Procedure: All residents on admission will be consented (sic) at risk for fall and ambulation will be monitored for safety. A fall risk assessment will be completed by the nurse at the time of admission and initial care plan will identify those residents at risk for falls, ADL (activity of daily living) care plan will include fall risk. Fall risk assessment will be done after any incident of fall and quarterly with care plans updated .Staff will educate residents on safety and any special needs of a resident at risk for falls .All residents with incident of falls will be reviewed by DON (director of nurses) for proper interventions to prevent more falls this will include referral to therapy and restorative as appropriate. Care plans will be updated with new interventions. Medications will be reviewed for possible causes .Monthly all falls will be reviewed for trends and taken to QA (quality assurance) meeting . A facility policy titled, Incident Reports, documented: Policy: To ensure all incidents of falls or other type of accidents will be assessed and monitored by Director of Nursing, Physician and Administrator to assure the highest quality of care is being given to each resident and that each incident/accident receives immediate attention . Procedure . 6. The Charge Nurse will completely fill out an Incident form, including immediate measure to protect the resident . 8. The Charge Nurse will document in the resident chart what occurred and what was done immediately and what was done to protect the resident from further injury . 1. Resident #75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 12/30/16 at 6:10 p.m., documented the resident was very confused and not easily redirected due to her confusion. A fall risk assessment, dated 12/30/16, documented the resident was a high risk for falls with a score of 16. A score of 10 or above represented a high risk for falls. A nursing assistant care sheet, dated 12/3016, documented the resident was a fall risk. There were no interventions listed on the sheet to prevent occurences of falls. An incident report, dated 01/03/17 at 12:10 p.m., documented, .this nurse alerted by CNA staff to room 114. Upon arrival res sitting on bottom facing bathroom, in front of w/c (wheelchair) res assessed, res denies hitting head or any pain .steps taken to prevent recurrence .monitor closely . A nurse's note, dated 01/03/17 at 12:30 p.m., documented, This nurse called by CNA (Certified nurse assistant) staff to room 114 upon arrival res (Resident) sitting on bottom in front of bed in front of w/c (Wheelchair) . 0 (No) injury noted . A fall risk assessment dated [DATE] documented the resident was a high risk for falls with a score of 18. A score of 10 or above represents a high risk for falls. A nurse's note, dated 01/05/17 at 2:00 p.m., documented, Res cont (continues) to get (arrow up) out of chair & (and) bed (without) assistance. res wanders off from chair . An incident report, dated 01/05/17 at 6:05 p.m., documented, Resident found sitting on her buttocks /c (with) her knees bent in front of her. She was in room 305 and stated to this nurse 'I fell out of the bed'. She was attempting to climb into .bed .0 (no) injury noted to her buttocks .level of consciousness AAO (alert and oriented) X1 (name only) .steps taken to prevent recurrence .monitor res q (every) hour . There was no documentation to show the facility implemented the monitoring of the resident every hour. An admission assessment, dated 01/11/17, documented, the resident was sometimes understood, sometimes made self understood and had a vision impairment. The resident's cognition was severly impaired, she wandered the facility which intrudes on the privacy or activities of others. The resident required one person limited assitance with transfers, walking in the room, walking in the corridor; extensive assistance with locomotion on and off the unit. The resident was not stable but able to stabilize self without staff assitance when moving from a seated to standing position, walking, turning around, moving on and off the toilet; and surface to surface transfers. The resident had two non-injury falls since being admitted to the facility. A care plan, dated 01/11/17, documented, Problem: (Resident) is at risk for falls r/t (related to) HTN (hypertension) medications, psychotropic drugs unsteady gait. Problem (Named resident) does not like to sit in her w/c and is often seen ambulating around unit. 01/03/17 Falls: Fall in room 0 (no) injuries. 01/05/17 fell trying to get into bed 0 (no) injuries. Goals The resident will maintain current functional level without falls thru next review. Approach .Keep call light within reach while in his (sic) room .Assure proper foot wear .Encourage resident to ask for assistance with transfers, bed mobility as needed .Keep pathways clear, well lighted and clutter free .observe for side effects of medications and report them to the MD (medical doctor) if present for further orders .Observe for LOC (level of consciousness) changes and report to Md as needed .Redirect (Resident) when she is out of her chair .educate staff to be aware of when (Named resident) is trying to transfer ambulate to re assure & (and) re direct (Named resident) as needed . A nurse's note, dated 01/14/17 at 8:30 p.m., documented, Up amb. (ambulating) in hallways part of the evening continue to wander around on unit . A nurse's note, dated 01/15/17 at 9:30 p.m., documented, Resident continues to ambulate without wheelchair . A nurse's note, dated 01/21/17 at 9:30 p.m., documented, Resident has been ambulating in hall all day . There was no documentation to show one person assistance was provided while she was up ambulating all day, as her assessment documented she required on 01/11/17. An incident report, dated 01/25/17 at 10:30 a.m., documented, .This nurse alerted by staff that res (resident) was frightened by another res fell back & hit head on floor .type of injury .laceration .swelling .level of consciousness AAO X1 .steps taken to prevent recurrence .educate staff to be aware of her when she is trying to transfer/ambulate (without) wc (wheel chair) to reassure redirect prn- monitor closely when ambulating encourage w/c . A physician's telephone order, dated 01/25/17 at 10:30 a.m., documented, Send to (Acute care facility) .D/T (due to) fall (head). A nurse's note, dated 01/25/17 at 11:00 a.m., documented, .nss (normal saline solution) and gauze applied to stop bleeding .B/P (blood pressure) 195/107 .complains of pain unable to verbalize rate of pain . A second nurse's note, dated 01/25/17 at 12:00 p.m., documented, .fall investigation actual recall from staff .res had stood up and was touching another residents shoulders in front of her The other resident swatted her direction and .she fell backwards striking her head on the floor .Staff was educated on (sic) to be aware of when she is trying to transfer/ambulate without w/c to reassure & redirect as needed A physician's telephone order dated 01/25/17 at 1:45 p.m., documented the resident had returned to the facility. A hospital consultation report, dated 01/25/17, documented, clinical information fall/head inj (injury) fall .findings generalized volume loss is noted evidenced by prominent suction pattern and proportionate prominence of the ventricular system .impression small posterior scalp hematoma . An After Care Instructions dated 01/25/17, documented, .You have been diagnosed with [REDACTED].if you take a blood thinner like Warfarin .the bruising may be worse .apply ice to help with pain and swelling A physician telephone order dated 01/25/17 at 5:00 p.m., documented, Apply ice to contusion on back of head for 15 to 20 mins (minutes) as tolerated QID (four times daily) X (times) 3 days. A fall risk assessment, dated 01/25/17, documented the resident was a high risk for falls with a score of 19. A score of 10 or above represents a high risk for falls. There were no new interventions implemented when the resident returned from the acute care facility to prevent falls. A nurse's note, dated 01/26/17 at 9:38 a.m., documented, Res c/o (complained of) pain to head unable to rate pain X 1 dose Tylenol 325 mg PO PRN (Name deleted PA) to follow up /c (with) later. An incident report, dated 01/28/17 at 4:30 p.m. documented, Resident was in wheelchair trying to transfer from wheelchair to chair tried to sit in chair misses chair and sat on floor bottom first 0 (no) injuries .resident was complaining she wanted to go home why couldn't she go home .name and title of witness (name deleted) LPN (licensed practical nurse) .steps taken to prevent recurrence continue to monitor . A nurse's note, dated 01/28/17 at 6:30 p.m., documented the resident had a fall witnessed by the nurse. Resident did not hit her head. Resident was trying to transfer herself from the wheel chair to chair and missed falling to her bottom. There were no injuries documented. A fall risk assessment, dated 01/28/17, documented the resident was a high risk for falls with a score of 23. A score of 10 or above represented a high risk for falls. A nurse's note, dated 01/29/17 at 7:45 a.m., documented, Resident was in bed got up with out assistance fell into the floor. CNA's (certified nurse aides) went to check resident found resident on floor. Resident was assessed had complaints of pain in (L) (left) hip unable to move (L) leg. Vls (vitals) done B/P 174/88 p (pulse) 70 (r) (respiration) 20 temp (temperature) 98. (Named emergency services) called resident to (acute care facility) .for evaluation. Doctor on call called Daughter also called. Administrator notified family stated will call later to check if resident is back from hospital. An incident report, dated 01/29/17 at 7:45 a.m., documented, resident ambulating without assistance .type of injury .pain (L) (left) hip .steps taken to prevent recurrence . Fx (fracture) (R) (right) hip-follow post op directions . A physician's telephone order, dated 01/30/17, documented, Send to ER (emergency room ) for eval (evaluation) as of 01/29/17. A fall risk assessment,, dated 01/30/17, documented the resident was a high risk for falls with a score of 22. A score of 10 or above represented a high risk for falls. This was decreased from the last assessment of 1/28/17, which was scored a 23. A hospital discharge summary, dated 02/01/17, documented, .Admission [DIAGNOSES REDACTED].history of present illness .resident fell at the nursing home and brought to the ER (emergency room ) where she was found to have a left tib-fib fracture .she had fallen several days ago and hit the back of her head. She also had bruising on the left temple and preorbital region from the fall .past medical history .dementia probably Alzheimer's time (type) .wide spread osteoarthritis . An interview was conducted on 04/04/17 at 8:40 a.m., with licensed practical nurse (LPN) #2. She was asked to describe the resident and her level of cognitive skills. She stated, the resident was oriented to self, had a severe cognitive decline, and would occasionally recognize her family. She was asked if the resident was able to use the call light or remember to ask staff for assitance. She stated staff would frequently show the resident how to and remind her to use the call light, but she was not able to understand and comprehend that because of her cognition. She then stated, She had no short term or long term memory. She was asked what level of assistance the resident required with transfers and ambulation. She stated the resident was a one to two person assist with transfers. She added the resident used a wheelchair and would forget she couldn't walk because of she had an unsteady gait. She then stated, She would get up out of the wheel chair a lot and walk, but she was very unsteady. She was asked when the facility identified the resdient as a fall risk. She stated the resident's gait was not steady when she was admitted . She then stated, We were warned she was a very high fall risk. The resident had to be one on one the first day she was admitted . She stated when the resident was received from the discharging facility they made us aware that she had a lot of falls, would get up and walk away from her wheel chair. We received her knowing she was a very high fall risk and the family confirmed it. She was asked if the resident had remained on one on one while at the facility. She stated, We could not do one on one because we didn't have enough staff but we had to monitor her closely. She added, the certified nurse aides had to monitor the resident closely. She was asked what it meant to monitor the resident closely. She stated, They would keep an eye on her and redirect her. She was asked how often the aides or other staff were to check on the resident. She stated at least every two hours. She was asked what interventions were in place for fall prevention. She stated frequent rounds were made if she was in bed, a lot of staff monitoring, use call light and remind the resident to ask for assitance, keep pathways clear and clutter free, proper footwear and non-skid socks. She was asked where the documentation was for the resident's monitoring per her fall interventions. She stated it was not documented anywhere but the nurses should document in the nurse's notes. She then added we do not keep a formal log or documentation of the checks. She was asked how effective the interventions for falls were. She stated, Knowing the resident, it was not effective knowing her cognition. She then stated, We tried to be there we just couldn't be there all the time. An interview was conducted on 04/04/17 at 9:08 a.m., with CNA #5 regarding the resident and falls. She was asked what level of assitance the resident required with activities of daily living (ADL'S). She stated the resident would get up out of the wheel chair on her own and walk without anyone watching her. She then stated the resident required supervision to limited hands on assitance with all ADL's. She was asked if the resident was at risk for falls. She stated, Yes. She was at risk, her balance was off and she did a lot of shaking. She stated, It was not safe for her to get up and walk on her own. She was asked how long the resident had been at risk for falls. She stated since admission. She was asked what interventions she had to follow for falls. She stated keep her close by, offer something to distract her, snacks, and check on her. She was asked how often she had to check on the resident. She stated, Every two hours we were to check on her. She was asked where an aide would document the monitoring or checking on a resident. It should be on the ADL sheets but we never documented it. She was asked if the resident had the ability to know how to use the call light or ask staff for assitance when she needed it. She stated we encouraged her to ask for help, but she never did. She then stated the resident could not use the call light. An interview was conducted on 04/04/17 at 9:25 a.m., with the director of nursing regarding the resident. She was asked what the resident's cognition was. She stated the resident was very disoriented and confused and would respond to her name only. She then stated, She did not respond to anything else. She was asked if the resident had the capacity to use her call light and to ask staff for assistance. She stated until the facility gets to know the resident we didn't know if she had the ability to remember or not. She then stated, Just because they are confused doesn't mean you don't encourage and ask them to use the call light. She was asked if the resident required assistance with transfers and ambulation. She stated, She was very unsteady and unsafe. She didn't want assistance. She stated the resident was very unsteady when she got up on her own. She was asked if the resident was a risk for falls. She stated the resident needed assitance, was incontinent, disoriented, and she ambulated independently at times when she needed assistance. She was asked when the resident had been identified as a fall risk. She stated on admission. She was asked what interventions were in place to aide in the prevention of falls. She stated we were monitoring and redirecting her at first, then watched her closely, and told her to not get up by herself. She was asked how often the resident required monitoring. She stated, she was to be checked on every one to two hours. She was asked what interventions for falls were on the care plan. She stated, Call light, proper footwear, encourage her to ask for assistance, keep pathway clear well lighted, watch side effects for medications, redirect back to wheel chair, educate staff to monitor when resident is trying to ambulate. She was asked if the interventions on the incident reports were interventions to be implemented and updated on the care plan. She stated, They should be on her care plan because the staff implements those interventions. She was asked to review the incident reports and the care plan and compare interventions. She looked through the incident reports and stated the care plan was not updated for monitoring every hour. She was asked if the facility reviewed the falls and looked at the interventions to see how appropriate they were for this resident. She stated, Sometimes they worked and other times they didn't work. She was asked how well the fall interventions had worked for the the resident and if the facility had increased supervision. She stated, The interventions were working. An interview was conducted on 04/04/17 at 10:30 a.m., with LPN #4, the nurse who completed the resident's admission. He was asked to describe her level of cognition. He stated she was confused, oriented X 1 to person and she not aware of anything else. He then stated, She would ambulate without her wheel chair and was a very high fall risk. He was asked what fall interventions were in place for the resident. He stated, Visual checks and not to be left in her room by herself. He was asked how often staff were to complete the visual checks. He stated, Every two hours and as needed. He was asked to look at the fall care plan interventions. He reviewed the interventions and then asked if the interventions were appropriate for this resident. He stated there could have been better interventions because of her cognition, not knowing and understanding. He then stated, I saw after working with her a short time that these interventions would not work. He then stated the resident didn't understand to use and could not use the call light. The resident also couldn't remember to use the call light. He was asked if the facility had implemented monitoring of the resident every hour as a fall intervention. He stated the certified nurse aides were busy and couldn't do the hourly checks. 2. Resident #87 was admitted to the facility with [DIAGNOSES REDACTED]. A fall risk assessment, dated 08/04/16, documented, the resident was a high fall risk. A care plan, dated 08/05/16 and last updated on 02/07/17, documented, Problem: Resident is at risk for falls related to unsteady gait, HTN (hypertension), and anti-psychotic drug use . Goal: Resident will maintain current functional level without fall thru next review . Plan: 1. Keep call light within reach while in his (sic) room 2. Assure proper foot wear. 3. Encourage resident to ask for assistance with transfers, bed mobility as needed. 4. Keep pathways clear, well lighted and clutter free 5. Observe for side effects of medications and report to MD (medical doctor) if present for further orders. 6. Observe for LOC (level of consciousness) changes and report to the MD as needed . 10/21/16 dressing to L (left) elbow . 10/28/16 'I fell and hit my arm' 1/10/17 dressing to elbow 1/17/17 fell no injuries 2/1/17 Tripped and fell . Sent to ER (emergency room ). No injuries 2/7/17 fell . Skin Tear . The resident's clinical record documented the resident had falls on the following dates: 10/28/16, 01/07/17, 02/01/17, and 02/07/17. The care plan was not updated with a new interventions after the falls. There was no fall investigation conducted after the falls. A quarterly assessment, dated 02/11/17, documented the resident was moderately impaired in cognitive skills for daily decision making and was unable to stabilize for ambulation without staff assistance. On 03/30/17 at 2:15 p.m., the resident was observed to get up from the couch and began walking. There were no staff members close by to assist the resident. The resident was observed to ambulate down the hall and then turn around and walk back to the nurse's station three times. Two staff members were observed to walk past the resident and not stop. At 2:22 p.m., a staff member brought the resident her walker and walked away. The resident continued to ambulate down the halls with her walker and without assistance. On 04/03/17 at 11:20 a.m., certified nurse aide #2 stated she preferred the resident to utilize her walker because she was so wobbly without it. At 12:55 p.m., the director of nurses was asked if the resident was supposed to ambulate only with staff supervision. She stated she must have either a family member or staff member present when she ambulates. She then stated she will often forget her walker and leave it somewhere. She further stated if a resident experienced a fall staff were supposed to monitor the resident every hour. She acknowledged there was no documentation of staff monitoring the resident after a fall occurred. She was asked how should staff monitor a resident. She stated staff members should be close enough by to the resident to grab them if they start to fall. On 04/05/17 at 2:40 p.m., the director of nurses was asked if the care plan had been updated to include the falls on 10/28/16, 01/07/17, 02/01/17, and 02/07/17. She stated the care plan had not been updated.

Based on observation, record review and interview, it was determined the facility failed to provide assessment, supervision and monitoring for a resident with fourteen falls, which resulted in injury and actual harm for one (#4) of six sampled residents for whom falls were reviewed. Resident #4 experienced falls that resulted in lacerations, hematomas, and hospitalization . A state-reported incident form documented the resident had a [DIAGNOSES REDACTED]. The incident form documented the resident was started on hospice per the family and the resident's doctor. The facility failed to: a. Develop and implement appropriate interventions on the resident's care plan. The intervention which required him to use the call light was inappropriate for his cognition level. b. Ensure frequent falls were properly assessed and monitored. c. Ensure ambulation was provided by staff. d. Ensure the resident was wearing his helmet during the incident in which he sustained a life threatening injury. This intervention was proposed by the resident's spouse and not the facility. e. Monitor and perform frequent monitoring/checks of the resident. The facility's Casper Report, dated 10/07/13, documented 27 residents had triggered for falls. Findings: A facility policy documented, "The facility will protect residents from injury by falls through risk assessment and identification. The Quality assurance nurse will write plans of correction to decrease the facility's frequency of falls." Resident #4 was admitted to the facility on [DATE]. He had [DIAGNOSES REDACTED]. Fall risk assessments dated 03/07/13, 03/12/13, 05/05/13, 05/20/13 and 07/21/13, documented the resident was a high risk for falls with a score of 14 . A fall risk assessment with an illegible date documented the resident was a high risk for falls with a score of 15. An assessment score of 10 or higher was considered a high risk for falls. The care plan dated 03/12/13, documented: "Resident at risk for falls... Approach 1) Encourage the resident to ask for assistance of staff (a line was drawn through this intervention. There was no indication who had revised the care plan.) 2) Ensure call light is in reach, answer promptly 3) Therapy to evaluate and treat per orders (a line was drawn through this intervention. There was no indication who had revised the care plan.) 4) Anticipate needs, provide prompt assistance 5) Assure lighting is adequate and areas are free of clutter 6) Encourage socialization and activity attendance - as tolerated 7) Falling star program (a line was drawn through this intervention. There was no indication who had revised the care plan) 8) Monitor chair and bed position 9) Monitor closely by staff while in wheelchair 10) To wear bike helmet while up and to be check freq (checked frequently) while in bed" A date of 05/14/12 (sic) was written next to this intervention. A second page of the care plan for falls documented: "Approaches 5/5/13 Low bed c safety mat 8/29/13 Apply Torso support while up in chair 2. Call light within reach 3. Assure proper footwear 4. Encourage resident to ask for assistance with transfers, bed mobility, ambulation, etc. 5. Keep pathway clear and free of clutter 6. Observe for wet, slippery floors 7. Observe for side effects from meds 8. Observe for changes in LOC 9. Keep all areas well lit 10. Send to ER for injury if happens 11. Monitor attempts to stand or get out of bed and redirect as needed..." The resident's admission start up orders dated 03/07/13, documented he was to be administered Depakote ER 250 mg, one tab per mouth two times a day, Seroquel 50 mg one tablet two times a day, Vistaril 50 mg one tablet two times a day for (agitation), Seroquel 100 mg one tab per mouth two times a day (for agitation), Klonopin 0.25 mg three times a day (for agitation) and Seroquel 300 mg one tablet at hour of sleep (for agitation). The resident had fourteen falls between 03/12/13 and 10/01/13. The incident reports documented: On 03/12/13 at 1:15 p.m., the incident report documented he was observed to stand up from his wheelchair. He fell and landed on his buttocks and sustained no injuries. The interventions were to encourage the resident not to get up without assistance and closely monitor the resident while he was in the wheelchair. The report documented he was confused. At 4:10 p.m., the incident report documented the resident was in the TV room when he tried to get up and leave. He fell , striking his head on the floor, and sustained a two inch laceration above his left eye. He was transported to a local emergency room where the laceration was glued closed. The intervention was to keep the resident where staff could see and monitor him for attempts to stand up. The report documented he was disoriented. A physician's orders [REDACTED]." A physician's orders [REDACTED]. "Discontinue Seroquel 50 mg per mouth two times a day. Give Seroquel 100 mg per mouth, two times a day at 8 a.m. and 2 p.m. Give Seroquel 300 mg per mouth, at hour of sleep for dementia with behaviors." On 03/16/13 at 2:45 p.m., an incident report documented the resident was attempting to stand up, wheel chair was unlocked and suddenly moved which resulted in the resident falling to the floor. The intervention was to provide re-orientation and keep the resident within sight to monitor closely. He sustained no injuries. The report documented he was confused. On 03/17/13 at 11:45 a.m., an incident report documented the resident was being fed in the dining room and suddenly stood up and fell backwards. The interventions were to help him back to his wheelchair and re-orient him. Additional interventions documented the resident needed to be supervised by staff and redirected. He sustained no injuries. The report documented he was confused. On 03/19/13 at 9:00 a.m., an incident report documented, "CMA heard a bang. She looked up and seen res. on floor over foot pedal. Res sitting on his knees c head on floor." The resident sustained [REDACTED]. The documented intervention was to clean and steri-strip the laceration and start neuro checks. He was documented as oriented times one. A state reportable incident form dated 03/19/13, documented the resident was seated in the lobby when he tried to get out of his wheelchair. Nurses' notes dated 04/13/13 and 04/17/13, documented the resident continued to be lethargic and not as he used to be. A new order was obtained to discontinue Klonopin, Seroquel, Depakote and Vistaril. A monthly social service note dated 04/13 documented, the resident is more alert and his eyes were open. An incident report dated 05/02/13 at 6:25 a.m., documented the resident was found on the floor of his room in front of the bathroom door. There was no documentation as to the location of the wheelchair. The interventions were to have aides get him up first and place him within sight of staff. He sustained no injuries. The report documented he was confused. A state reportable incident form dated 05/02/13, documented the resident was found next to the restroom sitting down. His fall risk was rated at a 22. He did not have any safety awareness. He tried to stand and walk. His legs were weak. The intervention was for staff to redirect as needed. On 05/05/13 at 2:45 a.m., the incident report documented the resident was found on the floor next to his bed. The documented interventions were to put the resident in a low bed with a safety mat, get him up if he was awake, and place him where staff could observe him. He sustained no injuries. The report documented he was confused. A state reportable dated 05/05/13, documented the resident was assessed by the charge nurse. He had a hematoma on the middle of his forehead and neuro checks were started. On 05/14/13 at 9:15 p.m., the incident report documented the resident was found on hall 400's floor. He had a laceration above his right eye. He was documented as oriented to self only. The laceration was treated in the facility. The documented intervention was the resident's wife bought a bike helmet for the resident to wear while he was up. There was no documentation as to the location of the wheelchair. A nurse's note dated 05/14/13, documented the wife was concerned about the falls and purchased a bike helmet for the resident. On 05/16/13 at 6:30 p.m., the incident report documented the resident climbed out of the geri-chair two times, landed on the floor and was wearing a helmet. The documented intervention was to wear a biking helmet while up to protect head. He sustained no injuries. The report documented he was confused. A state reportable dated 05/16/13, documented the resident was in the lobby. He attempted to stand and fell to the floor. His left eyebrow was bruised. He was placed with a staff member for 1:1 monitoring. His fall risk was rated at a 21. He had very poor cognition and safety awareness. The interventions were for him to wear a biking helmet while up to prevent further head injuries and to keep him where he could be re-directed. On 05/20/13 at 1:00 a.m., the incident report documented he was found crawling across the floor of his room and sustained a laceration to the left side of his head. The documented intervention was the resident was sent to the emergency room and kept 24 hours for observation. The MRI was negative for intracranial bleed. The incident report documented he was confused. The state reportable incident report dated 05/20/13, documented he tried to get up and ambulate by self. He has generalized weakness. He wore a bike helmet while up. A quarterly resident assessment dated [DATE], documented the resident was severely impaired in cognition and was totally dependent on staff. He required the assistance of two staff members for ADLs and transfers. He rarely understood others or made himself understood by others. A social service note dated 06/27/13, documented, "Cont to be in geri chair and is more alert he is more alert he is, up in his geri chair most of the time, he tries to get up and walk most of the time..." A social service note dated 07/10/13, documented, "Cont to be in a geri chair and tries to get up on his own..." On 07/21/13 at 9:50 a.m., the incident report documented the resident stood up out of chair, walked three feet and fell on his buttocks. The documented intervention was for staff to provide assistance when the resident was ambulating. He sustained no injuries. The report documented he was confused and was not wearing a bike helmet. A pharmacy consult to the resident's primary physician dated 08/07/13, documented the pharmacist requested a reduction of Seroquel 100 mg at hour of sleep to 75 mg at hour of sleep because he tried to stand up without assistance on a fairly routine basis. The physician declined. The rational provided was that the resident had ongoing psychosis, insomnia and aggressive behaviors. On 08/27/13, the resident was placed on Risperdal (an antipsychotic) 0.5 mg every morning. The medication was to be discontinued on 09/09/13. This medication plus progesterone were started for inappropriate sexual behaviors. On 08/28/13 at 11:30 a.m., the incident report documented, ".. a staff member stated they heard a bang in the dining room on hall 300. The resident was found sitting in front of his wheelchair." The DON added to the side of the report, "Res. attempted to lean forward & stand @ the same time. fell to the Lt hit his Lt. Fore head and Lt Elbow on the Table next to him. W/n 20 min Res experienced Vomiting- sent to (local ER) for evaluation." The documented interventions were to "X-ray to (L) shoulder to elbow sent to local ER) for eval." The report documented the resident was confused but did not address as to weather or not he was wearing the safety bike helmet. A state reportable incident form for the same incident documented, "...Dx c/ subdural hematoma (bleeding under the skin near the brain area) Surgery not an option. Res. started on Hospice per family & MD." A physician's orders [REDACTED]. This physician's orders [REDACTED]. A social service note dated 08/29/13, documented, "Cont to try and get out of his chair..." On 10/01/13 at 10:15 p.m., an incident report documented he was found on the floor next to the soft mat. The bed was in low position. The intervention was to check on him more frequently. On 10/14/13 at 7:30 a.m., the resident was observed seated in a wheelchair with a torso support in place. He was seated in the lobby next to the front door. It was observed that staff was busy seating other residents at their tables in the dining rooms. No one was seated at the nurse's station. He was not continually monitored. At 7:55 a.m., he was transported to the dining room. The resident was unattended for twenty five minutes. On 10/15/13 at 11:00 a.m., CNA #5 was interviewed. She was asked if she had ever been given special instructions about the care of residents with fall precautions. She stated they were to be kept in the lobby or dining room where someone could watch them. She was asked whose responsibility it was to watch them while they were in the lobby or dining room. She stated she wasn't sure whose responsibility it was. She was asked if there was a plan of care available for residents with frequent falls. She stated just the ADL book, so we know when to give them showers. She was asked if the ADL book told staff if a resident required frequent monitoring or frequent visual checks. She stated it did not. She was asked if the resident wore a helmet. She stated she was not aware that he was supposed to wear one. She was asked if she knew where it was. She stated she did not know. At 11:05 a.m., LPN #1 was asked if the resident wore a helmet. She stated, "I've never seen him wear one. I wasn't aware he was supposed to wear one." She was asked if she knew where the helmet was. She stated she did not. On 10/16/13 at 9:50 a.m., CNA #3 was observed propelling the resident down hall 400. The resident's wheelchair was observed to have one foot pedal on the right. The resident's right foot was observed resting on the foot pedal. The left foot was observed to intermittently drag on the floor as he was propelled down the hall. CNA #3 was asked why the chair only had one foot pedal. She stated, "Oh, he just puts both feet on top of the other one." The CNA left the resident sitting in the wheelchair outside the door to his room. At 9:55 a.m., CNA #1 was observed to approach the resident, propel him into his room and close the door. The surveyor entered behind the staff member. The second foot pedal to the wheelchair was observed lying under the bed. When asked about the equipment, CNA #1 stated it was broken. The CNA positioned the resident's wheelchair toward the foot of the bed and pulled the privacy curtain. The CNA then stood in front of the resident, placed her left arm underneath his left arm and jerked him up, pulling him to his feet. The resident was observed to resist the CNA and shuffle his feet back and forth as if trying to run away. Once the resident was in a standing position, the CNA pushed his sweat pants down past his thighs to his ankle areas. The resident continued to resist the staff. The surveyor asked CNA #1 if she usually performed care for this resident alone. She stated he was a two person assist, but her help was performing a shower for another resident. The resident was observed to sway back and forth, reaching and pulling on the privacy curtain as the CNA tried to hold him up and remove the soiled brief. His pants were still around his ankles and his feet were crossed. The surveyor asked the CNA if she had been inserviced on how to transfer the resident safely. She stated, "He usually stands up and let us change him." The surveyor asked the staff member if she was ever trained on how to safely transfer a resident. She stated, "No, I have not been inserviced." The surveyor asked the CNA how long she had been employed by the facility. She stated, "Two months." She was then asked how long she had worked as an CNA. She stated, "This is my first CNA job, so two months." The surveyor instructed the CNA to assist the resident to the side of the bed and allow him to sit down. The care was then provided and completed with the assistance of CNA #2. On 10/17/13 at 11:10 a.m., an interview was conducted the the DON. She was asked how the staff knew how much assistance a resident required. She stated, "Its on the care plan and their day sheets." She was asked how the staff was made aware of residents who were at high risk for falls to ensure safety. She stated, "It's all on the care plan and daily care sheets." She was then asked if her staff had been inserviced on the use of gait/transfer belts. She stated, "I can't tell you the number of times we have been over this with them, its a constant daily reminder." The DON was informed of the above observation made by the surveyor with the staff member and resident #4. She made no direct comment, except to say "Unbelievable, absolutely unbelievable." On 10/16/13 at 10:00 a.m., the DON was interviewed. She was asked if the resident wore a helmet. She stated, "No, he would not wear it." She was asked if his refusal to wear the helmet was documented. She stated she didn't know, she would check. At 4:00 p.m., CNA #7 was asked asked if she had been given special instructions about the resident's falls. She said that when he was up they were supposed to watch him. She was asked if the facility ever provided her with detailed information about how to prevent this resident's falls. She stated we have the ADL book. She was asked if the ADL book provided information about monitoring or walking the resident. She said she didn't think so. The CNA added he used to be able to walk really well but he had been kept in a wheelchair. He can still walk with assistance. At 4:30 p.m., CNA #6 was interviewed. She was shown the butterfly stickers on some of the resident's name plates and asked what they meant. She stated she thought they were for decorations. The resident did not have butterfly stickers on his name plate. She was asked what the colored dot stickers on the name plates meant. She stated they had never been explained to her. At 4:40 p.m., the DON was asked if the facility had a method of identifying residents who were at high risk for falls. She stated there was no identification system but she would inservice staff or give staff one on one instructions. She was asked if there was documentation of the inservices or one on one instructions. She stated she wasn't sure. On 10/17/13 at 10:00 a.m., the resident's ADL book was reviewed. It contained no documentation about frequent visual checks, monitoring, or wearing a helmet. At 10:30 a.m., the administrator and DON were interviewed. They were asked if the interventions documented in the care plan and incident reports had been implemented. The DON stated physical therapy was not consulted because he was too confused to follow instructions. She was asked for documentation. She stated there wasn't any. She was asked if he was provided restorative care. She stated no due to his lack of ability to follow instructions. The DON stated he would not wear the helmet. She was asked for documentation. She said there wasn't any. They were asked if he was ambulatory when he was admitted . They said that some of the time he was. They were asked if staff ever walked the resident. They said when he was first admitted they would walk him and he would settle down. They stated they still walk him. They were asked for documentation of staff walking the resident. They said there wasn't any. The DON stated they monitored him by placing him in the front lobby. She was asked if anyone was assigned to keep him in view. She stated everyone was responsible for watching him. They were asked why he wore the torso restraint. The DON stated because he reached forward then he would fall. They were asked why he was on hospice. The DON stated because when he returned from the hospital after the fall on 08/28/13, they thought he was going to die. He had sustained a subdural hematoma and it was inoperable. He probably doesn't need hospice anymore. They were asked if the direct care givers had access to a care plan that provided interventions for the resident's falls. The DON stated they could refer to the ADL (activities of daily living) book.

On 06/29/11, an immediate jeopardy (IJ) situation was determined to exist due to the facility's failure to assess residents to determine their ability to smoke independently and the facility's failure to provide supervision for residents who required supervision while smoking. At 3:10 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ. At 3:20 p.m., the administrator, DON, MDS coordinator and activity director were notified of the IJ situation in regard to the facility's failure to assess residents ability to smoke independently and to provide supervised smoking for residents who required supervision to smoke. The facility's plan of removal was accepted on 06/29/11 at 5:01 p.m. The plan of removal documented: "Plan of Removal 06/29/11 1. All residents are to be and will be supervised when smoking effective immediately. All residents will be assessed upon admission and quarterly. Each resident will be reassessed for functional/mental ability in regards to smoking by 6PM on 06/29/11. Each resident/family member(s) will be informed of the smoking policy prior to admission and sign documentation in regards to this matter by 6PM on 06/29/11. If responsible party is unable to comply, a 30 day notice and assistance with placement to another facility will be offered. 2. All resident cigarettes will be under lock and key and administered at the assigned smoking times with the supervision of assigned staff. All residents will insure (sic) that their cigarettes have been placed in the up-right ash tray before leaving the smoke area. 3. Residents will be informed that all smokers are supervised effective immediately. Any family member/friend etc. will bring all smoking materials to the front office during weekdays and give to the weekend nurse on duty if brought in on the weekend. No cigarettes and/or lighters are to be given directly to the resident. 4. All staff from every department will continue to be and have been in-serviced on 06/29/11 by 10PM in regards to the smoking rules. All staff is to report any possible burned areas noted on resident clothing and/or belongings to the Administrator, DON, MDS coordinator and/or the charge nurse immediately upon observation. 5. A notice will be posted at the entry way of the facility to inform all visitors of the smoking policy. The notice documented, "Attention: This is a supervised smoking facility. If you are bringing smoking materials to a loved one please turn them in to the front office or to the charge nurse. Thank you for your cooperation. Management." 6. Supervised smoking hours will be from 7AM to midnight with staff supervision only. 7. All assisted residents that require a smoking apron will have one on during smoking time." On 06/30/11 at 9:00 a.m., the employees who were on duty were interviewed about the new smoking policy. Two employees stated they had not received an in-service on smoking. Another employee who had been in-serviced stated not all smokers had to be supervised. All three employees were in-serviced at that time by the administrator. At 9:45 a.m., the IJ was removed. The deficiency remained at a pattern level with potential for more than minimal harm. Based on observation, clinical record review, review of policy and procedure and staff and resident interviews, it was determined the facility failed to ensure: a. adequate supervision was provided for three (#5, 12, and #21) of four sampled residents who required supervision with smoking. Two (#5 and #12) of the residents were observed smoking without supervision, and two(#5 and #21) of the residents were observed to have multiple burn holes in multiple pieces of clothing. This resulted in an immediate jeopardy (IJ) situation. This had the potential to affect six residents identified by the facility who required supervision while they smoked; b. a smoking safety assessment was performed on a quarterly basis, per facility policy, to identify the need for supervised smoking for one (#5) of four sampled residents who smoked. The resident had burn holes in his clothing. This resulted in an immediate jeopardy (IJ) situation. This had the potential to affect six residents identified by the facility who required supervision while they smoked; and c. adequate supervision and preventive interventions were provided to prevent falls for three (#1, #6 and #10) of 12 sampled residents. This had the potential to affect 60 residents identified by the facility who had fallen within the past six months. A facility policy titled, "Edmond Health Care Center, Smoking", documented: "Policy: It is the policy of the (facility) to maintain a safe and hazard free environment for all residents. Subject: Smoking To insure safety the following rules regarding smoking are in effect: 1. All residents that wish to smoke will have a Safe Smoking Evaluation completed by Nursing, Social Services, or Administration. 2. Residents who are considered independent smokers will be allowed to keep their own cigarettes and lighters as long as they do not abuse the privilege by smoking in unauthorized areas or at unauthorized times or giving cigarettes to supervised smokers. 3. Independent smokers not adhering to this policy may receive a verbal or written warning, or be placed on supervised smoking privileges only. 4. Supervised smokers will not be allowed to keep cigarettes or lighters. Staff will have their materials in the smoking area and will stay on site for supervision. A smoking apron will be required for all supervised smokers and will be provided by the facility. 5. Non-supervised smoking will be allowed from 7:00 AM to Midnight. 6. Supervised smoking will be at 6:30 AM, 8:30 AM, 1:00 PM, 3:00 PM, 6:00 PM and 9:00 PM for a duration of two cigarettes or 15 minutes whichever comes first. 7. The only authorized smoking area is the enclosed patio. 8. Residents not adhering to the supervised smoking policy may receive a verbal or written warning, or lose their privileges for 24 hours from the time of the infraction. Continuing to be non-compliant with the supervised policy will result in losing the privilege entirely, or being asked to find residency elsewhere." A facility policy titled, "Supervised Smoking Policy and Procedure Revised 6/16/2010", documented: "1. It is the goal of Edmond Health Care Center to ensure a safe environment for all residents and employees. 2. All residents, upon admission will be placed on supervised smoking for a period of 30 (thirty days) for staff to monitor their safety performance with cigarettes and lighters. 3. It is facility policy that all residents that use tobacco products will be assessed for smoking at the time of admission. 4. If a newly admitted resident does not smoke, facility will only complete: date, resident, check area for non-smoking with signature and date of signature. 5. When a resident has an Impaired Cognitive Skill, they will remain on supervised Smoking. 6. When a resident cannot communicate the need for assistance while attempting to use fire related items, they will remain on Supervised Smoking. 7. When a resident has been identified with a Visual Impairment, not allowing them to identify where the smoking urn is located, ashes in lap and or cigarette burned down to the tip, increasing chances of injury, the resident will remain on Supervised Smoking. 8. When a resident is assessed for having an impairment that would limit his/her capabilities of placing cigarette to mouth, disposing of ashes and or maintain a safe distance from body parts to prevent injuries, the resident will remain on Supervised Smoking. (such as tremors, paralysis, broken bones and etc.) 9. When a resident receives Oxygen Therapy, he/she will remain on supervised smoking. 10. When a resident has a history of smoking related incidents, he/she will remain on Supervised Smoking. 11. Interventions will be implemented based on Smoking Safety Assessment. 12. Resident will be informed of the Smoking Safety Assessment and Supervised Smoking Policy and Procedure. 13. Smoking Safety Assessments will be completed on a quarterly basis or as needed for all smokers. 14. Staff will be in the presents (sic) of/assisting as needed, at Supervised Smoke Times. 15. Supervised Smoke Times will be at odd hours beginning at 9:00 am and ending at 9:00pm. Discretion will be used by the Charge Nurse for Supervised after hours smoking. 16. Supervised smokers will not be allowed to carry cigarettes or lighters. At the end of the supervision smoking session, staff will return cigarettes and lighters to designated area. 17. Residents who are assessed to be safe to smoke alone will be allowed to carry their own cigarettes and lighters as long as they do not abuse the privilege by smoking inside the facility, smoking at unauthorized times (9:00pm to 9:00am) or places, giving supervised smokers cigarettes, lighters or fire related material." 1. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 03/01/10: "...Problem 8. Potential for injury R/T smoking... Goals 1. (Resident) will have no injuries R/T smoking during this review period and will smoke only in approved smoking areas... Approaches 1. Perform smoking assessment according to facility policy 2. Explain/show where designated smoking areas are --- repeat PRN 3. Monitor PRN when smoking to assure residents safety 4. Provide encouragement to stop smoking." A smoking safety assessment, dated 01/20/11, documented the resident was independent in cognitive skills for daily decision making, used a wheelchair and had a limitation in range of motion (right hemiparesis). He did not have a history of smoking related incidents and did not require supervised smoking. An update to the care plan, dated 06/01/11, documented, "doing well - no injury r/t smoking is monitored closely cont POC." A quarterly assessment, dated 06/05/11, documented the resident was independent in his cognitive skills for daily decision making. He required supervision to extensive assistance with his activities for daily living. He had a limitation in ROM in both lower extremities. On 06/28/11 at 9:45 a.m., during an initial tour of the facility, a cushion was observed on resident #23's wheelchair. There were multiple burn holes on the surface of the cushion. The resident was asked if that was his wheelchair cushion. The resident stated it was not his, but was his roommates cushion, and the cushions had been switched during an outing. Resident #23's roommate, resident #5, was asked if he smoked. He stated, "Yes." He was asked if ashes from his cigarettes caused the burn holes on the cushion. He stated the cushion was not his. He was asked if he ever dropped his cigarettes. He stated, "There has been a mix up with the cushions." At 2:47 p.m., resident #5 was asked if he could smoke anytime he wanted to. He stated, "Yes I can when I want." He was asked if staff were present for supervision. He stated, "I am not supervised for smoking." On 06/29/11 at 8:45 a.m., resident #5 was asked if he ever dropped ashes on his clothing. He stated, "Yeah." He was asked if the surveyor could look at his clothes. He agreed. The surveyor observed burn holes in the resident's clothes and immediately asked the resident if a second surveyor could look at the clothes as well. The following observations were made: -One pair of blue pants had three burn holes near the zipper. -A sweat shirt had a burn hole on the back of the arm. -A pair of gray sweat pants had two burn holes, one in the groin area and one near the thighs. -One blue T-shirt had a burn hole on the front - in the abdominal region. -A green jacket had five burn holes. -There was one burn hole in a maroon sweatshirt. -A gray pullover sweatshirt had one burn hole. -There was a burn hole in a blue satin shirt. -A burn hole was present in a red/black western shirt. At 9:47 am the DON asked if she was aware that resident #5 had burn holes in his clothing. She stated, "No I was not aware of (resident's) burn holes." She was asked when smoking evaluations/assessments were conducted for the residents. She stated, "Annually, but I have now been looking at them quarterly." She was asked when the last time resident #5 was evaluated. She stated, "I don't know." She was asked to look at the resident's clinical record for documentation of an assessment/evaluation. After looking through the resident's record, she stated, "Let me go look in his other chart. I don't see it here." At 10:45 a.m., resident #5 was observed smoking on the porch unsupervised. He was not wearing a protective apron. At 11:10 a.m., resident #5 was observed smoking on the porch unsupervised. He was not wearing a protective apron. At 11:40 a.m., the MDS coordinator produced two smoking assessments for resident #5. One was dated 03/17/10 and the other 01/20/11. She stated she did not have any others. 2. Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. A safe smoking evaluation, dated 04/10/11, documented the resident was intermittently confused and forgetful. The resident also displayed behaviors and symptoms of psychosis and required supervision. A smoking safety assessment, dated 05/03/11 documented the resident had impaired cognitive skills with long and short term memory loss. She used a walker and utilized oxygen on an as needed basis. She had a history of [REDACTED]. She needed assistance with lighting a cigarette and required supervision. A safe smoking evaluation, dated 05/19/10, documented the resident had long and short term memory problems, was confused, delusional and experienced hallucinations. She was unable to extinguish a cigarette and attempted to put a lit cigarrette into her pocket. The resident was on medications that could affect safety. She reqiured supervision. The facility identified the resident was a smoker who needed supervision. The resident's care plan, dated 06/16/11, did not address the resident's need for supervision while smoking. On 06/29/11 at 10:05 a.m., three residents were observed outside smoking. Two (residents #12 and #18) were to be supervised by a staff member. There was no staff present. Smoking aprons were not in use. At 10:30 a.m., resident #12 was observed sitting alone on the porch smoking a cigarette. There was no staff member present with the resident. The resident was not wearing a smoking apron. 3. Resident #21 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 04/26/10, documented: "...Problems Smoker... Goals (Resident) will smoke only in approved areas with supervision during this review period... Interventions Safe smoking evaluation quarterly and PRN... Instruct in approved smoking area and times as needed... Staff to keep cigarettes and lighter at all times... (Resident) to use safety apron when smoking... monitor for changes in smoking abilitities..." A smoking safety assessment, dated 07/30/10 documented the resident had impaired cognitive skills for daily decision making due to short and long term memory loss and was tremulous. He had a history of [REDACTED]. The resident was instructed but did not understand the facility smoking policy. It further documented the resident was to wear a smoking apron and required supervised smoking. An update to the care plan, dated 01/24/11, documented, "...in room found remains of 3 cigarettes in a stryofoam cup c H20 next to him - smell of cigarette smoke very strong in room. Resident denies smoking in room. (Resident) was instructed again 'no smoking in his room." A smoking safety assessment, dated 04/16/11, documented the resident had impaired cognitive skills for daily decision making due to short and long term memory loss and was tremulous. He had a history of [REDACTED]. The resident was instructed but did not understand the facility smoking policy. It further documented the resident was to wear a smoking apron and required supervised smoking. On 06/29/11 at 9:15 a.m., CNA #3 was asked if she knew of any residents who had burn holes in their clothing due to smoking. She stated, "A couple of residents have burn holes." She reported resident #21 had burn holes in his clothing. At 9:30 a.m., resident #21 was asked if he ever smoked by himself. He stated, "No." He was asked if the surveyor could look at his clothes. He stated, "Ok." The following observations were made: -A pair of brown sweat pants had three burn holes. -A second pair of brown sweat pants had three burn holes. -One gray sweatshirt had four burn holes. -A hooded gray jacket had one burn hole. -A yellow jersey had one burn hole. At 9:45 a.m., the DON was asked which residents were to be supervised while they smoked. She stated residents #12, 16, 17, 18, 21 and #22. She was asked about the times the residents were allowed to smoke. She stated, "On odd hours... 1:00, 9:00, 11:00, 3:00 and sometimes we play it by ear." She was asked how many smoking aprons were in the facility. She stated, "I am not sure." 4. Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 06/30/10, documented: "Problem Potential for falls r/t weakness, impaired mobility, psychotropic drug use, cognitive impairment and history of falls. Goals (Resident) will have no falls through to next review date. Approaches Keep bed at lowest level when she is in bed Evaluate cause of any falls and implement plan to decrease risk. Keep call light within reach and instruct how to use for help with each contact. Answer call light promptly. Keep environment free from obstruction, clutter and well lighted." An incident/accident report form, dated 01/23/11 at 1:00 p.m., documented, "Res slid from w/c and fell on the floor at the D/R entrance. Res was returning from lunch..." A form titled Interventions Related to Incident Reports, dated 01/23/11, documented, "...Intervention: Staff to monitor res during meals + apply L.B. (lap buddy) (after) res finished eating." An incident/accident report form, dated 01/28/11 at 9:45 a.m., documented, "Sitting in hallway 3, removed lap buddy + was found sitting on floor...No apparent injury..." A form titled Interventions Related to Incident Reports, dated 01/28/11, documented, "Intervention: Res to be where staff can monitor res while up in w/c." An incident/accident report form, dated 03/05/11 at 1:00 p.m., documented, "Res slid out of w/c at the nurses station. No apparent injury..." A form titled Interventions Related to Incident Reports, dated 03/05/11, documented, "Interventions: Res to be monitored closely by staff to provide time for res have lap buddy off and still be safe." An incident/accident report form, dated 03/17/11 at 6:00 p.m., documented, "Res slid onto floor after meal while lap buddy was off..." A form titled Interventions Related to Incident Reports, dated 03/17/11, documented, "Interventions: Res to be monitored for movement away from the table + to be redirected as needed." An incident/accident report form, dated 03/26/11 at 9:30 a.m., documented, "Res slid from the edge of her w/c to the floor. No injury reported..." A form titled Interventions Related to Incident Reports, dated 03/26/11, documented, "Interventions: Res to be where staff can monitor her actions + redirect her." A form titled Interventions Related to Incident Reports, dated 04/09/11, documented, "Incident: Slid out of the w/c while @ dinner. No injury noted. Interventions: Res to be redirect when needed if through c meal, needs lap buddy on." A form titled Interventions Related to Incident Reports, dated 05/01/11, documented, "Incident: Crawled out of bed on to the mat by the bed. No injury. Interventions: Res agitated and gotten up in her w/c." An incident/accident report form, dated 05/02/11 at 5:30 a.m., documented, "Observed resident on lower body on floor mat. Upper body on floor in fm c tennis shoes on..." An incident/accident report form, dated 05/11/11 at 2:50 p.m., documented, "Aide found resident on the floor off of her floor matt. Brought resident in her w/chair to the nurses station. 2 hematomas about size of penny noted on her forehead..." There were no interventions for this fall on 05/11/11. An incident/accident report form, dated 05/20/11 at 1:00 p.m., documented, Found on mat on floor next to bed c head against dresser..." A form titled Interventions Related to Incident Reports, dated 05/20/11, documented, "Interventions: Res is on low bed s/t this behavior to prevent injury and is care planned." The June 2011 monthly physician's orders [REDACTED]." An incident/accident report form, dated 06/11/11 at 2:00 p.m., documented, "Resident found sitting on the floor by the side of her bed..." A form titled Interventions Related to Incident Reports, dated 06/11/11, documented, "Intervention: Ice pack placed + neuro chg done. Res is on low bed c mat." An annual assessment, dated 06/15/11, documented the resident was severely impaired in cognitive skills for daily decision making, required total assistance with transfers and used a trunk restraint daily. It also documented the resident had two falls with no injury and two fall with minor injury since the date of the last assessment. An incident/accident report form, dated 06/20/11 at 5:30 p.m., documented, "Res stood up from her w/c for no apparent reason and slid to the floor thereby sustaining a minor skin tear on L hand." A form titled Interventions Related to Incident Reports, dated 06/20/11, documented, "Interventions: Res to have lap buddy place directly p dinner completed." An incident/accident report form, dated 06/27/11 at 2:00 p.m., documented, "Found face down on floor on mat next to bed. Active ROM (upper) + (lower) ext. Has 4 cm abrasion middle forehead. (No) bleeding." There were no interventions for this fall on 06/27/11. On 06/28/11 at 4:45 p.m., the resident was observed up in her wheelchair in the hall with a lap buddy in place. She was unable to remove the lap buddy on command. The resident was sitting quietly at the time of the observation. On 06/29/11 at 2:05 p.m., the director of nursing was asked where restraint reduction assessments were kept. She stated the assessments "fell through the cracks" and were not being done. On 06/30/11 at 8:20 a.m., the DON was asked what the facility had done to try and prevent falls for the resident. She stated there was not a lot they could do with the resident. She stated the resident could no longer remove the lap buddy as she had in the past. The DON also stated the resident had a lot of falls in the dining room. She was asked if the resident was supervised during meals. She stated, "Yes." She was asked if the resident was supervised, then why did the resident fall so much in the dining room. She stated the resident would push herself back from the table and slide down to the floor. She stated there was no staff sitting at the same table as the resident as she was in the main dining room and not in the assisted dining room. The DON was asked if the resident would benefit from being placed in the assisted dining room to prevent falls. She stated, "Yes, she would benefit." The DON was asked what they were doing to prevent the resident's falls from her bed. She stated the resident was already on a low bed with a mat and didn't know of anything else they could try. She was asked if they had considered mattress bolsters and/or other protective devices. She stated, "No." She stated she thought they were not allowed to use anything of that type. On 06/30/11 at 9:45 a.m., the resident was observed up in her wheelchair near the nurse's station. A lap buddy was in place in front of the resident. 5. Resident #1 was admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. An incident report, dated 02/22/11, documented the resident was found on the floor sitting and calling for help. An intervention form (titled "Interventions related to incident reports"), dated 02/22/11, documented the resident was to be instructed in the use of the call light and to ask for help. A care plan problem, dated 03/01/11, documented a risk for falls related to lower extremity weakness, impaired cognition, and poor safety awareness. The interventions documented for the problem were the following: Skilled therapies to increase strength, improve endurance, instruct in use of motorized wheelchair, and improve safety awareness; Encourage and allow independence within the resident's ability; Keep corridors and rooms clear and free of hazards and well lighted; Keep environment free from obstruction and clutter; Encourage socialization and activity attendance as tolerated; and Provide restorative care as needed after skilled therapies are discontinued. A care plan problem, dated 03/01/11, documented the resident had altered mental status with short and long term memory deficit and decreased judgement and cognition. The care plan documented a call light was to be at the bedside, within reach, and the staff were to answer it promptly. The care plan documented to use repetition with all instructions and to use simple, familiar phrases. An incident report, dated 03/05/11, documented the resident slid out of his recliner without calling for help. An intervention form, dated 03/05/11, documented to show the resident the call light and to monitor him frequently while in his chair. An incident report, dated 03/15/11, documented the resident was found sitting in front of his recliner in his room. The form documented the resident stated he was trying to go "to the chair." An intervention form, dated 03/15/11, documented the resident was to be placed in his recliner, when not using his electric wheelchair, with feet elevated. An incident report, dated 03/16/11, documented the resident had attempted to transfer from the wheelchair to the recliner and sat on the floor. An intervention form, dated 03/16/11, documented the resident was encouraged to use his call light and to tell someone on his way to his room that he needed help. An incident report, dated 04/02/11, documented the resident attempted to transfer himself from his motorized wheelchair to a recliner, unassisted, and fell . The form documented the resident did not use his call light. An intervention form, dated 04/02/11, documented the resident was to be followed to his room, placed in the recliner or bed with his call light in reach, and to be monitored and redirected. A care plan update, dated 04/21/11, documented 1/2 rails to be used for turning and positioning. An incident report, dated 05/02/11, documented the resident was observed sitting on his buttocks in his room with his knees bent. The form documented the resident stated he fell . An intervention form, dated 05/02/11, documented the resident was encouraged to use the call light. An incident report, dated 05/20/11, documented the resident attempted to transfer himself from the wheelchair to the toilet without calling for assistance and fell . The report documented the resident was to be closely monitored while up in a wheelchair. The report documented the care plan was updated. An intervention form, dated 05/20/11, documented the resident was encouraged to use his call light. A quarterly assessment, dated 05/29/11, documented the resident was severely impaired related to cognition and had disorganized thinking. The assessment documented the resident required limited assistance with bed mobility, extensive assistance with transfers, and was nonambulatory. The assessment documented the resident required supervision during locomotion, on and off the unit, while in a wheelchair. The assessment documented the resident had two falls since the prior assessment on 02/28/11. An incident report, dated 06/10/11, documented the resident was found lying on the floor by his bed. An intervention form, dated 06/10/11, documented the resident was sent to the hospital for wound care. The resident's care plan did not document the continued falls or new interventions to prevent further falls after the 04/21/11 update. On 06/28/11 at 11:05 a.m., the resident was observed, in his room, sitting in his motorized wheelchair. The resident was dressed and had socks and sandals on. The call light was within reach. At 11:47 a.m., the resident was observed driving the motorized wheelchair through the lobby. At 1:45 p.m., the resident was observed sitting in his recliner in his room. 6. Resident #6 was admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. The care plan, with an origination date of 03/02/10, addressed potential for falls and the use of a merry walker. Documented interventions on the care plan related to the prevention of falls were as follows: Resident will wear proper fitting shoes that are supportive with non skid soles for ambulation, Ambulation to be supervised for safety, Good lighting in living areas, Monitor for changes in transfer abilities with possible referral to physical therapy and/or restorative care, Anticipate and meet needs, Coordinate with staff to ensure a safe environment with floors even and free from spills or clutter and adequate, glare-free light, Provide activities that minimize the potential for falls while providing diversion and distraction, Alert staff/resident and family to risk for falls, Keep areas free of clutter, Keep call light within reach at all times- remind resident to use call light for assistance with each contact. Answer call light promptly, and Remind and assist to bathroom every two hours while awake - check every two hours while sleeping. A care plan update, dated 11/19/10, documented for the resident to use a merry walker when out of bed, for staff to monitor the resident's ability to maneuver with the merry walker, and to release the resident from the walker every two hours for exercise, range of motion, and toileting. The update documented to reassess the need and effectiveness (of the merry walker) every month. An incident report, dated 01/29/11, documented the resident fell out of a chair in the dining room. An intervention form, dated 01/29/11, documented the resident was to be monitored by staff at all times while at the dining room table. An incident report, dated 02/04/11, documented the resident turned her merry walker over. An intervention form, dated 02/(blank)/11, documented the resident tipped the merry walker over on the right side after being stuck while ambulating in the facility. The form documented the resident was to be supervised and monitored by staff while in the merry walker and redirected out of potential areas that could cause resident to become stuck. An incident report, dated 03/17/11, documented the resident stood up from a chair at the table and stumbled to her knees. An intervention form, dated 03/17/11, documented the staff were to monitor the resident when she was sitting in a chair and to assist when she stood up. A quarterly assessment, dated 03/23/11, documented the resident was unable to complete an interview, had short an

On 03/29/10 at 8:00 a.m., an Immediate Jeopardy (IJ) situation was identified regarding the facility's failure to cook and serve unpasteurized shell eggs in a manner to prevent the likelihood of foodborne illness. The facility staff had prepared unpasteurized fried eggs with liquid yolks. This affected 14 (#6, 8, 10, 18 and 22 through #31) of 14 sampled residents who were served unpasteurized fried eggs with liquid yolks. The Oklahoma State Department of Health (OSDH) was contacted on 03/29/10 at 9:50 a.m., and verified the existence of the IJ. At 9:55 a.m., the dietary manager (DM) and director of nurses (DON) were notified of the IJ situation in regard to the unpasteurized fried eggs with liquid yolks which were served to residents. They were asked to provide a list of residents who had been served soft cooked fried eggs for the breakfast meal. The administrator was not present in the facility when the DM and the DON were notified of the IJ situation. At 10:40 p.m., a plan of removal was presented to the survey team and documented the following: "PLAN OF REMOVAL 03/29/10 DIETARY: 1. In the event the kitchen runs out of eggs the staff will change the menu for breakfast/lunch and /or dinner to a different menu. 2. The facility has deliveries 3 times weekly, if dietary becomes low on supplies the Dietary Manager or designee will notify the Administrator. 3. The supplies will be checked by the (certified dietary manager) 3 times weekly to assure the facility has pasteurized eggs in the building. 4. Staff will be in-serviced on proper protocol in the handling and serving of eggs by 2pm on 03/29/10." A list of residents who had been served soft cooked fried eggs for the breakfast meal was provided to the survey team. At 11:30 a.m., the OSDH was contacted in regard to the facility's plan of removal and verified acceptance of the plan of removal. At 1:30 p.m., the administrator was notified of the survey team's acceptance of the facility's plan of removal. On 03/30/10 and 03/31/10, interviews were conducted with dietary staff. They were asked if they had been inserviced in regard to the preparation of soft cooked eggs. They stated they had been inserviced and were not to prepare/serve soft cooked unpasteurized eggs. On 03/31/10 at 9:15 a.m., the survey team confirmed the facility had implemented the plan of removal and the administrator, dietary manager and the corporate diet technician were notified the IJ had been removed as of 03/29/10 at 2:00 p.m. The deficient practice remained at the level of no actual harm with the potential for more than minimal harm with more than a very limited number of residents affected. Based on observation, interview and record review, it was determined the facility failed to: I. cook and serve unpasteurized shell eggs in a manner to prevent the likelihood of foodborne illness. The facility staff had prepared unpasteurized fried eggs with liquid yolks. This affected 14 of 14 (#6, 8, 10, 18 and 22 through #31) sampled residents who were served unpasteurized fried eggs with liquid yolks. II. store food and maintain the kitchen in a sanitary manner. Findings: I. On 03/29/10 at 8:00 a.m., during a tour of the kitchen, the surveyor observed a tray of shell eggs on the food preparation table across from the grill. The eggs were not stamped with a "P" to indicate they were pasteurized. The DM was in the process of frying eggs on the grill. As she transferred them from the grill to the individual plates the yokes were not firm. The DM was asked if she had pasteurized eggs. She stated she was "out" (of pasteurized eggs) and had gone to the store after she arrived at work, to purchase eggs. She was shown the eggs in the tray did not contain a stamp to indicate they were pasteurized. She was asked how many soft fried eggs she had served that morning. She stated, "About 10." At 8:20 a.m., the surveyor observed residents #10, 18, 28, 30 and #31 after a plate with a soft cooked fried egg had been served to each of them. At 8:55 a.m., two surveyors, the DM and the corporate diet technician observed the plate of resident #28 with a soft cooked egg. The DM stated she knew unpasteurized eggs were to be hard cooked and not served soft cooked. At 9:50 a.m., the surveyor asked resident #30 about the egg he was served for breakfast. He stated he had a soft cooked fried egg every day and liked the yolks runny. The DM had provided the surveyors with a list of residents who were served soft cooked fried eggs for breakfast on 03/29/10. Residents #10, 18, 30 and #31 were not on the list. She was informed of the surveyor's observations of the resident's plates with soft cooked fried eggs at breakfast. She acknowledged the soft cooked fried eggs and added their names to the list. Residents who were served soft cooked fried eggs were as follows: 1. Resident #28 was [AGE] years old and had [DIAGNOSES REDACTED]. 2. Resident #30 was [AGE] years old and had [DIAGNOSES REDACTED]. 3. Resident #18 was [AGE] years old and had [DIAGNOSES REDACTED]. 4. Resident #31 was [AGE] years old and had [DIAGNOSES REDACTED]. 5. Resident #10 was [AGE] years old and had [DIAGNOSES REDACTED]. 6. Resident #6 was [AGE] years old and had [DIAGNOSES REDACTED]. 7. Resident #22 was [AGE] years old and had [DIAGNOSES REDACTED]. 8. Resident #23 was [AGE] years old and had [DIAGNOSES REDACTED]. 9. Resident #24 was [AGE] years old and had [DIAGNOSES REDACTED]. 10. Resident #25 was [AGE] years old and had [DIAGNOSES REDACTED]. 11. Resident #26 was [AGE] years old and had [DIAGNOSES REDACTED]. 12. Resident #27 was [AGE] years old and had [DIAGNOSES REDACTED]. 13. Resident #29 was [AGE] years old and had [DIAGNOSES REDACTED]. 14. Resident #8 was [AGE] years old and had [DIAGNOSES REDACTED]. The dietary policy and procedure manual documented the following in regard to bacterial foodborne illness: "...Name of illness: Salmonellosis. Examples of foods involved: Poultry...eggs...What Causes It: Salmonellae. (Bacteria) widespread in nature, lives and grows in intestinal tracts of human beings and animals. Symptoms: Severe headaches, followed by vomiting, diarrhea. abdominal cramps, and fever...elderly, and persons with low resistance are most susceptible. Severe infections cause high fever and may even cause death...Transmitted by eating contaminated food...Preventive measures: Salmonellae in food are destroyed by heating the food to 140 F (Fahrenheit) and holding for 10 minutes or to high temperatures for less time; for instance. 155 F for a few seconds. Refrigeration at 40 F inhibits the increase of Salmonellae, but they remain alive in foods in the refrigerator or freezer..." II. On 03/29/10 at 7:40 a.m., an environmental tour of the kitchen was conducted. The following was observed: a. A red bucket of liquid with a white rag in it was on top of the food preparation table. The DM was asked what was in the bucket. She stated it was bleach and soap water. She was asked if the bucket was to be setting on the food preparation table. She stated, "No." b. The bottom shelf of the metal food preparation table was rusted. A wooden rolling pin was stored on the shelf. c. Dried food debris was on the inside roof of the Panasonic microwave. The facility's "Cleaning of Microware Ovens" policy documented: "...To maintain the microwave oven in clean, (odor) free condition...Wipe the interior of the oven with hot sudsy water..." d. Hanging over the food preparation table was a scratched/cracked white rubber spatula with dried debris and a black Ecko spatula with dried debris. e. Dried debris was on the motor and white pipe under the dishwasher. At 9:03 a.m., the 3 freezers in the activity room were observed with the DM. The inside of the lid was detached on the General Electric freezer. A box of chicken fried steak was open to air. The DM acknowledged the broken freezer lid and the box of chicken fried steak open to air. At 03/30/10 at 3:20 p.m., the DM and the corporate diet technician were shown the above findings in the kitchen. They acknowledged the findings.