Every finding on record at Oak Hills Living Center

Based on record review and interview, the facility failed to provide necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent the worsening of a pressure injury for 1 (#3) of 4 sampled residents reviewed for pressure ulcers. These failures resulted in progression of the wound to an unstageable pressure injury with necrotic tissue, periwound infection, undermining, and transfer to the emergency department for evaluation and treatment.The DON identified 12 residents received wound care services. Findings:A skin assessment for Resident #3, dated 03/10/26, did not show a wound to Resident #3's right elbow. A nurse progress note for Resident #3, dated 03/12/26, showed the staff identified an open wound to the resident's right elbow, notified the physician and the wound care team, and initiated treatment with triple antibiotic ointment daily.A skin assessment for Resident #3, dated 03/12/26, showed an open wound to Resident #3's right elbow. A skin assessment for Resident #3, dated 03/17/26, showed a scab to Resident #3's right elbow. A wound care company document for Resident #3, dated 03/19/26, showed the wound care company evaluated the resident's heel wound, but it did not address, assess, or document the right elbow wound.A skin assessment for Resident #3, dated 03/24/26, showed a wound to Resident #3's right elbow. A wound care company document for Resident #3, dated 03/26/26, showed the wound care company evaluated Resident #3 and assessed the right elbow wound as an unstageable pressure injury with symptoms of periwound infection, necrotic tissue, and undermining. The document showed they recommended transfer to the emergency department for treatment.A nurse progress note for Resident #3, dated 03/27/26 at 5:55 a.m., showed the resident returned from the hospital with antibiotic therapy for a wound infection.A wound care company document for Resident #3, dated 03/27/26, showed the resident's wound demonstrated increased necrotic tissue.A care plan for Resident #3, dated 04/08/26, showed the resident had impaired mobility and wounds. The care plan showed the resident had limited mobility to upper and lower bilateral extremities. The care plan showed the resident had a left heel pressure ulcer initiated on 01/06/26 and showed the resident had a right elbow wound initiated on 03/12/26. The care plan did not include interventions to turn or reposition the resident to prevent worsening of skin integrity. On 07/29/26 at 2:05 p.m., CNA #4 stated Resident #3 was on restorative services for right sided weakness and needed assistance with positioning and repositioning.On 07/29/26 at 2:35 p.m., the DON stated wound healing should be evaluated through routine wound assessments to include measurements, visual assessment, and periwound temperature. The DON stated wound care should be evaluated routinely, and care plans should include interventions such turning and repositioning to prevent skin breakdown and promote healing; especially for residents with impaired mobility.

Based on observation, record review, and interview, the facility failed to provide a pest free, clean, homelike environment for 1 (#4) of 3 sampled residents reviewed for homelike environment.The administrator identified 110 residents resided in the facility.Findings:On 07/22/26 at 9:58 a.m., an observation was made of a live small cockroach on the outside of Resident #4's teal colored personal refrigerator in their room. Small dead cockroaches were also observed frozen inside Styrofoam cups and on the wired bottom portion inside of the refrigerator's freezer section.On 07/29/26 at 1:25 p.m., an observation was made of small frozen cockroaches inside of Resident #4's personal refrigerator freezer. Resident #4 was observed taking out Styrofoam cups from the refrigerator that were sitting next to a dead cockroach inside of the freezer.A quarterly MDS assessment for Resident #4, dated 04/24/26, showed the resident had a BIMS score of 15, which indicated intact cognition. A facility policy titled Pest Control Policy, dated 07/01/26, read in part, Food storage, waste disposal, housekeeping, laundry, and build maintenance practices will support pest prevention by eliminating conditions that contribute to pest activity.On 07/22/26 at 9:52 a.m., Resident #4 stated they were still experiencing a cockroach infestation and had seen other bugs in their room.On 07/29/26 at 1:14 p.m., Resident #4 stated staff were not cleaning the inside of their refrigerator properly.On 07/29/26 at 1:26 p.m., Resident #4 stated they were not happy with the way their room was.On 07/29/26 at 1:31 p.m., CNA #1 stated the facility had some problems with cockroaches in the past, and there were still some here and there. They stated housekeeping needed to move things and wipe them down in a resident's room, so they did not get bugs. CNA #1 stated Resident #4 had baby cockroaches behind their refrigerator last year.On 07/29/26 at 1:43 p.m., CNA #1 stated Resident #4's refrigerator should be getting cleaned. They stated pest problem areas should be looked at, and pest control should be informed. They stated housekeeping staff should be asking Resident #4 if they can clean out the refrigerator. They stated having frozen bugs in the refrigerator was not a homelike environment.On 07/29/26 at 2:01 p.m., the housekeeping supervisor stated staff were supposed to look in personal refrigerators and clean in and around them. They stated if a resident had cockroaches in their refrigerator, then they would talk to the resident about taking that one out and getting a new one.On 07/29/26 at 2:11 p.m., the housekeeping supervisor stated the housekeeping staff had not cleaned Resident 4's refrigerator yet and they were not sure of how long the bugs had been in the fridge.On 07/29/26 at 3:03 p.m., the administrator stated if the facility knows a resident has pest control issues around a piece of furniture, it is moved and cleaned or thrown away and replaced. They stated housekeeping staff checked the personal refrigerators, and they would let the administrator know if there was a pest problem.

Based on record review and interview, the facility failed to ensure a baseline care plan was completed accurately for elopement risk for 1 (#5) of 16 sampled residents reviewed for baseline care plans.The administrator identified 110 residents resided in the facility.Findings:A behavioral health center stay summary for Resident #5, dated 06/29/26, showed the resident was at risk for elopement and lacked reliable decision-making capacity. A behavioral health center new patient referral for Resident #5, dated 07/06/26, showed the resident was at risk for poor judgement and impulses and wandering behaviors. A baseline care plan for Resident #5, dated 07/15/26, showed the resident was not marked as an elopement risk.A BIMS assessment for Resident #5, dated 07/15/26, showed the resident had a BIMS score of 6, indicating severe cognitive impairment.An incident report for Resident #5, dated 07/22/26, showed Resident #5 had eloped from the facility through another resident's room window.On 07/28/26 at 2:54 p.m., the administrator stated Resident #5 was placed in the secured unit due to being a wanderer and a potential risk for elopement. They stated they knew the resident was a potential risk for elopement due to hospital records and family interviews that were received upon Resident #5's admission to the facility.On 07/29/26 at 10:20 a.m., the administrator stated they could not explain why Resident #5's baseline care plan did not show they were an elopement risk. They stated it should have been.

Based on record review and interview, the facility failed to ensure secured windows were maintained in secure units to prevent elopement for 1 (#5) of 3 sampled residents reviewed for elopement.The corporate nurse consultant identified 40 residents were at risk for elopement in the facility.Findings:On 07/28/26 at 1:23 p.m., all windows on Hall 100, where Resident #5 resided, were observed. All windows in the hall were secured shut by screws. An elopement risk assessment for Resident #5, dated 07/14/26, showed the assessment was partially completed with no wandering or elopement history recorded. A BIMS assessment for Resident #5, dated 07/15/26, showed the resident had a BIMS score of 6, indicating severe cognitive impairment.An elopement risk assessment for Resident #5, dated 07/17/26, showed the assessment was partially completed with no wandering or elopement history recorded. An incident report for Resident #5, dated 07/17/26, showed the resident had eloped from the facility through another resident's room window, walked to an area with a low fence and jumped over. The resident was seen wandering by a bystander and reported to the police. The police evaluated the resident, contacted the facility, and took the resident to a local hospital. The hospital reported the resident was okay and did not sustain any injuries to the facility.Prior to the elopement on 07/17/26, no documentation was found the facility was conducting window alarm checks for maintenance purposes in the secured units.Hospital emergency room notes for Resident #5, dated 07/17/26, showed the resident was not in acute distress or respiratory distress. The notes showed Resident #5 was documented as being well-hydrated and had no concerns documented on their wellness exam. A care plan focus for Resident #5, dated 07/21/26, showed the resident was at risk for elopement and wandering.On 07/28/26 at 9:54 a.m., CNA #2 stated they had worked on Resident #5's hall and had not been trained on how to check if windows were secured on the hall. They stated no window alarms were going off when Resident #5 eloped from the facility.On 07/28/26 at 2:14 p.m., the facility's previous maintenance staff was contacted. They stated they left the faciity on [DATE]. They stated they did not check the window alarms and did not put in the window screws. They stated they knew the alarm system was messed up.On 07/28/26 at 2:54 p.m., the administrator stated window alarms had been placed on secure unit windows in November of 2025 and windows were screwed shut the day of the elopement on 07/17/26. They stated maintenance staff were supposed to be checking the window alarms often, but they got away from that at some point. On 07/29/26 at 10:45 a.m., Resident #5 stated they left through another resident's window the day they eloped and there was no alarm on it. They stated they were easily able to open the window. Resident #5 stated the other resident had shown them how to open the window prior to their elopement.

Based on observation, record review, and interview, the facility failed to ensure staff performed hand hygiene between doffing and donning gloves during wound care treatment for 1 (#8) of 1 sampled resident observed for wound care. The DON identified 12 residents received wound care services.Findings:On 07/28/26 at 10:00 a.m,, wound care observation treatment for Resident #8 showed LPN #3 removed soiled gloves and applied a clean pair of gloves without performing hand hygiene between glove changes.A policy titled Wound Care, last revised 10/2010, showed hand hygiene should be performed before applying gloves and after removing gloves.A policy titled Handwashing/Hand Hygiene, last revised 09/2019, showed hand hygiene should be performed before applying gloves and after removing gloves.A policy titled Infection Prevention and Control Program, last revised 01/01/26, read in part, Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.On 07/28/26 at 10:36 a.m., LPN #3 stated they should have performed hand hygiene between each glove change.On 07/29/26 at 2:32 p.m, the DON stated hand hygiene should be performed before and after each glove change during wound care treatments.

A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 11/07/25 related to the facility's failure to provide supervision to prevent elopement.Based on observation, record review, and interview, the facility failed to ensure a resident requiring increased visual checks was not neglected for 1 (#1) of 3 sampled residents reviewed for neglect.LPN #1 identified 119 residents resided in the facility. The DON identified 21 residents at risk for elopement. Findings:On 11/18/25 at 5:46 a.m., window alarms were observed in all rooms on hall 500, the secured dementia unit.On 11/18/25 at 10:46 a.m., CNA #1 demonstrated a window alarm to be functioning by raising the window. The alarm sounded upon the window being raised.On 11/18/25 at 10:53 a.m., the fence outside the secured dementia unit was observed. There was a chain link fence. In some areas there was also a wooden fence. The chain link fence was less than 6 feet tall and the wooden fence was 6 feet.An undated admission record for Resident #1 showed the resident admitted to the facility on [DATE] with diagnosis which included Wernicke's encephalopathy.Resident #1's care plan, revised 10/29/25, showed Resident #1 was insisting on leaving and had told a family member they were walking home if the family member did not come and get them. The care plan showed Resident #1 was then placed on a secured dementia unit and increased visual checks. A revision of the care plan on 11/07/25 showed window alarms were ordered and would be put in place upon arrival and staff education was completed on elopement.Resident #1's admission assessment, dated 11/03/25, showed the resident had a BIMS score of 8 which indicated moderate cognitive impairment, and they were independent with ambulation. The assessment showed Resident #1 was a wandering risk.Resident #1's hospital record, dated 11/07/25, showed Resident #1 flagged down a police officer on the side of the road with complaints of leg pain and weakness. The record showed the police called an ambulance service who took Resident #1 to the hospital. The record showed at approximately 6:50 a.m. EMS contacted the facility and reported Resident #1 was in their custody and the resident would be returned to the facility. The record showed Resident #1 returned to the facility at 8:40 a.m. The record showed healing abrasions to Resident #1's anterior shins bilaterally.A Nurse Charting Note, dated 11/07/25 at 8:58 a.m., showed Resident #1 had abrasions noted to knees bilaterally, not bleeding, scab noted, minor bruising noted to top of hand. The note showed Resident #1 voiced no pain.An Abuse, Neglect, Misappropriation & Prevention Program policy, effective 11/07/25, read in part, Adequate staffing and supervision must be maintained at all times.A Resident Monitoring/Behavior Sheet reviewed showed Resident #1 was placed on one-on-one monitoring from 11/07/25 through 11/13/25. One-on-one stopped when the window alarms were installed in all rooms located on hall 500. Nurse Competencies reviewed showed competencies were completed with nursing staff on 11/07/25 through 11/25/25.In-services reviewed showed on 11/10/25 at 2:00 p.m., the facility conducted in-services on abuse response/rounding tool and care plan management.A Quality Assurance and Performance Improvement on 11/11/25 showed interventions which included door/window alarm testing, rounding log review, staff education on elopement, rounds, and care planning.An untitled monitoring log showed window alarms were monitored on 11/12/25 through 11/30/25.On 11/18/25 at 11:08 a.m., Resident #1 stated they had gone across the hall, went out the window, and crawled under the fence. They stated they got out front and walked down the street. They stated they realized how far the walk was, so they flagged down a policeman. They stated, I shouldn't have done it, I shouldn't have left.An undated written statement from CNA #1 showed they had only seen Resident #1 at the beginning of the shift. They stated they had only checked on some residents and not all.On 12/01/25 at 11:59 a.m., CNA #1 stated that increased rounds would be maybe every hour instead of two.On 12/01/25 at 1:20 p.m., CMA #2 stated they had seen Resident #1 at the beginning of the shift. They stated they conducted rounds at 6:00 a.m. and not at 3:00 a.m. They stated Resident #1 was continent, so they had not conducted rounds on them. CMA #2 stated they could not remember what time the other rounds had been conducted and between rounds they had been watching television.On 12/02/25 at 11:17 a.m., assistant police chief stated the responding officer had picked up Resident #1 three miles from the facility on 11/07/25 at 5:33 a.m.On 12/02/25 at 12:47 p.m., Resident #1 pointed out the window and stated they went under the fence right there at the end. Resident #1 stated they were unsure how far they walked, but they went pretty far.On 12/02/25 at 3:41 p.m., the former administrator stated they reviewed the camera on 11/07/25. They stated rounds were not completed every two hours, the hall was dark, and the medication aide and the nurse were both sleeping.On 12/02/25 at 3:43 p.m., the former administrator stated they observed Resident #1 on the camera coming out of their room on 11/07/25 around 4:30 a.m. to 4:45 a.m. and walk straight across the hall into another room. They stated Resident #1 never came out of the room. On 12/02/25 at 3:45 p.m., the former administrator stated sleeping and not conducting rounds was neglect. On 12/03/25 at 4:31 p.m., corporate nurse consultant #1 stated, That night I think there were some failures.

A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 11/07/25 related to the facility's failure to provide implement interventions for a resident with a known history of elopement.Based on record review and interview, the facility failed to implement care plan interventions for 1 (#1) of 3 sampled residents reviewed for care plan interventions with a known history of elopement risk.LPN #1 identified 119 residents resided in the facility. The DON identified 21 residents at risk for elopement.Findings:A Routine Resident Checks (Rounding Policy), dated 11/07/25, read in part, It is the policy of this facility to ensure the safety, well-being and supervision of all residents through consistent, documented routine resident checks (rounds) conducted at least every two (2) hours and more frequently as indicated by resident condition, care plan, or risk status. Increased Visual Checks - Enhanced frequency of rounding (e.g., every 15-60 minutes) for residents identified as high risk for falls, elopement, behavior changes, or medical instability.An undated admission assessment for Resident #1 showed the resident was admitted to the facility on [DATE] with diagnosis which included Wernicke's encephalopathy.Resident #1's care plan, revised 10/29/25, showed Resident #1 was insisting on leaving and had told a family member they were walking home if the family member did not come and get them. The care plan showed Resident #1 was then placed on a secured dementia unit and increased visual checks. Resident #1's admission assessment, dated 11/03/25, showed the resident had a BIMS score of 8 which indicated moderate cognitive impairment, and they were independent with ambulation. The assessment showed Resident #1 was a wandering risk.Resident #1's hospital record, dated 11/07/25, showed Resident #1 flagged down a police officer on the side of the road with complaints of leg pain and weakness. The record showed the police called an ambulance service who took Resident #1 to the hospital. The record showed at approximately 6:50 a.m. EMS contacted the facility and reported Resident #1 was in their custody and the resident would be returned to the facility. The record showed Resident #1 returned to the facility at 8:40 a.m. The record showed healing abrasions to Resident #1's anterior shins bilaterally.Resident #1's care plan, revised 11/07/25, showed window alarms were ordered and would be put in place upon arrival and staff education was completed on elopement.Nurse Competencies reviewed showed competencies were completed with nursing staff on 11/07/25 through 11/25/25.In-services reviewed showed on 11/10/25 at 2:00 p.m., the facility conducted in-services on abuse response/rounding tool and care plan management.A Quality Assurance and Performance Improvement on 11/11/25 showed interventions which included door/window alarm testing, rounding log review, staff education on elopement, rounds, and care planning.On 12/01/25 at 1:23 p.m., CMA #2 stated they had not done rounds at 3:00 a.m. They stated rounds were done at 6:00 a.m. They stated were unsure if any other rounds were done. They stated they were at the nurse's station during most of their shift watching television.On 12/01/25 at 1:25 p.m., CMA #2 stated they had probably not followed the resident's care plan.On 12/03/25 at 2:10 p.m., the interim administrator stated they viewed the video and they had seen an employee at the desk with their head down.On 12/10/25 at 2:12 p.m., the interim administrator stated they would expect staff to ensure residents were safe and accounted for during their shifts. On 12/03/25 at 4:19 p.m., the minimum data set coordinator stated increased visual checks would be each time you go by them, maybe every hour.On 12/03/25 at 4:31 p.m., corporate nurse consultant stated there were failures that night.

Based on record review and interview, the facility failed to ensure a resident was free from abuse for 1 (#2) of 3 sampled residents reviewed for abuse.The DON identified 115 residents resided in the facility.Findings:An undated facility policy titled Abuse and Neglect Policy, read in part, The Abuse/Neglect Policy of this facility will be implemented to ensure all residents entrusted in our care will be free from mental, verbal, or physical abuse. It is our goal to provide quality care to our residents.1.An undated admission Record showed Resident #2 had diagnoses which included major depressive disorder and anxiety disorder.Resident #2's annual assessment, dated 09/18/25, showed the resident's cognition was intact with a BIMS score of 15. No behaviors were documented on the assessment.An Incident Report Form, dated 09/29/25, read in part, Resident [#2] went to kitchen to ask that [their] cup be washed out. [Certified Dietary Manager] told resident [ Resident #2] 'hang on a minute.' Resident [#2] began cussing and using profanity and called [Certified Dietary Manager] a [explicit] and [Certified Dietary Manager] reciprocated calling Resident [#2] a [explicit]. Cup was thrown by resident [Resident #2] towards employee. Staff immediately intervened to cease altercation. No physical injuries noted to resident. Employee suspended. Investigation initiated .Investigation concluded. Abuse substantiated. Interviews with staff completed. Interview with resident completed. Interviewed other residents about this employee, no other reports of abuse noted. Family member at drink station when incident happened, family member with statement of what was witnessed. No other residents witnessed incident. After viewing facility camera footage, verbal abuse and incident confirmed. [Certified Dietary Manager] terminated. Safe surveys completed and no other allegations reported. Trauma assessment completed. [Name withheld} counseling to visit with resident. Abuse Policy in-service completed with all staff. Incident reviewed in morning meeting and will be reviewed at next scheduled QAPI meeting.On 10/22/25 at 3:09 p.m., Resident #2 stated, they went to the kitchen to ask for their cup to be washed, the certified dietary manager grabbed them and hit them in the arm with the door. The certified dietary manager grabbed my hand, it was annoying. They called me a [explicit]. I called them a [explicit] back. They were just rude and ignored me. I did not like that. On 10/23/25 at 8:53 a.m., dietary aide #1 stated they had witnessed the resident get upset due to the certified dietary manager taking a minute to assist them. It was probably frustrating. They both used the B word. I knew the resident said it first, but that did not make it right.

The Immediate Jeopardy (IJ) has been removed based on a determination resulting from an Informal Dispute Resolution (IDR).On 09/18/25 at 1:23 p.m., a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect residents from physical abuse. Resident #2 was involved in an altercation with Resident #1 resulting in a fist fight and Resident #1 falling to the ground. Resident #2 continued to sit on and hit Resident #1. Resident #1 lost their balance during the altercation and fell to the floor resulting in a fracture of their left femur.Based on record review and interview, the facility failed to ensure a resident was protected from physical abuse inflicted by another resident for 1 (#1) of 4 sampled residents reviewed for abuse.The administrator identified 117 residents resided in the facility.Findings:An undated facility policy titled Abuse and Neglect Policy, read in part, The Abuse/Neglect Policy of this facility will be implemented to ensure all residents entrusted in our care will be free from mental, verbal, or physical abuse. It is our goal to provide quality care to our residents.1. An undated diagnoses report showed Resident #1 had diagnosis which included displaced intertrochanteric fracture of left femur.Resident #1's quarterly assessment, dated 08/08/25, showed Resident #1 had a BIMS score of 8, which indicated moderately impaired cognition and the resident was independent with sit to stand transfers.A nursing note, dated 09/01/25 at 11:47 p.m., read in part, [Resident #1] had fight with [Resident #2] at TV area. [Resident #1] was beaten by [Resident #2]. [Resident #1] was in w/c before [they] were attacked. It was reported that [they] hit [Resident #2] which [led] to [them] being attacked.A Quality Assurance & Performance Improvement form, dated 09/01/25, showed the residents were separated and assessed. Family, physician, Adult Protective Services, law enforcement, and the DON were notified of the incident. Interviews and safe surveys were completed. In-services were conducted.An Oklahoma State Department of Health final report, for an incident dated 09/02/25, showed Resident #1 observed to be in altercation with Resident #2. Resident #2 was on the floor hitting Resident #1 in different parts of the body. Resident #2 was throwing objects at Resident #1. Staff intervened. Emergency transport was called. The police department was called. Resident #2 had scrapes that were cleaned and dressed. Resident #1 was sent to the emergency room to be evaluated. Resident #2 was placed on every 15-minute checks. Resident #2 was transferred to a mental health facility for psychiatric evaluation and treatment. Resident #1 was sent to the emergency room following the altercation due to complaints of left leg pain after losing their balance during the altercation and falling on their left side. Evaluation confirmed a left femur fracture, and surgical repair was completed.A Every 15-minute Safety Monitoring form, initiated on 09/02/25 at midnight, showed Resident #2 remained on monitoring until 09/04/25 at 5:45 p.m.Resident #1's care plan, revised on 09/05/25, read in part, [Resident #1] had fight with [Resident #2] at TV area. Resident #1 was beaten by [Resident #2]. [Resident #1] was in w/c before [they] were attacked. It was reported that [they] hit [Resident #2] which [led] to [them] being attacked.On 09/17/25 at 11:38 a.m., Resident #1 stated Resident #2 came from behind and started hitting them in the face. Resident #1 stated they went to the ground and hurt their leg.09/17/25 at 11:40 a.m., Resident #1 stated they did not know why Resident #2 hit them, as they were just sitting there watching television when it happened. 2. An undated diagnoses report showed Resident #2 had diagnoses which included anxiety (onset date 06/01/25) and major depressive disorder (onset date 07/05/24).Resident #2's quarterly assessment, dated 07/16/25, showed the resident had a BIMS score of 12, which indicated moderate cognitive impairment.A nursing note, dated 09/01/25, showed at approximately 9:20 p.m. Resident #2 was observed to be in an altercation with Resident #1 and was observed to be on the floor in the day room with Resident #2 striking Resident #1 in different areas of the body.A nursing note, dated 09/04/25, showed Resident #2 was transferred to a mental health facility at approximately 5:30 p.m.Resident #2's care plan, revised on 09/05/25, read in part, [Resident #2] observed to be in an altercation with [Resident #1] and was observed to be on the floor in the day room with [Resident #1] striking [Resident #1] in different areas of [their] body. Resident [#2] was continuing to be confrontational even after staff intervened.At the time of exit Resident #2 remained out of the facility.An In-Service Topic form, dated 09/08/25, showed the facility conducted a behavior management in-service with all staff.An In-Service Topic form, dated 09/08/25, showed the facility conducted an assessing psychosocial effects in-service and a timely reporting in-service with staff.An In-Service Topic form, dated 09/09/25, showed the facility conducted a response to resident-to-resident in-service with staff.On 09/17/25 at 1:32 p.m., the administrator stated the process for involving QAPI was to put interventions in place immediately and discuss during the QAPI meeting. They stated all incidents were discussed in their morning stand up meeting. They stated they attached an incident review report to each incident. The administrator stated the report was a QAPI tool.On 09/18/25 at 9:29 a.m., licensed practical nurse #1 stated there was a fist fight. They stated Resident #1 was on the floor and Resident #2 continued to punch Resident #1.On 09/18/25 at 10:51 a.m., the DON stated there had been no behavior management training prior to 09/05/25.On 09/18/25 at 10:57 a.m., the administrator stated the incident between Resident #1 and Resident #2 happened in the day area. They stated Resident #1 always sat in that area. They stated Resident #1 had stood up at their chair and Resident #2 walked into the area and the two residents started to fight. They stated a CNA came to the area and broke up the fight.On 09/18/25 at 12:19 p.m., CNA #2 stated the facility had provided abuse training after the above incident.On 09/18/25 at 12:41 p.m., CNA #3 stated the facility provided a lot of abuse training. They stated the last abuse training was the week of 09/08/25.

Based on record review and interview, the facility failed to ensure a resident's personal funds were not misappropriated for 1 (#4) of 4 sampled residents reviewed for abuse. The assistant director of nursing identified 112 residents resided in the facility. Findings: An undated Abuse and Neglect policy, read in part, no resident shall be subject to abuse. Resident #4 had diagnoses which included bipolar and anxiety. An Incident Report Form, dated 03/12/25, read in part, Reported to this admin [administrator] by SSD [social service director]. Resident called [their] card and realized the balance was very low and stated [they] should have about $1000 .Resident then stated, 'I should have never given [CNA #5] my card [SSI debit card]' .Various charges noted today: [nail salon] $145, [gas station] $70, 2 ATM [automated teller machine] withdrawals $43 and $62, [cell phone carrier] $74. On 03/13/25 at 1:20 p.m., Resident #4 stated a couple of months ago, CNA #5 asked if they could borrow some money. They stated CNA #5 knew they received SSI. Resident #4 stated they gave CNA #5 the card and told them they could use it for gas and groceries, but that was not what it was used for. On 03/17/25 at 10:25 a.m., Resident #4 was asked if they got their nails done. They stated, No. Resident #4 was asked if they paid a bill to a phone carrier. They stated, No. Resident #4 was asked if they made purchases at the grocery store. They stated they loved the grocery store, but did not get to go there. On 03/17/25 at 10:40 a.m., the administrator stated a medication aide let Resident #4 use their phone to order food. The administrator stated Resident #4 checked the last few transactions made on the SSI debit card and knew some of the charges were not made by them. The administrator was asked what the policy was for misappropriation. They stated, Termination, it's a form of abuse.

On 01/17/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Resident #18 was free from abuse by not implementing company policy and procedures. This resulted in Resident #18 experiencing psychosocial harm. A nursing note, dated 12/25/24 at 9:39 a.m., read in part, [Resident #18] was observed walking down 400 hallway. [Resident #54] got mad and started ranting saying that,I will stub them because they didn't like that particular resident. The note also read, [Resident #54] pulled out a rail road track nail with the gestures of attacking [Resident #18]. The note also read, This Nurse yelled for help along side the Nurse aide who was close and witnessed they rushed to intercept and prevent any possible attack to the [Resident #18] who was asked to go back in their room. [Resident #54] did not succeed and the DON with another Nurse managed to retrieve the track nail from [Resident #54]. On 01/14/25 at 2:32 p.m., the DON was asked about reporting abuse according to company policy and procedures for the 12/25/24 note. They stated they did not believe it was resident abuse because Resident #54 was on hall 400 and Resident #18 was sent another hall. On 01/15/25 at 9:32 a.m., the DON was asked about company policy and procedures for reporting of the 12/25/24 note. They stated, It's an behavioral incident. No documentation was reported at the time of the incident. According to policy it should have been reported. On 01/16/25 at 10:23 a.m., CNA #1 was asked about the 12/25/24 note. They stated, [Resident #54] was the instigator. I feel like [they] overheard that [they] was flirting. [Resident #54] started walking towards [them] and said I'm going to beat [Resident #18] ass. Then [they] was moved to hall one. On 01/16/25 at 11:41 a.m., Resident #18 was asked about the 12/25/24 incident. They stated, I remember everything and everyday. [Resident #54] yelled at me and was trying to get me to fuss and fight. I tried to avoid [Resident #54] but, I felt nervous and unsafe. On 1/17/25 at 4:20 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 1/17/25 at 4:34 p.m., the administrator and DON were notified of the immediate jeopardy situation and was provided the IJ template. On 1/21/25 at 8:12 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal documented, Plan of removal for abuse, neglect and exploitation. 1. On 12/27/24 resident #54 had a Risk Management Agreement put into place due to resident consuming alcohol outside of facility and returning to facility becoming agitated and verbally aggressive. The resident has had no further behaviors since 12/25/24. 2. Psych Consult (Millennium) notified of residents past aggressive and verbal behaviors when under the influence. PA conducted a Tele Med evaluation 1/17/25 and noted no behaviors since 12/25/24 and resident has not exhibited any threatening or aggressive behaviors at this time. 3. On 1/15/25 residents' primary care physician documented that resident is not a threat to [them] or others and has not been in the past month. How will the facility ensure that other residents, outside of hall 400, are safe? 4. Resident has been placed on Q15 minute behavior monitoring and if any aggressive behaviors are noted resident will be placed on 1:1 monitoring until aggressive behaviors subside. What are the details of in-servicing nursing staff? Is this licensed nurses, nurse aides, all staff, etc? 5. In-service conducted with nursing staff (to include nurses, med aides, and CNA', as well as other departments.) over Abuse and Neglect and management of aggressive residents was completed on 12/28/24 and again on 1/17/25. All other nursing staff not present will be in-serviced before working their next shift. Agency has been notified of the in-service required and materials have been provided. They will in-service any contract staff that work at Oak Hills before their next shift scheduled. 6. The Administrator, DON, and ADON's have been in-serviced over recognizing mental and verbal abuse and the Incident Reporting and Investigation Policy. 7. Resident #18 has been moved to a different hall to create distance between [them] and resident #54 per [their] request when interviewed. 8. Safe Surveys have been conducted on hall 400 and throughout the building randomly. No other residents have any complaints or concerns. 9. Resident 54 care plan updated accordingly. On 01/21/25 at 11:33 a.m., after interviews with the facility staff, review of resident safe surveys, and in-services on abuse, the immediacy was lifted. The deficient practice remained at a potential for more than minimal harm. Based on record review and interview, the facility failed to ensure a resident was protected from resident to resident abuse for one (#18) of three sampled residents reviewed for abuse. The administrator identified 114 residents in the facility. Findings: An undated Abuse and Neglect policy, read in part, w. 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. The policy also read, The Abuse/Neglect of this facility will be implemented to ensure all residents entrusted in our care will be free from mental, verbal, or physical abuse. An undated document titled, Things Residents Don't Need or Should Avoid, read in part, 11. Residents are encouraged not to consume ALCOHOLIC BEVERAGES or use of any DRUGS NOT ORDERED BY THE PHYSICIAN. The facility may obtain a physician's order for alcohol use as physician deems appropriate either routine or for special activities. If any outside drug or alcohol use is suspected, nurse should monitor resident's condition and notify physician as indicated. The Unusual Occurrence policy, revised 12/2007, read in part, 3. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within (48) hours of reporting the event or as required by federal and state regulations. 1. Resident #18 had a diagnoses which included unspecified schizophrenia. A quarterly assessment, dated 11/22/24, documented the resident's cognition was moderately impaired. On 01/16/25 at 11:41 a.m., Resident #18 was about the 12/25/24 incident. They stated, I remember everything and everyday. [Resident #54] yelled at me and was trying to get me to fuss and fight. I tried to avoid [Resident #54], but I felt nervous and unsafe. A annual assessment, dated 11/24/24, documented the resident's cognition intact. An Admission Packet, signed by Resident #54 on 11/17/22, read in part, [DRUG FREE AND HEALTH CARE CENTER POLICY] It is the policy of this facility to provide a safe environment that promotes the welfare of its residents, associates and visitors. Substances and alcohol abuse threatens the quality of patient care and the safety of our residents and associates. This facility therefore, will maintain a drug and alcohol free Health Care Center policy. A physician's order, dated 04/10/24, read in part, May consume alcoholic beverages unless otherwise contraindicated .Status Discontinued . End Date 04/26/24 .Revision Date. A nursing note, dated 04/03/24, read in part, This nurse heard screaming and yelling, I ran to the front and saw resident [Resident #54] yelling in residents' face and attempted to hit them, staff intervened and separated both residents. [Resident #54] smelled of alcohol. Residents were separated by staff, res continued to be combative, yelling and attempting to attack other residents. Resident escorted to room, police notified. Police arrived and calm resident down for a few minutes, resident then ran back into TV and continued to make threatening remarks towards and other residents. A behavior note, dated 07/04/24, read in part, while I was in [Resident #54] room tending to [their]roommate [Resident #54] became irate yelling about the staff not taking care of [them] and catering to [their] roommate. I attempted to talk to resident to alleviate [their] concerns when I smelled alcohol on [their] breath. Resident continued to fuss and cuss with a raised voice and followed me into the hallway calling me bitches and yelling fuck you and accusing the 3-11 staff for killing all the residents that have passed. I tried to reason with resident but they became worse. A nursing note, dated 08/02/24, read in part, [Resident #54] was drunk and belligerent. angrily kicking and punching doors, walls and other objects in the hall. Running into other residents' rooms and threatening them. Waking up residents and taking them to their room, cussing and threatening staff. A behavior note, dated 08/13/24, read in part, [Resident #54] drunk and is screaming and cussing and trying to pick a fight with the other residents. A nursing note, dated 11/02/24, read in part, [Resident #54] signed self out on 7-3 shift, returned to facility around 3p.m. being loud yelling at staff members calling them names, several staff members smelt alcohol on residents breath. A annual assessment, dated 11/24/24, documented the resident's cognition intact. A Care Plan, dated 12/02/24, read in part, [Resident #54] is at risk for behavior problems. [Resident #54] has hx (history) of consuming mouthwash containing alcohol as well as signing self out the facility to obtain alcohol becoming intoxicated. The care plan also read, Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. A behavior note, dated 12/03/24, read in part [Resident #54] is drunk starting trouble with another resident and staff, threatening to beat them up, kicking and banging on their door, yelling threats and accusations up and down the hall. A nursing note, dated 12/25/24 at 9:39 a.m., read in part, [Resident #18] was observed walking down 400 hallway. [Resident #54] got mad and started ranting saying that,I will stub them because they didn't like that particular resident. The note also read, [Resident #54] pulled out a rail road track nail with the gestures of attacking [Resident #18]. The note also read, This Nurse yelled for help along side the Nurse aide who was close and witnessed they rushed to intercept and prevent any possible attack to the [Resident #18] who was asked to go back in their room. [Resident #54] did not succeed and the DON with another Nurse managed to retrieve the track nail from [Resident #54]. There were no new interventions implemented after the incident on 12/25/24. On 01/15/25 at 9:32 a.m., the DON was asked about the company policy and procedure for the 12/25/24 note. They stated, It's an behavioral incident. No documentation was reported at the time of the incident. According to policy it should have been reported. On 01/15/25 at 9:37 a.m., the director of clinical care was asked about behaviors in the 12/03/24 behavior note. They stated, It is an pattern of behavior. On 01/15/25 at 9:38 a.m., the DON was asked about the company policy and procedures for the 12/03/24 behavior note. They stated, I was unaware of the situation and its been reported that [Resident #54] drinks mouthwash to get drunk. On 01/15/25 at 9:58 a.m., the director of clinical care was asked about the company policy and procedures for the 11/02/24 nursing note, they stated, They should have put it in the Spectrum binder, so they can notify the PA. On 01/15/25 at 10:04 a.m., the DON was asked about the company policy and procedures for the 08/02/24 note. They stated, No incident report was done for 08/02/24. On 01/15/25 at 10:05 a.m., the DON was asked about the company policy and procedures for resident protection. They stated, We usually put it in a care plan. On 01/15/25 at 10:17 a.m., the director of clinical care was about the company policy and procedures concerning the 08/02/24 note. They stated, The way it's stated in the nursing notes, yes. It's vague. It should have been reported as alleged abuse. On 01/15/25 at 10:18 a.m., the DON stated, The 08/02/24 incident, I take it as two different situations. On 01/15/25 at 10:19 a.m., the DON was asked about the company policy on incident reporting for the 08/02/24 behavior note. They stated an incident report should have been done. On 01/15/25 at 10:22 a.m., the director of clinical care was asked about incident reporting procedures according to policy for the 08/02/24 note. They stated, An incident report should have been done. On 01/15/25 at 1:31 p.m., a revised care plan for Resident #54 was received on 01/15/25 at 1:31 p.m. by the regional nurse. The undated care plan, read in part, [Resident #54] is at risk for behavior problems. [Resident #54] has a hx (history) of consuming mouthwash containing alcohol as well as signing self out of facility to obtain alcohol becoming intoxicated. Has a history of pan handling for money. [Resident #54] can become verbally and physically aggressive to staff and peers. [Resident #54] is known to kick walls and other things when angry or intoxicated. [Resident] typically goes back to the resident he was angry with and will apologize to them for his behavior. On 01/16/25 at 10:23 a.m., CNA #1 was asked about the 12/25/24 note. They stated, [Resident #54] was the instigator. I feel like [they] overheard that [they] was flirting. [Resident #54] started walking towards [them] and said I'm going to beat [Resident #18] ass. Then [they] was moved to hall one. On 01/16/25 at 11:41 a.m., Resident #18 was asked about the 12/25/24 incident. They stated, I remember everything and everyday. [Resident #54] yelled at me and was trying to get me to fuss and fight. I tried to avoid [Resident #54], but I felt nervous and unsafe. On 01/17/25 at 9:39 a.m, the DON was asked about the 08/02/24 note. They stated the note read, [Resident #54] is drunk and belligerent and No labs or breathalyzers were used to confirm this statement. On 01/17/25 at 9:41 a.m., the DON was asked about policy and procedures for residents who consume alcohol concerning the 08/02/24 note. They stated, We don't have a policy for breathalyzers. I cannot confirm this happened! That's someone's opinion. On 01/17/25 at 9:54 a.m., LPN #5 was asked about reporting abuse according to company policy, They stated, Ensure the resident is safe and report it immediately to my superior that day and document. On 01/17/25 at 9:55 a.m., LPN #5 was asked about alcohol consumption of residents according to policy. They stated, Alcohol, its not allowed, its not encouraged, we would have to doctors orders to see what kind of meds they are taking. On 01/17/25 at 9:56 a.m., LPN #5 was asked about identified concerns related to alcohol consumption with residents. They stated they would report the use of alcohol to nursing leadership. On 01/17/25 at 9:57 a.m., the DON was about Resident #54's signed admission packet and alcohol consumption. They stated, If they sign out and go drink the facility can't control it. [Resident #54] was notorious for drinking mouthwash. On 01/17/25 at 9:57 a.m., the regional nurse was asked about Resident #54's alcohol consumption according to company policy and procedures. They stated, Things residents don't need or should avoid policy, number 11. We are going to put update the careplan. We are not a treatment center. On 01/17/25 at 9:58 a.m., the administrator was asked about the company policy and procedures for incident reporting. They stated, Have we addressed it promptly? Probably not. On 01/17/25 at 11:15 a.m., the director of clinical care was asked about incident reporting according to company policy. They stated, According to Abuse/Neglect Policy and Unusual Occurrence policy it (facility reported incident) should have been submitted within two hours. On 01/17/25 at 11:16 a.m. the clinical director of client care was asked about identifying unsafe residents in the 12/03/24 behavior note. They stated, No. On 01/17/25 at 11:17 a.m., the DON was asked to identify unsafe residents in the 12/03/24 behavior note. They stated, No. On 01/17/25 at 11:18 a.m., the DON was asked if an investigation was done according to company policy and procedures for the 12/03/24 behavior note. They stated, No. On 01/17/25 at 11:26 a.m., the director of client care was asked about identifying abuse according to company and procedure and identifying psychological harm. They stated,During the event of some these incidents they were not safe.

Based on observation, record review, and interview, the facility failed to ensure: a. wound care was provided as ordered for two (#12 and #57); b. care was coordinated for a non pressure wound for one (#12); c. an order was obtained prior to providing wound care to a resident's wound for one (#12); d. the nurse was notified when the dressing of a wound became dislodged for one (#12); e. staff documented changes in the resident's skin before leaving for the day for one (#12); and f. treatment orders were obtained at the time a new wound was identified for one (#12) of four sampled residents reviewed for non pressure skin conditions. This resulted in actual harm when Resident #12's left gluteal fold wound increased in size after the facility failed to provide treatment as ordered. The administrator identified 114 residents resided in the facility. The DON identified 10 residents with non pressure wounds resided in the facility. Findings: A Wound Care policy, revised 10/2010, read in parts, Verify that there is a physician's order for this procedure .The following information should be recorded in the resident's medical record .They type of wound care given .The date and time the wound care was given .The name and title of the individual performing the wound care .Any change in the resident's condition .All assessment data .obtained when inspecting the wound If the resident refused the treatment and the reason .The signature and title of the person recording the data. 1. Resident #12 had diagnoses which included vasculitis, MASD to the left gluteal fold, full thickness friction/ shear wound of right thigh, bipolar disorder, and schizoaffective disorder. A Physician Order, dated 12/19/24, documented to cleanse left gluteal fold with ns, pat dry, apply calcium alginate, cover with dry dressing daily and prn. The above order did not transfer onto the December 2024 or January 2025 MAR/TAR. There was no documentation this gluteal fold wound care was provided in December 2024 or January 2025. A Wound Progress Note, dated 01/02/25, documented the resident had, a. partial thickness vasculitis wound to their right lower leg that measured 13.5cm length x 4cm width x 0.1cm depth, b. a partial thickness vasculitis wound to their left lower leg that measured 0.7cm length x 0.7cm width x 0.1cm depth, and c. full thickness MASD to their left gluteal fold that measured 0.4cm length x 0.3cm width x 0.1cm depth. A Wound Progress Note, dated 01/09/25, documented the resident had, a. partial thickness vasculitis wound to their right lower leg that measured 19.5cm length x 7cm width x 0.1cm depth, b. partial thickness vasculitis wound to their left lower leg that measured 12.5cm length x 2cm width x 0.1cm depth, c. full thickness MASD to their left gluteal fold that measured 3cm length x 2cm width x 0.1 cm depth, and d. full thickness friction/shear to their right thigh (initial encounter) that measured 1.5cm length x 2cm width x 0.1cm depth. The note did not document the resident had any wounds to their feet. The note was signed by the wound NP. A Physician Order, dated 01/09/25, documented to cleanse bilateral lower leg with ns, pat dry, apply xeroform, ABD pad, and rolled gauze wrapped loosely daily and prn. A Physician Order, dated 01/09/25 with a start date 01/11/25, documented right inner thigh: cleanse with ns, pat dry, apply xeroform to wound bed, cover with dry dressing Tuesday, Thursday, and Saturday. The 24 hour report book for Resident #12's hall did not document the new wound to Resident #12's right thigh was communicated. The 24 hour report book did not communicate the wounds to Resident #12's feet were communicated when LPN #2 was made aware of the concern on 01/10/25. A Physician Order, dated 01/14/25, documented to cleanse wounds to bilateral foot with normal saline, pat dry, apply silver alginate to areas with purulent drainage, cover non-purulent area with Vaseline gauze, wrap with rolled gauze, daily and as needed. There was no documentation related to the condition of the resident's wounds to their bilateral feet in the clinical record prior to the surveyor observing wound care on 01/14/25. On 01/14/25 at 10:28 a.m., LPN #2 entered Resident #12's room to provide wound care. LPN #2 was observed telling Resident #12 I can't touch your feet until wound care looks at it Thursday. Resident #12 was observed with dressings to her bilateral feet. There was no date observed on the dressings. LPN #2 stated it was their fault, and that they had completed the dressing change on 01/13/25 with the hospice nurse. LPN #2 stated they could not touch the resident's feet until wound care evaluated them. LPN #2 stated hospice did not want them to be messed with until they were evaluated. There was no dressing observed on Resident #12's left leg. LPN #2 stated it was supposed to be there. LPN #2 stated stated it was there yesterday. On 01/14/25 at 10:38 a.m., Resident #12 was observed with dressings to their bilateral feet. There was a red brown soilage observed on the underside of the resident's left foot. 01/14/25 at 10:51 a.m., LPN #2 stated the wound care to Resident #12's lower legs were to be completed every morning. LPN #2 stated the wounds would go back and forth with healing. LPN #2 stated the resident's skin was very thin. On 01/14/25 at 10:54 a.m., LPN #2 stated it was their understanding the hospice shower aide took Resident #12's sock off and the skin came off the left foot. LPN #2 stated both feet were just kind of raw and really flaky. They stated staff had been putting Aquaphor on the resident's legs for months. LPN #12 stated the issue with the resident's feet occurred Friday 01/10/25. They stated they received an order to treat the feet yesterday (01/13/25) to put silver alginate and xeroform on it. LPN #2 stated the order came from hospice, and LPN #2 helped the hospice nurse with dressing the resident's feet yesterday. LPN #2 stated hospice did not want Resident #12's feet messed with until the wound doctor could evaluate them. LPN #2 stated the undated dressings had been on the resident's feet since yesterday. LPN #2 was asked about the soilage on the resident's left foot dressing. LPN #2 stated they could change it and let hospice know they had to change it. LPN #2 stated hospice had cultured the wounds yesterday. LPN #2 stated when the hospice aide had removed Resident #12's sock, they stated the resident's skin stuck to the sock. LPN #2 stated it was just the top layer of the resident's foot like a flesh wound. LPN #2 stated they cleaned the area with normal saline, and yesterday when they were looking at it, there was some on the bottom as well. LPN #2 stated on Friday they had cleaned the area and covered it with a four by four. LPN #2 was asked if the doctor was notified and was an order received for the wound care they provided to this area on Friday. LPN #2 stated they texted the resident's hospice but, I don't know if they came out because it happened at 2:45 3:00 o'clock. There was no documentation an order was obtained to provide wound care to the resident's feet until 01/13/25. On 01/14/25 at 11:05 a.m., LPN #2 stated they were not aware of a wound on the resident's right inner thigh. LPN #2 looked in the computer and stated they did need to complete wound care to the resident's right thigh. LPN #2 stated the order had come in on the 11th and that was the reason they did not see it because it was for Tuesdays, Thursdays, and Saturdays. LPN #2 stated today was the first day they would be doing it. They stated usually staff wound report changes related to residents during shift change and wound document it in the report book as well. LPN #2 stated no one had reported this wound to them. On 01/14/25 at 11:07 a.m., LPN #2 walked over to the report book, flipped through the 24 hour report sheets, and stated staff did not document the new wound to the resident's right inner thigh in the book. On 01/14/25 at 11:08 a.m., LPN #2 stated they knew Resident #12 had a wound to the left gluteal fold in the past, but it had healed. LPN #2 stated they saw the order in the resident's record, but it was not showing up on the MAR to complete. LPN #2 stated the wound care to the left gluteal fold was supposed to be completed every day shift. LPN #2 stated the last time they had completed wound care to the area would have been in December. On 01/14/25 at 11:13 a.m., LPN #2 stated ADON #1 made wound rounds with the wound team and would let staff know if there were changes. They stated ADON #1 would also put new orders in for the wound care when needed. On 01/14/25 at 11:16 a.m., LPN #2 stated the wound NP measured resident wounds weekly on Thursdays. On 01/14/25 at 12:33 p.m., Resident #12 was observed in the main dinging area seated in their wheelchair. There was bright red soilage observed on the resident's left foot that continued over the lateral side. On 01/14/25 at 12:36 p.m., LPN #2 stated they would see if the resident would allow a dressing change to their feet after lunch. They stated there were activities from two to four the resident would not want to miss. On 01/14/25 at 1:09 p.m., the DON stated apparently Resident #12 had a stage two pressure ulcer that resolved on the left gluteal fold. The DON stated then the left gluteal fold wound came back. They stated when staff put the new order in, they put it under TAR and marked no documentation required. The DON stated the wound care had been being done, but they had no documentation to support this. The DON stated from 12/19/24 to present, there was no documentation the wound care was completed on the TAR. The DON stated there was no documentation the wound care was provided. On 01/14/25 at 2:03 p.m., ADON #1 stated if a resident experienced a change in their skin condition, staff would notify ADON #1 or get an order from the wound care NP. ADON #1 stated if staff let them know, they would notify the wound care NP. On 01/14/25 at 2:04 p.m., ADON #1 stated they made rounds with the wound care NP weekly on Thursday. On 01/14/25 at 2:05 p.m., ADON #1 stated whoever rounded with the wound care provider was responsible for putting the new orders in. On 01/14/25 at 2:06 p.m., ADON #1 stated the nurses on the floor were responsible for providing wound care. ADON #1 stated when there were changes, they would put the order into the electronic record, and then printed the new order out, and placed it at the nurses' station. On 01/14/25 at 2:09 p.m., ADON #1 stated the left gluteal fold was MASD and the right thigh was a shear wound. They stated the gluteal fold was to receive wound care daily and the right thigh was Tuesdays, Thursdays and Saturdays. On 01/14/25 at 2:12 p.m., ADON #1 stated they were off when the left gluteal fold wound care started on 12/19/24. They stated the staff member had put it in without requiring documentation. On 01/14/25 at 2:14 p.m., ADON #1 stated the wound care NP saw the resident on 01/09/25 and started wound care for the resident's left thigh. On 01/14/25 at 2:15 p.m., ADON #1 stated they should have put the new wound on the report sheet. On 01/14/25 at 2:29 p.m., Resident #12 was observed in the main dining area with a red tinged dressing present to their left foot. Resident #12 did not permit the dressing change to their feet prior to the surveyors leaving on 01/14/25. On 01/15/25 at 10:08 a.m., LPN #2 stated they did not document the findings of Resident #12's skin to their feet after the event involving the hospice aide removing the resident's socks and the skin coming off. LPN #2 stated they were on their way out and forgot to put a note it. LPN #2 stated they remembered what the feet looked like, but they did not put a note in at the time. LPN #2 stated they put a note in yesterday because their supervisor had informed them they did not document it, so they completed a late entry. On 01/15/25 at 10:14 a.m., LPN #2 stated they were a new nurse and might have the policy wrong. They stated to their understanding they were supposed to contact the hospice nurse to get orders from them. LPN #2 stated with wounds they usually told the hospice nurse and they usually told ADON #1. They stated on Friday they were running out of the facility and it was their fault. They stated normally on wounds they would tell ADON #1 and they would contact the wound care doctor. LPN #2 stated on Friday, they dropped the ball. LPN #2 stated the wound was superficial and there was nothing on the bottom. On 01/15/25 at 12:14 p.m., LPN #2 and CNA #4 turned Resident #12 to their right side for wound care. There was no dressing present to the resident's left gluteal fold. LPN #2 stated, There is not even a bandage on it, so it probably came off when they changed it. LPN #2 stated normally when a bandage came off, staff would inform the nurse so they could replace it. LPN #2 stated they were not informed the bandage had come off. On 01/15/25 at 12:16 p.m., Resident #12's left gluteal fold was observed to have an open area with red beefy skin present with light pink tissue surrounding the edges of the wound. The wound appeared to be approximately a half dollar in size. On 01/15/25 at 12:19 p.m., LPN #2 placed the 2 inch x 2 inch calcium alginate dressing over the left gluteal fold wound which barely covered the edges of the wound. On 01/15/25 at 12:27 p.m., the DON stated they would have to get the facility policy for what do do if staff identified a change in the resident's skin. On 01/15/25 at 1:14 p.m., the DON chose for the surveyor to ask policy questions in the presence of the regional clinical director, the administrator, the regional nurse. On 01/15/25 at 1:16 p.m., the regional clinical director stated if a resident had a brand new wound, the staff wound notify the provider. They stated if the resident was an established wound care provider patient, they would call and notify them. On 01/15/25 at 1:18 p.m., the regional clinical director stated if the resident was a hospice resident and there was a change in the resident's skin, they would notify the hospice provider or nurse. On 01/16/25 at 8:11 a.m., the wound NP stated they came every Thursday and saw Resident #12. They stated the resident was paralyzed and stiff with a lot of autoimmune issues like vasculitis on their lower legs. They stated the leg wounds responded well to xeroform. They stated the resident had a suprapubic catheter that did not always fit well and contributed to MASD in the folds and buttocks. They stated staff had a difficult time turning the resident. They stated the buttock wounds usually healed rather quickly. They stated they believed the left gluteal fold was treated with calcium alginate and an ABD and was changed they believed three times a week, but probably more due to wetness. They stated the resident was recently put back on hospice. They stated before they left on Thursdays, a spread sheet was provided to the facility related to wounds. On 01/16/25 at 8:17 a.m., the wound NP stated they believed the resident's catheter had rubbed their right thigh causing the wound. The wound NP stated the resident did refuse wound care at times and the resident had the right to do so. The wound NP reviewed the measurements of the gluteal fold and stated it had gotten worse when comparing the last two weeks. On 01/16/25 at 8:20 a.m., the wound NP stated they spoke with ADON #1 on Tuesday who reported the resident had broke out with one between the toes. The wound NP stated they believed hospice had given them orders and they took a culture due to purulent drainage. On 01/16/25 at 8:26 a.m., the wound NP stated if staff did not provide wound care are ordered, the wounds would get much worse. They stated they had previously debrided the resident's legs to help with the vasculitis. 2. Resident #57 had diagnoses which included chronic pain syndrome and anxiety disorder. A Physician Order, dated 01/09/25, documented to cleanse posterior left shoulder with normal saline, pat dry, apply calcium alginate to wound bed, cover with dry dressing one time a day for wound care. The January 2025 TAR documented wound care to the resident's left shoulder was not provided on Sunday 01/12/25. 01/09/25 at 11:14 a.m., Resident #57 stated they recently had a suspicious mole removed from their shoulder. They stated staff were supposed to clean and dress the wound every day. Resident #57 stated their dressing change did not always happen as ordered. They stated last weekend it was not changed Saturday or Sunday. On 01/14/25 at 8:53 a.m., RN #1 was observed removing a dressing from Resident #57's left shoulder. There was an approximately dime sized wound with minimal yellow drainage observed. The wound had a pink center with white outer edges. On 01/14/25 at 8:57 a.m., RN #1 stated Resident #57 had a history of skin cancer. They stated the resident had an appointment with the dermatologist approximately 15 days ago and they removed an area to the resident's left shoulder. RN #1 stated there was an order for wound care until the area was resolved. On 01/14/25 at 8:58 a.m., RN #1 stated Resident #57's wound care was provided daily. On 01/21/25 at 11:10 a.m. ADON #1 stated staff would document wound care was provided in progress notes. ADON #1 reviewed Resident #57's January 2025 TAR for the blank on the 12th and stated apparently staff did not mark it. They stated, I don't know if they didn't do it. On 01/21/25 at 2:11 p.m., the DON stated if the wound care area for documentation was blank, if staff did not write a note and it was not documented, it was not done.

Based on record and interview, the facility failed to thoroughly investigate an allegation of abuse for two (#18 and #54) of three sampled residents reviewed for abuse and neglect. The administrator reported the census was 114. Findings: An undated Abuse and Neglect policy, read in part, w. 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. The Unusual Occurrence policy, revised 12/2007, read in part, 3. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within (48) hours of reporting the event or as required by federal and state regulations. 1. Resident #18 had diagnoses which included unspecified schizophrenia. A nursing note, dated 11/29/24, read in part, another resident on hall 400 reported that [Resident #18] had offered [them] 7$ and a coke for a hand job. Another resident on 300 hall reported that [Resident #18] asked for a blowjob. [Resident #18] admitted to doing these things and was asked to stay away from other resident. There was no documentation an investigation was completed for the incident. On 01/16/25 at 3:10 p.m., the DON reported no incident report was done. On 01/16/25 at 3:11 p.m. the regional nurse stated, No incident report was done. 2. Resident #54 had diagnoses which included bipolar and major depressive disorder. A behavior note, dated 08/02/24 at 10:43 p.m., read in part, [Resident #54] drunk and belligerent, angrily kicking and punching doors, walls and other objects in the hall. Running into other residents' rooms and threatening them. A nursing note for Resident #54, dated 12/03/24 at 5:32 p.m., read in part, is drunk starting trouble with [Resident #18] and staff, threatening to beat him up, kicking and banging on his door, yelling threats and accusations up and down the hall. A nursing note for Resident #54, dated 12/25/24 at 9:39 a.m., read in part,[Resident #18] was observed walking down 400 hallway. [Resident #54] got mad and started ranting saying that, 'I will stub them' because they didn't like that particular resident. The note also read, [Resident #54] pulled out a rail road track nail with the gestures of attacking [Resident #18]. The note also read, This Nurse yelled for help along side the Nurse aide who was close and witnessed they rushed to intercept and prevent any possible attack to the [Resident #18] who was asked to go back in their room. [Resident #54] did not succeed and the DON with another Nurse managed to retrieve the track nail from [Resident #54]. There was no documentation investigations were completed for the incidents. On 01/15/25 at 9:58 a.m., the DON stated, No incident report was done. On 01/17/25 at 11:10 a.m., the regional director of client care was about company policy and procedures for investigating incidents. They reported there was no state reportable submitted according to policy and they had no records of investigation according to company policy and procedures. On 01/17/25 at 11:16 a.m. the regional director reported the 12/03/24 incident should have been reported within two hours and according to policy. On 01/17/25 at 11:19 a.m., the regional director reported the unusual occurrences number three in the company policy should have been followed.

Based on record review and interview, the facility failed to ensure assessments were completed timely for two (#67 and #98) of 28 sampled residents reviewed for resident assessments. The administrator identified 114 residents resided in the facility. Findings: 1. An Annual Resident Assessment, dated 8/23/24, was the last assessment completed for Resident #67. A billing census documented billing had been stopped on 9/26/24. There was no discharge assessment. 2. An Admission Resident Assessment, dated 8/12/24, was the last assessment completed for Resident #98. A billing census documented billing had been stopped on 8/26/24. There was no discharge assessment. On 01/21/25 at 11:51 a.m., MDS #1 stated Resident #67 was a death in facility on 9/06/24. They stated it had not been completed, but should have been completed within 14 days of the discharge. MDS #1 stated Resident #98 discharged on [DATE], but the discharge had not been completed. They stated there was no reason why it was not completed within the 14 day requirement. On 01/21/25 at 6:15 p.m., ADON #1 brought in LPN #5 to respond to questions about the MDS assessments because they were not familiar with MDS. LPN #5 stated that both discharges had not been completed within the required time frame, but they should have been.

Based on observation and interview, the facility failed to ensure the low temperature dishwasher had the appropriate amount of chemicals to sanitize dishes for three of four observations of dishwasher chemical sanitization level checks. ADON #1 identified 112 residents ate meals from the kitchen. Findings: An undated Dishwashing by Use of a Machine policy, read in part, check the machine during each procedure to determine if detergent, wetting agent, and chemical sanitizer is being dispensed properly. On 01/07/25 at 7:49 a.m., the DM measured the chemical sanitizer in the dishwasher and it did not register on the chemical strip. The DM realized the sanitizer was empty and added about two gallons to the five gallon bucket attached to the dishwasher. They then primed the dishwasher several times and was still unable to get a reading on the chemical strip. They stated the chemical strip should register between 50 parts per million of chloride (ppm) and 100 ppm. They stated they had not checked it this morning, but last night it was fine. They stated they were going to call the dishwash company to have them come check it. They stated they could sanitize dishes in the sink. On 01/07/25 at 11:30 a.m., staff were observed continuing to use the dishes that were ran through the low temperature dishwasher. They were not sanitizing the dishes in the sink. On 01/07/25 at 11:39 a.m., the DM tried different strips due to realizing the correct strips that maintenance had provided. Those strips were for [NAME] chloride checking and registered at 1ppm. The highest number they checked for was 20 ppm. They stated they did realize the [NAME] strips could not be used to check for appropriate amounts of chloride required to sanitize dishes. On 01/07/25 at 11:45 a.m., both the maintenance director and administrator were made aware that the [NAME] strips were not appropriate to check for chloride levels in a low temperature dishwasher. On 01/08/25 at 10:36 a.m., the DM once again checked with different chemical strips provided by the maintenance director. Those chemical strips were also not able to appropriately check for proper chloride ppm for a low temp dishwasher. On 01/08/25 at 10:43 a.m., the administrator was informed that it had now been over 24 hours of using a low temperature dishwasher without being able to check for proper sanitization. They stated they would shut down the dishwasher and use paper products until the dishwasher was fixed.

Based on observation, record review, and interview, the facility failed to ensure: a. wound care was provided in a manner to prevent cross contamination for two (#12 and #57) of three sampled residents observed for wound care; b. a urinary catheter was stored in a manner to prevent cross contamination for one (#12) of one sampled resident observed with a urinary catheter; and c. infection control logs were completed for five (#22, 25, 54, 81, and #86) of five sampled residents reviewed for staph infections. The administrator identified 114 residents resided in the facility. The DON identified 10 residents with non pressure wounds, two residents with staph infections, and two residents with urinary catheters resided in the facility. Findings: A Handwashing/Hand Hygiene policy, revised 08/2019, read in parts, This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Hand hygiene products and supplies .shall be readily accessible .Use alcohol-based hand rub .before moving from a contaminated body site to a clean body site during resident care. An Infection Prevention and Control Program policy, dated 2023, read in part, A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases of all residents. 1. Resident #12 had diagnoses which included vasculitis, MASD to the left gluteal fold, full thickness friction/ shear wound of right thigh, bipolar disorder, and schizoaffective disorder. A Physician Order, dated 06/15/24, documented to change foley catheter every month on the day shift on the 15th. A Wound Progress Note, dated 01/09/25, documented the resident had, a. partial thickness vasculitis wound to their right lower leg that measured 19.5cm length x 7cm width x 0.1cm depth, b. partial thickness vasculitis wound to their left lower leg that measured 12.5cm length x 2cm width x 0.1cm depth, c. full thickness MASD to their left gluteal fold that measured 3cm length x 2cm width x 0.1cm depth, and d. full thickness friction/shear to their right thigh (initial encounter) that measured 1.5cm length x 2cm width x 0.1cm depth. The note was signed by the wound NP. A Physician Order, dated 01/09/25, documented to cleanse bilateral lower leg with ns, pat dry, apply xeroform, ABD pad, and rolled gauze wrapped loosely daily and prn. On 01/14/25 at 10:21 a.m., LPN #2 was observed getting the following items ready for Resident #12's wound care: rolled gauze, five-five by nine xeroform petroleum dressings, three-five packs of normal saline vials, four by four gauze, a plastic cup, four five by nine ABD dressings and gloves and sat them on the wound care tray. On 01/14/25 at 10:28 a.m., LPN #2 obtained a gown from the cart, entered Resident #12's room, and placed the tray on the bedside table. LPN #2 placed a bag of gloves on the table and opened a biohazard bag and placed it on the bed. LPN #2 donned a pair of gloves and a gown. LPN #2 removed the dressing to the right leg and threw in the biohazard bag. LPN #2 pointed to the resident's left leg that did not have a dressing and stated it was supposed to be there. On 01/14/25 at 10:33 a.m., LPN #2 removed their gloves, obtained keys from their pocket, opened the door, removed their gown, and obtained a bottle of sanitizer from their treatment cart in the hall. LPN #2 sanitized their hands and placed the bottle back in their pocket. LPN #2 donned another gown and gloves. LPN #2 then squirted normal saline on the right leg wound and wiped the wound up and down using the same piece of gauze. LPN #2 then squirted the wound again two more times with saline, and used the same gauze to pat all over the wound back and forth and threw it in the biohazard bag. On 01/14/25 at 10:35 a.m., LPN #2 got more saline, squirted it on the wound, and used a new gauze and wiped all over the wound again. LPN #2 removed their gloves and threw them in the biohazard bag. On 01/14/25 at 10:36 a.m., LPN #2 obtained the bottle of hand sanitizer out of their pocket, used it, then placed it back in their pocket. LPN #2 donned gloves, placed xeroform on the right shin, then ABD pads, then rolled the dressing with rolled gauze and secured it with tape. On 01/14/25 at 10:39 a.m., LPN #2 removed their gloves placed them in the biohazard bag, removed hand sanitizer from their pocket, used the sanitizer, then placed it back in their pocket. On 01/14/25 at 10:40 a.m., LPN #2 got the vial of normal saline, squirted it on the left leg wound, and used gauze to wipe up and down over the same open area back and forth with the same piece of gauze. LPN #2 obtained more saline and another piece of gauze and wiped up the wound and back down the wound with the same piece of gauze. LPN #2 stated they were a new nurse and just got their license in March. On 01/14/25 at 10:41 a.m., LPN #2 removed their gloves, used sanitizer from their pocket, and replaced it in their pocket. On 01/14/25 at 10:42 a.m., LPN #2 donned gloves, placed xeroform on the left leg wound, then ABD pads, then wrapped it with rolled gauze and secured it with tape. On 01/14/25 at 10:43 a.m., LPN #2 removed their gloves and placed them in the biohazard bag, obtained a pen from their pocket, and attempted to write on the tape on the dressings. The pen would not write, so LPN #2 used a marker of Resident #12's with their bare hands that was located on the bedside table to intital and date both dressings. LPN #2 did not sanitize their hands after wound care before touching the resident's marker. On 01/14/25 at 11:18 a.m., LPN #2 stated staff were to wash their hands before and after they entered a resident room. LPN #2 stated when completing wound care staff would sanitize after changing their gloves, between dirty to clean, and if visibly soiled they would wash them with soap and water. On 01/14/25 at 11:19 a.m., LPN #2 stated they would change their gloves when going from soiled to clean. They stated staff should clean a wound by patting from inner to outer areas. On 01/14/25 at 12:58 p.m., LPN #2 stated they should have placed the hand sanitizer on the table instead of taking it in and out of their pocket. LPN #2 stated they should not have used the resident's pen to write on the dressing. LPN #2 stated they forgot to date the dressing the day before and they panicked. On 01/15/25 at 12:11 p.m., Resident #12's urinary catheter bag was observed on the floor with the plastic valve piece exposed. LPN #2 stated, It's supposed to be on the bed, I'll fix it. On 01/15/25 at 1:19 p.m., the regional clinical director stated urinary catheters were to be placed in a privacy bag, then at a level lower than the bladder. They stated the catheter bag should never be on the floor. On 01/14/25 at 10:38 a.m., Resident #12 was observed with dressings to their bilateral feet. There was a red brown soilage observed on the underside of the resident's left foot. 01/14/25 at 10:51 a.m., LPN #2 stated the wound care to Resident #12's lower legs were to be completed every morning. LPN #2 stated the wounds would go back and forth with healing. LPN #2 stated the resident's skin was very thin. On 01/14/25 at 1:50 p.m., the DON stated for wound care, staff should wash hands prior to getting their supplies set up and whenever wound care was completed. The DON stated staff could sanitize their hands between glove changes. On 01/14/25 at 1:52 p.m., the DON stated staff should change their gloves when going from dirty to clean. The DON stated they should sanitize their hands and change their gloves. On 01/14/25 at 1:53 p.m., the DON stated they would change their gloves and sanitize or wash their hands and put new gloves on after cleaning a wound. The administrator stated on average, staff would need to change their gloves around four times during wound care. The DON stated staff should start at the center and work their way out when cleaning a wound. 2. Resident #57 had diagnoses which included chronic pain syndrome and anxiety disorder. A Physician Order, dated 01/09/25, documented to cleanse posterior left shoulder with normal saline, pat dry, apply calcium alginate to wound bed, cover with dry dressing one time a day for wound care. The January 2025 TAR documented wound care to the resident's left shoulder was not provided on Sunday 01/12/25. 01/09/25 at 11:14 a.m., Resident #57 stated they recently had a suspicious mole removed from their shoulder. They stated staff were supposed to clean and dress the wound every day. Resident #57 stated their dressing change did not always happen as ordered. They stated last weekend it was not changed Saturday or Sunday. On 01/14/25 at 8:50 a.m., RN #1 entered Resident #57's room and donned a pair of gloves for wound care. On 01/14/25 at 8:51 a.m., RN #1 moved the resident's bedside table with their gloved hands, moved a sheet of wax paper to the resident's bed, opened a 4 inch by 5 inch super absorbent dressing, opened a vial of saline, squirted it on four by four gauze, then opened another saline vial and squirted it on the same four by four gauze. On 01/14/25 at 8:53 a.m., RN #1 opened the calcium alginate 2 inch by 2 inch dressing and removed the old dressing to Resident #57's left shoulder with the same gloved hands. RN #1 threw the old dressing in the trash bag, removed their gloves, and sanitized their hands. There was an approximately dime sized wound with minimal yellow drainage observed. The wound had a pink center with white outer edges. On 01/14/25 at 8:54 a.m., RN #1 donned a new pair of gloves, cleaned the wound three times with saline and gauze, dried the area with gauze, then placed the new calcium alginate and 4 inch by 5 inch super absorbent dressing on the resident's wounds. RN #1 failed to change gloves or wash/sanitize hands after cleaning the wound prior to placing a clean dressing. On 01/14/25 at 8:57 a.m., RN #1 stated Resident #57 had a history of skin cancer. They stated the resident had an appointment with the dermatologist approximately 15 days ago and they removed an area to the resident's left shoulder. RN #1 stated there was an order for wound care until the area was resolved. On 01/14/25 at 8:58 a.m., RN #1 stated Resident #57's wound had not experienced an infection and was improving. On 01/14/25 at 9:02 a.m., RN #1 stated staff were to use hand sanitizer between resident care as long as they were not visibly soiled. They stated they usually washed their hands about the third use. RN #1 stated they used gloves for everything. On 01/14/25 at 9:03 a.m., RN #1 stated for changing gloves, they would remove gloves prior to coming out of a resident's room. They stated as far as during a procedure, they would take multiple gloves in the room and discard them when they got dirty and put on clean gloves like they did during wound care. On 01/14/25 at 9:04 a.m., RN #1 stated usually they would change gloves after cleaning a wound before placing the clean dressing on. 3. A State Reportable Incident form, dated 12/12/24, documented the facility had experienced a staph infection outbreak and cultures were completed. It documented the outbreak included Residents #22, 25, 54, 81, and #86. The December 2024 infection control log contained the following entries, a. Resident #25 admitted ,d+[DATE] onset date skin, the site section was blank, infection related diagnoses skin, culture no, the organism section was blank, the date resolved section was blank, b. Resident #54 admitted ,d+[DATE], onset date skin, the site section was blank, infection related diagnoses wound, culture 12/19, the organism section was blank, the date resolved documented EBP, c. Resident #86 admitted ,d+[DATE], onset date skin, infection related diagnoses wound, culture 12/20, the organism section was blank, the date resolved section was blank, d. Resident #81 admitted ,d+[DATE], onset date skin, infection related diagnoses wound, culture 12/26, the organism section was blank, the date resolved section documented EBP, and e. Resident #22 admitted ,d+[DATE], onset date skin, infection related diagnoses wound, organism hosp, date resolved EBP. The facility map for infections for December 2024 did not identify organisms of infection to identify a trend. On 01/16/25 at 1:39 p.m., ADON #1 stated when a resident was placed on an antibiotic, they would put the information in antibiotic book and an infection screening would be completed. On 01/16/25 at 1:43 p.m., ADON #1 stated they would identify a trend occurred if two or three people had the infection. The DON stated if they had the same organism and how it was transmitted, the facilty would take the steps to address the transmission throughout all departments. On 01/16/25 at 1:45 p.m., the DON stated if a trend was identified, the facility would put a plan in place to disrupt the transmission. The DON stated the staff would be inserviced related to the outbreak. On 01/16/25 from 1:57 p.m. through 2:12 p.m., ADON #1 reviewed the facilty infection control log for December 2024. ADON #1 stated it was not completed accurately. ADON #1 stated the dates under the admitted should have been under the onset date. ADON #1 stated the information under the onset date should have been under the site. ADON #1 stated Residents # 22, 25, 54, 81, and #86's logs did not document the organism or the date resolved. On 01/16/25 at 2:16 p.m., the DON stated the map should include the organism of infection. On 01/16/25 at 2:18 p.m., the DON stated the map for December 2024 did not identify the organism. The DON stated it should have shown organisms such as staph and ecoli instead of just documenting skin for the infection.

Based on observation, record review, and interview, the facility failed to ensure the physician was notified when a resident experienced a change in their skin condition that required medical intervention for one (#12) of four sampled residents reviewed for non pressure skin conditions. The administrator identified 114 residents resided in the facility. The DON identified 10 residents with non pressure wounds resided in the facility. Findings: An undated Physician Notification for Resident Change in Condition policy, read in parts, Document in the medical record the date, time and name of each physician notified, actions taken and/or resident's response to treatment .Physician notification may be indicated in the following situations .new or worsening wounds. Resident #12 had diagnoses which included vasculitis, bipolar disorder, and schizoaffective disorder. A Wound Progress Note, dated 01/09/25, documented the resident had a wound to their right lower leg, left lower leg, left gluteal fold and right thigh. The note did not document the resident had any wounds to their feet. The note was signed by the wound NP. A Physician Order, dated 01/13/25, read in part, Start - Wound care [one] dose for wound care ONE TIME AND PRN SOILING PRIOR TO WOUND CARE CONSULTATION: Cleanse with NS. Apply silver alginate to areas with purulent drainage. Cover non-purulent area with vaseline gauze. Wrap with rolled gauze. REFER TO WOUND CARE AT FACILITY FOR THURSDAY 01/16/25. A Physician Order, dated 01/14/25, documented to cleanse wounds to bilateral foot with normal saline, pat dry, apply silver alginate to areas with purulent drainage, cover non-purulent area with Vaseline gauze, wrap with rolled gauze, daily and as needed. On 01/14/25 at 10:28 a.m., LPN #2 entered Resident #12's room to provide wound care. LPN #2 was observed telling Resident #12 I can't touch your feet until wound care looks at it Thursday. Resident #12 was observed with dressings to their bilateral feet. There was no date observed on the dressings. LPN #2 stated it was their fault, and that they had completed the dressing change on 01/13/25 with the hospice nurse. LPN #2 stated they could not touch the resident's feet until wound care evaluated them. LPN #2 stated hospice did not want them to be messed with until they were evaluated. On 01/14/25 at 10:38 a.m., Resident #12 was observed with dressings to their bilateral feet. There was a red brown soilage observed on the underside of the resident's left foot. On 01/14/25 at 10:54 a.m., LPN #2 stated it was their understanding the hospice shower aide took Resident #12's sock off and the skin came off the left foot. LPN #2 stated both feet were just kind of raw and really flaky. They stated staff had been putting Aquaphor on the resident's legs for months. LPN #2 stated the issue with the resident's feet occurred Friday 01/10/25. They stated they received an order to treat the feet yesterday (01/13/25) to put silver alginate and xeroform on it. LPN #2 stated the order came from hospice, and LPN #2 helped the hospice nurse with dressing the resident's feet yesterday. LPN #2 stated hospice did not want Resident #12's feet messed with until the wound doctor could evaluate them. LPN #2 stated the undated dressings had been on the resident's feet since yesterday. LPN #2 was asked about the soilage on the resident's left foot dressing. LPN #2 stated they could change it and let hospice know they had to change it. LPN #2 stated hospice had cultured the wounds yesterday. LPN #2 stated when the hospice aide had removed Resident #12's sock, they stated the resident's skin stuck to the sock. LPN #2 stated it was just the top layer of the resident's foot like a flesh wound. LPN #2 stated they cleaned the area with normal saline and yesterday when they were looking at it, there was some on the bottom as well. LPN #2 stated on Friday they had cleaned the area and covered it with a four by four. LPN #2 was asked if the doctor was notified and was an order received for the wound care they provided to this area on Friday. LPN #2 stated they texted the resident's hospice, but I don't know if they came out because it happened at 2:45 3:00 o'clock. On 01/14/25 at 12:33 p.m., Resident #12 was observed in the main dining area seated in their wheelchair. There was bright red soilage observed on the resident's left foot that continued over the lateral side. On 01/14/25 at 12:36 p.m., LPN #2 stated they would see if the resident would allow a dressing change to their feet after lunch. They stated there were activities from two to four the resident would not want to miss. 01/14/25 at 2:29 p.m., Resident #12 was observed in the main dining area with a red tinged dressing present to their left foot. Resident #12 did not permit the dressing change to their feet prior to the surveyors leaving on 01/14/25. On 01/15/25 at 10:14 a.m., LPN #2 stated they were a new nurse and might have the policy wrong. They stated to their understanding they were supposed to contact the hospice nurse to get orders from them. LPN #2 stated with wounds they usually told the hospice nurse and they usually told ADON #1. They stated on Friday they were running out of the facility and it was their fault. They stated normally on wounds they would tell ADON #1 and they would contact the wound care doctor. LPN #2 stated on Friday, they dropped the ball. LPN #2 stated the wound was superficial and there was nothing on the bottom. On 01/15/25 at 12:27 p.m., the DON stated they would have to get the facility policy for what do do if staff identified a change in the resident's skin. On 01/15/25 at 1:14 p.m., the DON chose for the surveyor to ask policy questions in the presence of the regional clinical director, the administrator, the regional nurse. On 01/15/25 at 1:16 p.m., the regional clinical director stated if a resident had a brand new wound, the staff wound notify the provider. They stated if the resident was an established wound care provider patient, they would call and notify them. On 01/15/25 at 1:18 p.m., the regional clinical director stated if the resident was a hospice resident and there was a change in the resident's skin, they would notify the hospice provider or nurse. On 01/16/25 at 8:11 a.m., the wound NP stated they came every Thursday and saw Resident #12. They stated the resident was paralyzed and stiff with a lot of autoimmune issues like vasculitis on their lower legs. On 01/16/25 at 8:20 a.m., the wound NP stated they spoke with ADON #1 on Tuesday (01/14/25) who reported the resident had broke out with one between the toes. The wound NP stated they believed hospice had given them orders and they took a culture due to purulent drainage.

Based on observation and interview, the facility failed to provide a safe, clean, and comfortable shower room in three of the four shower rooms observed. ADON #1 identified the facility had seven shower rooms. Findings: An undated facility Safe Environment policy, read in part, facility will maintain a safe, comfortable, and homelike environment. The policy also read, the facility will be designed, constructed, equipped and maintained to protect the health and safety of residents, personnel and the public. On 01/21/25 at 10:03 a.m., housekeeper #1 stated they cleaned hall 500 shower room every day, but the rust stains leaking from the rusted safety bars would not come off no matter how much it they were scrubbed. They stated the brown paint on the floor was peeling up all over the place and the shower room acted as a storage room as well. They stated this shower room was about to be remodeled, but they were not sure when. On 01/21/25 at 10:05 a.m., the floor had a sticky residue that caused shoes to stick to the floor while walking in the shower room. The entire right side of the shower room was being used as storage. There were two mechanical lifts, a wheel chair, a walker, a mattress, a sling for the lift, multiple storage totes, closed boxes, 3-three drawer plastic containers, a bedside table with a closed box blocking access to the sink, and two large trash cans on wheels blocking access to the toilet. There was also a shower bench with one of the seat planks unattached. On 01/21/25 at 10:13 a.m., CNA #2 stated they believed all residents got a shower on their shower days in that shower room. They stated, We try to keep their feet dry when they get out to keep it from sticking. for the most part it works, they are going to be redoing it. They also stated, There is stuff in their but typically we don't use it for storage. The toilet and sink work and when we need to use them, we just move the trash bins out of the way. They stated they were unaware that one of the shower chairs was currently broken. On 01/21/25 at 10:21 a.m., hall 100 shower room was observed to have a full dirty laundry basket on the floor, the paint had started peeling on the floor, and one of the shower chairs by the cabinets did not have one of the wheels on it. The wheel was inside the shower stall. On 01/21/25 at 10:23 a.m., CNA #3 stated the laundry basket should have been taken to the dirty linen next door. They stated the floor had looked that way since at least April of 2024 when they started. They stated they do not use the broken shower chair. On 01/21/25 at 12:42 p.m., the administrator stated that hall 500 was going to be remodeled first as soon as survey was done and then hall 100 was next. The administrator stated they were aware the shower room had been used for storage. They called maintenance to have it cleaned back out, stating they were unaware that stuff was back in there. On 01/21/25 at 5:27 p.m., the maintenance director opened the door to the shower room for 600. They stated the power was off because the exhaust fan needed to be fixed. The temperature felt very cold. The shower room on hall 600 was located across from the exit door and the outside temperature was in the 30's at the time.

Based on observation, record review, and interview, the facility failed to ensure a resident care plan was revised for one (#57) of one sampled resident observed self-administering a medication. The administrator identifed no residents with orders to self-administer medications resided in the facility. Findings: A Care Plans policy, revised 12/2016, read in parts, Assessments of residents are ongoing and care plans are revised as information about residents and the residents' conditions change .The interdisciplinary team must review and update the care plan. Resident #57 had diagnoses which included chronic obstructive pulmonary disease with acute exacerbation and acute and chronic respiratory failure with hypoxia. Resident #57's care plan documented focus: the resident had a physician's order for unsupervised self-administration of the following medications: Albuterol sulfate, date initiated 06/13/22, revision date 06/13/22. It documented goal: Resident #57 would take medications safely as prescribed through the review date, date initiated 06/13/22, revision on 12/13/24. The interventions listed for this care plan goal were dated 06/13/22. The most recent Medication Self Administration Safety Screen form for Resident #57 was dated 06/13/22. A Physician Order, dated 09/10/24, documented ipratropium-albuterol inhalation solution (bronchodilator) 0.5-2.5 3MG/3ML one application inhale orally every six hours as needed for shortness of breath. There was no recent medication self-administration safety screen for Resident #57 to self-administer medications in the resident's clinical record. There was no physician's order to self-administer medications in the resident's clinical record. On 01/14/25 at 8:32 a.m., Resident #57 was observed seated on the side of their bed with a nebulizer mask on and the machine running. The resident stated they did breathing treatments once every six hours. They stated staff gave it to them and they did not keep the medication in their room. On 01/14/25 at 8:33 a.m., Resident #57 stated they turned the nebulizer machine off themselves. There was liquid observed in the canister of the nebulizer the resident had on their face. There was no staff observed in the room with the resident while the machine was running. On 01/14/25 at 8:59 a.m., RN #1 stated Resident #57 received a duoneb once on their shift. On 01/14/25 at 9:00 a.m., RN #1 stated Resident #57 had not been evaluated to their knowledge to self-administer medications. They stated they stayed with the resident the whole time during a breathing treatment. On 01/14/25 at 1:55 p.m., the DON stated staff were to watch residents when administering a nebulizer treatment and give them instructions on how to do it. The administrator stated staff were to stay with them the entire treatment. The administrator stated staff were not to leave the resident and were to ensure the tubing was dated properly and changed. On 01/14/25 at 1:56 p.m., the administrator stated there were no residents in the facility with orders to self- administer medications. On 01/17/25 at 8:33 a.m., MDS coordinator #1 stated they would first develop a baseline care plan when a resident admitted to the facility. They stated they completed an admission MDS to know what CAAs triggered. MDS Coordinator #1 stated they would then create a care plan off of the CAAs and anything extra such as diagnoses and medication classification. On 01/17/25 at 8:35 a.m., MDS coordinator #1 stated they tried to go through the 24 hour reports daily and wrote down any significant things that happened such as falls to capture them. They stated after completing quarterly MDS assessments, they would update care plans as a whole. On 01/17/25 at 8:37 a.m., MDS coordinator #1 reviewed Resident #57's care plan for self- administration of medications and stated they obtained the information for the care plan based off of a self-administration assessment completed for Resident #57. MDS Coordinator #1 stated Resident #57 had a self-administration assessment completed on 06/13/22, and they did not see an order for the resident to self-administer medications for this care plan. MDS Coordinator #1 stated staff did complete an assessment and obtain an order now, but they could not locate any before 01/14/25.

Based on record review and interview, the facility failed to ensure wound care was provided as ordered for one (#17) of two sampled residents reviewed for pressure ulcers. ADON #2 identified three residents with pressure ulcers resided in the the facility. Findings: A Pressure Ulcers/Skin Breakdown policy, revised 04/2018, read in parts, The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings .and application of topical agents. Resident #17 had diagnoses which included an unstageable pressure injury to the left heel and a deep tissue pressure injury to the right lateral heel. A Physician Order, dated 10/26/24, documented to cleanse left heel with ns, pat dry, apply santyl to wound bed, cover with calcium alginate, apply ABD pad, and wrap with rolled gauze and tape daily and PRN for soilage. A Physician Order, dated 12/20/24, documented to cleanse right lateral heel with ns, pat dry, apply calcium alginate to wound bed, cover with ABD pad, secure with tape daily and PRN. A Wound Progress Note, dated 12/26/24, documented Resident #17 had an unstageable pressure injury to the left heel and a stage three pressure injury to the right lateral heel. The December 2024 TAR did not document the treatment to the right lateral heel or left heel was completed on the 31st. A Physician Order, dated 01/02/25, documented to cleanse right lateral heel with ns, pat dry, apply Betadine BID and PRN. A Wound Progress Note, dated 01/09/25, documented Resident #17 had an unstageable pressure injury to the left heel and a deep tissue pressure injury to the right lateral heel. A Physician Order, dated 01/16/25, documented to cleanse right heel with normal saline pat dry, apply Betadine to area BID and PRN. The January 2025 TAR did not document the treatment was completed to the left heel on the 6th, the right lateral heel on the day shift of the 6th, or the right heel on the evening shift of 18th. On 01/21/25 at 5:40 p.m., ADON #1 was identified as familiar with Resident #17's wounds. ADON #1 stated Resident #17 had a left heel unstageable wound that was grafted last week. They stated the resident had poor circulation in their legs. ADON #1 stated the resident had a little spot on their outer right foot by the heel from a deep tissue injury. ADON #1 stated due to the recent graft, staff were to change the outer dressing on the left daily and PRN. They stated the right had a treatment of Betadine daily and leave open to air. ADON #1 stated wound care was documented in the TAR. On 01/21/25 at 5:46 p.m., ADON #1 reviewed the January 2025 TAR and stated the blanks on the 6th for the left heel the staff did not Click it off. ADON #1 stated, I'm hoping they did it. They stated it was the same for the right heel on the 6th and 18th. They stated, It doesn't look like it was done because it wasn't clicked off. On 01/21/25 at 5:48 p.m., ADON #1 reviewed the December 2024 TAR and stated the left and right heel on the 31st was red. ADON #1 stated, They probably didn't do it.

On 03/23/21 at 1:09 p.m. the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy situation regarding supervision to prevent accident hazards related to elopement and wandering. Resident #1 was admitted to the facility to the memory care secured unit. The resident was a high risk for wandering and exhibited exit seeking behaviors, and talking about leaving the building continuously. On 03/11/21 the resident had eloped from the facility through the exit door in the secured unit and then out a wooden gate that was unlocked. The resident was located 2.5 to 3.5 miles away from the facility and was returned to the facility by the local law enforcement. At 1:12 p.m. the administrator, corporate nurse and regional administrator was informed of the existence of the immediate jeopardy. A request was made for an acceptable plan to remove the immediacy. At 4:18 p.m. the facility submitted an acceptable plan of removal. The plan of removal was as follows: 'Plan of Removal for Immediate Jeopardy Situation at Oak Hills on 03/23/2021' The following interventions have and/or will be implemented to address the [Resident #1] incident, which administration was informed of by the surveyor on 03/23/2021: 1) Locks to the gate of the courtyard in the locked unit of the facility had previously been changed due to unrelated issues regarding staff making personal keys for the purpose of entering and exiting without clocking in and out; Known staff have been terminated. 2) The code to exit from the locked unit where the resident currently resides has been changed due to being informed by the surveyor the resident said she knows the code; this information was unable to be confirmed due to the resident being unable to state to staff or demonstrate knowledge. 3) All residents on the locked unit will have updated wander assessments to ensure all wander and elopement risks have been identified. 4) All care plans will be reviewed and updated for residents identified at risk for wandering or elopement. 5) All staff will be educated on the identification, reporting, and implementation of interventions related to wandering and elopement behaviors. 6) An investigation will be conducted of the incident. 7) The resident will be monitored every 15 minutes for elopement behaviors. Interventions will be completed by 11:59 p.m. on 03/23/2021 On 03/24/21 after reviewing all documentation from in-serviced, wandering assessments, care plans and interviewing staff the immediacy was lifted effective 03/24/21 at 1:15 p.m The facility was informed the immediacy could not be lifted until that time after all staff, including housekeeping had been in-serviced. The deficient practice remained at a pattern with no actual harm with potential for more than minimal harm. Based on observation, record review and interviews, it was determined the facility failed to assess, monitor and intervene for a resident who was a known wander and elopement risk. Resident #1 was admitted to the facility on the secured unit and had vocalized and attempted to leave the facility on several occasions. The resident on 03/11/21 did get out of the facility and eloped, ending up 2.5 to 3.5 miles away from the facility before being brought back by the police. This resulted in an immediate jeopardy situation. Resident #1 was admitted to the facility on [DATE] with diagnoses which included suicidal ideation's, cognitive communication deficits, dementia, [CONDITION(S)], anxiety, [CONDITION(S)] disorder, and [CONDITION(S)]. The resident was admitted to the secured unit and continued to be on the secured unit. A wandering assessment, dated 08/14/20, documented the resident was a high risk for wandering. A nursing assessment, dated 08/14/20, documented the resident had an unsteady gate and was confused. The resident further had short term, long term memory problems, hallucinated, and had delusions. The resident was independent in walking and locomotion. A review of the resident's initial care plan, completed upon admission, did not address the resident's risk for wandering. A wandering assessment, dated 09/03/20, documented the resident was a high risk for wandering. A wandering assessment, dated 12/02/20, documented the resident was a high risk for wandering. A review of the resident's car plan, dated 12/02/20, did not address the resident's wandering and risk for elopement. A nurse's note, dated 01/04/21 at 11:20 p.m., documented, In report stated that resident has been upset and agitated all day. Pacing, yelling at residents and staff. She was in common room pacing trying to open the door yelling and cursing. She then went to her room and cont [continued]. yelling and screaming that everyone was stealing from her and trying to hurt her and she wants to leave . The progress note was written by LPN #3. A nurse's note, dated 01/07/21 at 4:07 a.m., documented, Resident has been sitting in common room yelling, screaming and cursing since 2230 .She finally went into her room cont. screaming and cursing stated I a.m. leaving here tomorrow, I will run away from here. I know where to go . The note was written by LPN #3. A nurse's note, dated 02/20/21 at 4:15 a.m., documented, Res opened window in room and crawled outside to locked smoking area in the snow, nurse attempted to redirect but res refused to come back in, left res alone and res came back inside window at that time. The note was written by LPN #4. A quarterly assessment, dated 02/18/21, documented the resident was able to make herself understood, understood others, and was moderately impaired. The assessment further documented the resident wandered the facility and required supervision in all areas of activities of daily living. The resident did not require any assistive devices for ambulation such as a walker or wheel chair. A review of the resident's care plan, last updated on 02/18/21, did not address the resident's wandering and elopement risk. A nurse's note, dated 03/04/21 at 12:27 p.m., documented the resident was alert and able to make her needs known. The note was written by LPN #5. An electronic medication administration note, dated 03/09/21 at 7:15 p.m., documented, multiple elopement attempts. res not easily redirected. res becomes agitated with multiple redirection attempts . The note was written by LPN #2. A nurse's note, dated 03/10/21 at 1:52 a.m., documented, Cont. with disruptive behaviors this shift. Exit seeking, pacing up and down hall yelling and cursing threatening to run off .Redirection ineffective . The note was written by LPN #4. A review of the Oak Hills Daily Staff assignment Sheet, for 03/11/21, documented the following individuals were working on hall 100, the secured unit: LPN #1, the ADON, the charge nurse on the 7-3 shift; Certified medication aide #2 on the 7-3 and 3-11 shift; CNA #2 on the 7- 3 shift; LPN #2, the charge nurse on the 3-11 shift; [NAME] CNA 3-11 shift; CNA #4 on the 3-11 shift. An electronic medication administration note, dated 03/11/21 at 6:43 p.m., documented, res [Resident] cont [continues] to have exit seeking behaviors and screaming. The note was written by LPN #2. This was the only documented elopement issues on this date. An electronic medication administration note, dated 03/12/21 at 5:49 p.m., documented, res requires continuous redirection d/t [due to] screaming, cursing and exit seeking. The note was written by LPN #2. A review of the facilities incident reports did not contain any reports for Resident #1 exit seeking and getting away from the facility on 03/11/21. There was no documentation the facility had investigated the resident's elopement from the facility on 03/11/21. There was no documentation who notified the facility of the resident's elopement from the facility and located 2.5 to 3.5 miles away. There was no documentation in the progress notes or in the clinical record the resident had eloped from the facility and was returned by the police on 03/11/21. On 03/22/21 upon entrance to the facility a request was made to LPN #1, the assistant director of nursing, for a list of residents who were deemed at risk for elopement by the facility. A list was provided with 16 names highlighted as being at risk for elopement. She verified only the highlighted names were at risk. Resident #1 was not identified on the list as being a risk for elopement. At 10:25 a.m. a brief tour of the facility was conducted. The resident was observed in the secured unit located on hall 100. Observations were made of the entrance, exit doors to the unit including the exit door to the outside smoke area. The door had a key pad to unlock the door, the code was not posted or viably in site. A large wooden picket fence was located around the court yard. With two gates, one leaving to the side and back of the facility and another leading to the parking lot. LPN #6 stated Resident #1 was the only resident he knew that had gotten outside the wooden fenced area and was gone. He stated he was not sure how she got out, but was told that when he started working at the facility approximately a week ago. He was not sure of the date the incident had occurred. At 10:56 a.m., the resident was asked about leaving the facility. She stated she left through the gate in the smoke area because it was unlocked. She stated she was able to get outside because she knew the code to the exit door by watching it be put in and she had memorized it. When asked about the wooden gate she went through she stated there were no locks on it. She stated she did not want to be at the facility and that is why she left. She stated she had been on the current unit since she was first admitted . When asked how she got back to the facility, she stated I was brought back by the police. At 12:06 p.m. Certified Medication Aide (CMA) #1, identified resident #1 was as the only resident on the secured unit to elope. She had gotten out of the fence and left. He stated it had happened on the evening shift over a week ago and could not remember the exact date. He stated the police had picked her up and brought her back to the facility. He stated after the big escape the facility had put two locks on the gate. He then stated there were no locks on the gate at the time she had eloped from the facility. CMA #1 confirmed the resident was able to make you know how she was feeling and had attempted to get out of the facility numerous times. He stated the resident had resided on the secured unit since being admitted . At 1:30 p.m., LPN #1, the ADON stated the resident was cognitively intact and knows what she said and did. She then stated the resident had moments with her mental illness that she had not remembered things, but still would tell you what she wanted. When asked about the incident where she had eloped from the facility, she stated she did not know much about it other then what a co-worker had told her. She then stated the police had to bring her back to the facility. She stated she was not aware how long the resident had been gone or how the facility found out she was missing. She stated the resident had been brought back to the facility around supper time. She stated she was not sure who the director of nursing was at the time. LPN #1 stated the resident had resided on the secured unit since being admitted . She stated LPN #2 was the charge nurse on the evening shift when it had all occurred. LPN #1 did not indicate she had been working as a charge nurse on the secured unit on the day the event occurred and/or that she was present off site where the resident was located and brought back by the police. At 1:45 p.m., LPN #2 was interviewed about the incident. She stated it was around shift change at 3:00 p.m. when the resident had gotten away from the facility. She stated the resident had gotten out of the gate due to no locks being on them. She stated the resident had a lot of documentation in her chart that the resident had been attempting to leave the facility and spoke of it often. She stated the outgoing charge nurse was to complete the incident report and document, so she did not complete an incident report. She then identified the outgoing charge and said she completed the incident report. She confirmed she did not know how long the resident had been gone from the facility and that the police had to bring her back. At 1:53 p.m., LPN #1, the ADON was asked if there was an incident report completed, she stated no and there should have been. She then stated the nurse also should have documented it in the progress notes. A request was made for all the documentation regarding Resident #1 leaving the facility. At 4:45 p.m., Officer #1 stated he had been dispatched on 03/11/21 at 5:15 p.m. to assist with a resident from the facility. He then identified Resident #1 as the one he was dispatched to assist with. He stated there were four employees of the facility present when he arrived on scene. He stated he was dispatched to Jones Station Road, located off of Hiawassee Road, where the resident was located. The officer confirmed the location was approximately 2.5 to 3.5 miles away from the facility. Officer #1 stated the resident told him she did not want to go back and she left because she wanted to get out of the facility. When asked if the resident indicated how she got away from the facility he confirmed she said she left through a locked door that she knew the code to, but would not disclose how she knew the code. He then stated she said the gate was unlocked. He stated the resident finally agreed he could take her back to the facility and he had one of the employees ride with him. When asked if he had the names of the employees present and who rode back with him, he stated he knew they were employees, but did not know the names because he did not do a report. On 03/23/21 at 9:33 a.m., a request was made to interview LPN #1, the ADON. The corporate nurse stated the employee was not going to be at work. She then stated the nurse had told her there were no additional documentation and/or an incident report regarding the incident. At 9:35 a.m., LPN #7, the care plan and MDS Coordinator, was asked about the residents wandering and elopement risk. She stated she had only been working at the facility approximately three weeks and would have to review the resident's chart. She was asked to review the care plan and then asked if the resident's care plan was developed to address the wandering risk and an elopement risk. After looking through the care plan she stated the care plan did not address the wandering and elopement risk the resident had. She was then provided the wandering assessments and shown the nurses' notes. She stated the resident's care plan should have addressed the elopement and wandering. She then stated the progress notes documented the resident attempted to exit the facility and get away frequently. At 9:51 a.m., the corporate nurse stated the care plan did not address wandering and elopement. She stated the resident's cognition was moderately impaired and it had improved since admission. She stated the resident had gone to the store on the date in question and that was the only information that was provided to her from the staff. She stated the care plan was not developed to address the elopement and wandering. She was asked if CMA #2, CNA #2, and CNA #4 was working. She stated CNA #2 and #4 was working and CMA #2 no longer worked at the facility. At 10:27 a.m. CNA #2 confirmed the resident had gotten out of the facility and was returned by the police. She stated the resident had gone through the wooden fence because it was unlocked. The CNA then stated a former employee noticed the resident walking down the road and notified the facility she was out. CNA #2 stated the resident was able to understand what she was doing and let you know what she wanted. CNA #2 stated the resident had a history of talking about and attempting to get out of the building. She added the resident had attempted to leave through her room window and got outside into the smoke area before being noticed. She then stated since working at the facility she had personally witnessed the resident attempt to go out the doors on numerous occasions. At 10:45 a.m., CNA #3 stated the resident had left the building and went through an unlocked gate. She stated she did not know how she got back to the facility. She then stated resident #1 had made several attempts of leaving and talked about leaving the facility all the time. She confirmed the resident had attempted to exit the facility through her bedroom window. At 10:57 a.m., the administrator stated the resident was brought back to the facility by the police. She stated LPN #1, the ADON, was with the resident when she was brought back to the facility. She stated the incident happened the day the resident went to the store with staff. She was asked if she knew where the resident was located and how the facility found out she had eloped from the building. She shook her head to indicate no and stated all she was told was the resident went to the store. She was asked if there was any documentation to support the resident leaving and going to the store. She indicated the facility had no documentation on what happened that day. She stated new locks had been put on the gate after the incident, due to finding out staff had keys that should not have had them. At 11:54 a.m., the maintenance manager stated he had put new locks on the wooden fence because staff had keys and were coming and going. He stated he did not know the resident had gone out the unlocked gate, but they were changed when staff was found to have keys. He stated it had been only a week since the new locks had been in place and he and the administrator were the only staff with the keys. At 12:00 p.m., CNA #4 stated she had came into work and received report that resident #1 had left the facility through an unlocked gate. She stated the resident was unattended when she left. She stated a former employee notified the facility the resident was walking down the road several miles away. She said the police had to bring the resident back to the facility. The resident had a history of attempting to get out of the facility through the doors and her bedroom window. She stated the resident also would say all the time she would be leaving the facility because she did not want to be there.

On 03/23/21 at 1:09 p.m. the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy situation regarding supervision to prevent accident hazards related to elopement and wandering. Resident #1 was admitted to the facility to the memory care secured unit. The resident was a high risk for wandering and exhibited exit seeking behaviors, and talking about leaving the building continuously. On 03/11/21 the resident had eloped from the facility through the exit door in the secured unit and then out a wooden gate that was unlocked. The resident was located 2.5 to 3.5 miles away from the facility and was returned to the facility by the local law enforcement. At 1:12 p.m. the administrator, corporate nurse and regional administrator was informed of the existence of the immediate jeopardy. A request was made for an acceptable plan to remove the immediacy. At 4:18 p.m. the facility submitted an acceptable plan of removal. The plan of removal was as follows: 'Plan of Removal for Immediate Jeopardy Situation at Oak Hills on 03/23/2021' The following interventions have and/or will be implemented to address the (Resident #1) incident, which administration was informed of by the surveyor on 03/23/2021: 1) Locks to the gate of the courtyard in the locked unit of the facility had previously been changed due to unrelated issues regarding staff making personal keys for the purpose of entering and exiting without clocking in and out; Known staff have been terminated. 2) The code to exit from the locked unit where the resident currently resides has been changed due to being informed by the surveyor the resident said she knows the code; this information was unable to be confirmed due to the resident being unable to state to staff or demonstrate knowledge. 3) All residents on the locked unit will have updated wander assessments to ensure all wander and elopement risks have been identified. 4) All care plans will be reviewed and updated for residents identified at risk for wandering or elopement. 5) All staff will be educated on the identification, reporting, and implementation of interventions related to wandering and elopement behaviors. 6) An investigation will be conducted of the incident. 7) The resident will be monitored every 15 minutes for elopement behaviors. Interventions will be completed by 11:59 p.m. on 03/23/2021 On 03/24/21 after reviewing all documentation from in-serviced, wandering assessments, care plans and interviewing staff the immediacy was lifted effective 03/24/21 at 1:15 p.m The facility was informed the immediacy could not be lifted until that time after all staff, including housekeeping had been in-serviced. Based on observation, record review and interviews, it was determined the facility failed to assess, monitor and intervene for a resident who was a known wander and elopement risk. Resident #1 was admitted to the facility on the secured unit and had vocalized and attempted to leave the facility on several occasions. The resident on 03/11/21 did get out of the facility and eloped, ending up 2.5 to 3.5 miles away from the facility before being brought back by the police. This resulted in an immediate jeopardy situation. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted to the secured unit and continued to be on the secured unit. A wandering assessment, dated 08/14/20, documented the resident was a high risk for wandering. A nursing assessment, dated 08/14/20, documented the resident had an unsteady gate and was confused. The resident further had short term, long term memory problems, hallucinated, and had delusions. The resident was independent in walking and locomotion. A review of the resident's initial care plan, completed upon admission, did not address the resident's risk for wandering. A wandering assessment, dated 09/03/20, documented the resident was a high risk for wandering. A wandering assessment, dated 12/02/20, documented the resident was a high risk for wandering. A review of the resident's car plan, dated 12/02/20, did not address the resident's wandering and risk for elopement. A nurse's note, dated 01/04/21 at 11:20 p.m., documented, In report stated that resident has been upset and agitated all day. Pacing, yelling at residents and staff. She was in common room pacing trying to open the door yelling and cursing. She then went to her room and cont (continued). yelling and screa.m.ing that everyone was stealing from her and trying to hurt her and she wants to leave . The progress note was written by LPN #3. A nurse's note, dated 01/07/21 at 4:07 a.m., documented, Resident has been sitting in common room yelling, screa.m.ing and cursing since 2230 .She finally went into her room cont. screa.m.ing and cursing stated I a.m. leaving here tomorrow, I will run away from here. I know where to go . The note was written by LPN #3. A nurse's note, dated 02/20/21 at 4:15 a.m., documented, Res opened window in room and crawled outside to locked smoking area in the snow, nurse attempted to redirect but res refused to come back in, left res alone and res ca.m.e back inside window at that time. The note was written by LPN #4. A quarterly assessment, dated 02/18/21, documented the resident was able to make herself understood, understood others, and was moderately impaired. The assessment further documented the resident wandered the facility and required supervision in all areas of activities of daily living. The resident did not require any assistive devices for a.m.bulation such as a walker or wheel chair. A review of the resident's care plan, last updated on 02/18/21, did not address the resident's wandering and elopement risk. A nurse's note, dated 03/04/21 at 12:27 p.m., documented the resident was alert and able to make her needs known. The note was written by LPN #5. An electronic medication administration note, dated 03/09/21 at 7:15 p.m., documented, multiple elopement attempts. res not easily redirected. res becomes agitated with multiple redirection attempts . The note was written by LPN #2. A nurse's note, dated 03/10/21 at 1:52 a.m., documented, Cont. with disruptive behaviors this shift. Exit seeking, pacing up and down hall yelling and cursing threatening to run off .Redirection ineffective . The note was written by LPN #4. A review of the Oak Hills Daily Staff assignment Sheet, for 03/11/21, documented the following individuals were working on hall 100, the secured unit: LPN #1, the ADON, the charge nurse on the 7-3 shift; Certified medication aide #2 on the 7-3 and 3-11 shift; CNA #2 on the 7- 3 shift; LPN #2, the charge nurse on the 3-11 shift; <BR/(NAME)CNA 3-11 shift; CNA #4 on the 3-11 shift. An electronic medication administration note, dated 03/11/21 at 6:43 p.m., documented, res (Resident) cont (continues) to have exit seeking behaviors and screa.m.ing. The note was written by LPN #2. This was the only documented elopement issues on this date. An electronic medication administration note, dated 03/12/21 at 5:49 p.m., documented, res requires continuous redirection d/t (due to) screa.m.ing, cursing and exit seeking. The note was written by LPN #2. A review of the facilities incident reports did not contain any reports for Resident #1 exit seeking and getting away from the facility on 03/11/21. There was no documentation the facility had investigated the resident's elopement from the facility on 03/11/21. There was no documentation who notified the facility of the resident's elopement from the facility and located 2.5 to 3.5 miles away. There was no documentation in the progress notes or in the clinical record the resident had eloped from the facility and was returned by the police on 03/11/21. On 03/22/21 upon entrance to the facility a request was made to LPN #1, the assistant director of nursing, for a list of residents who were deemed at risk for elopement by the facility. A list was provided with 16 na.m.es highlighted as being at risk for elopement. She verified only the highlighted na.m.es were at risk. Resident #1 was not identified on the list as being a risk for elopement. At 10:25 a.m. a brief tour of the facility was conducted. The resident was observed in the secured unit located on hall 100. Observations were made of the entrance, exit doors to the unit including the exit door to the outside smoke area. The door had a key pad to unlock the door, the code was not posted or viably in site. A large wooden picket fence was located around the court yard. With two gates, one leaving to the side and back of the facility and another leading to the parking lot. LPN #6 stated Resident #1 was the only resident he knew that had gotten outside the wooden fenced area and was gone. He stated he was not sure how she got out, but was told that when he started working at the facility approximately a week ago. He was not sure of the date the incident had occurred. At 10:56 a.m., the resident was asked about leaving the facility. She stated she left through the gate in the smoke area because it was unlocked. She stated she was able to get outside because she knew the code to the exit door by watching it be put in and she had memorized it. When asked about the wooden gate she went through she stated there were no locks on it. She stated she did not want to be at the facility and that is why she left. She stated she had been on the current unit since she was first admitted . When asked how she got back to the facility, she stated I was brought back by the police. At 12:06 p.m. Certified Medication Aide (CMA) #1, identified resident #1 was as the only resident on the secured unit to elope. She had gotten out of the fence and left. He stated it had happened on the evening shift over a week ago and could not remember the exact date. He stated the police had picked her up and brought her back to the facility. He stated after the big escape the facility had put two locks on the gate. He then stated there were no locks on the gate at the time she had eloped from the facility. CMA #1 confirmed the resident was able to make you know how she was feeling and had attempted to get out of the facility numerous times. He stated the resident had resided on the secured unit since being admitted . At 1:30 p.m., LPN #1, the ADON stated the resident was cognitively intact and knows what she said and did. She then stated the resident had moments with her mental illness that she had not remembered things, but still would tell you what she wanted. When asked about the incident where she had eloped from the facility, she stated she did not know much about it other then what a co-worker had told her. She then stated the police had to bring her back to the facility. She stated she was not aware how long the resident had been gone or how the facility found out she was missing. She stated the resident had been brought back to the facility around supper time. She stated she was not sure who the director of nursing was at the time. LPN #1 stated the resident had resided on the secured unit since being admitted . She stated LPN #2 was the charge nurse on the evening shift when it had all occurred. LPN #1 did not indicate she had been working as a charge nurse on the secured unit on the day the event occurred and/or that she was present off site where the resident was located and brought back by the police. At 1:45 p.m., LPN #2 was interviewed about the incident. She stated it was around shift change at 3:00 p.m. when the resident had gotten away from the facility. She stated the resident had gotten out of the gate due to no locks being on them. She stated the resident had a lot of documentation in her chart that the resident had been attempting to leave the facility and spoke of it often. She stated the outgoing charge nurse was to complete the incident report and document, so she did not complete an incident report. She then identified the outgoing charge and said she completed the incident report. She confirmed she did not know how long the resident had been gone from the facility and that the police had to bring her back. At 1:53 p.m., LPN #1, the ADON was asked if there was an incident report completed, she stated no and there should have been. She then stated the nurse also should have documented it in the progress notes. A request was made for all the documentation regarding Resident #1 leaving the facility. At 4:45 p.m., Officer #1 stated he had been dispatched on 03/11/21 at 5:15 p.m. to assist with a resident from the facility. He then identified Resident #1 as the one he was dispatched to assist with. He stated there were four employees of the facility present when he arrived on scene. He stated he was dispatched to(NAME)Station Road, located off of Hiawassee Road, where the resident was located. The officer confirmed the location was approximately 2.5 to 3.5 miles away from the facility. Officer #1 stated the resident told him she did not want to go back and she left because she wanted to get out of the facility. When asked if the resident indicated how she got away from the facility he confirmed she said she left through a locked door that she knew the code to, but would not disclose how she knew the code. He then stated she said the gate was unlocked. He stated the resident finally agreed he could take her back to the facility and he had one of the employees ride with him. When asked if he had the na.m.es of the employees present and who rode back with him, he stated he knew they were employees, but did not know the na.m.es because he did not do a report. On 03/23/21 at 9:33 a.m., a request was made to interview LPN #1, the ADON. The corporate nurse stated the employee was not going to be at work. She then stated the nurse had told her there were no additional documentation and/or an incident report regarding the incident. At 9:35 a.m., LPN #7, the care plan and MDS Coordinator, was asked about the residents wandering and elopement risk. She stated she had only been working at the facility approximately three weeks and would have to review the resident's chart. She was asked to review the care plan and then asked if the resident's care plan was developed to address the wandering risk and an elopement risk. After looking through the care plan she stated the care plan did not address the wandering and elopement risk the resident had. She was then provided the wandering assessments and shown the nurses' notes. She stated the resident's care plan should have addressed the elopement and wandering. She then stated the progress notes documented the resident attempted to exit the facility and get away frequently. At 9:51 a.m., the corporate nurse stated the care plan did not address wandering and elopement. She stated the resident's cognition was moderately impaired and it had improved since admission. She stated the resident had gone to the store on the date in question and that was the only information that was provided to her from the staff. She stated the care plan was not developed to address the elopement and wandering. She was asked if CMA #2, CNA #2, and CNA #4 was working. She stated CNA #2 and #4 was working and CMA #2 no longer worked at the facility. At 10:27 a.m. CNA #2 confirmed the resident had gotten out of the facility and was returned by the police. She stated the resident had gone through the wooden fence because it was unlocked. The CNA then stated a former employee noticed the resident walking down the road and notified the facility she was out. CNA #2 stated the resident was able to understand what she was doing and let you know what she wanted. CNA #2 stated the resident had a history of [REDACTED]. She added the resident had attempted to leave through her room window and got outside into the smoke area before being noticed. She then stated since working at the facility she had personally witnessed the resident attempt to go out the doors on numerous occasssions. At 10:45 a.m., CNA #3 stated the resident had left the building and went through an unlocked gate. She stated she did not know how she got back to the facility. She then stated resident #1 had made several attempts of leaving and talked about leaving the facility all the time. She confirmed the resident had attempted to exit the facility through her bedroom window. At 10:57 a.m., the administrator stated the resident was brought back to the facility by the police. She stated LPN #1, the ADON, was with the resident when she was brought back to the facility. She stated the incident happened the day the resident went to the store with staff. She was asked if she knew where the resident was located and how the facility found out she had eloped from the building. She shook her head to indicate no and stated all she was told was the resident went to the store. She was asked if there was any documentation to support the resident leaving and going to the store. She indicated the facility had no documentation on what happened that day. She stated new locks had been put on the gate after the incident, due to finding out staff had keys that should not have had them. At 11:54 a.m., the maintenance manager stated he had put new locks on the wooden fence because staff had keys and were coming and going. He stated he did not know the resident had gone out the unlocked gate, but they were changed when staff was found to have keys. He stated it had been only a week since the new locks had been in place and he and the administrator were the only staff with the keys. At 12:00 p.m., CNA #4 stated she had ca.m.e into work and received report that resident #1 had left the facility through an unlocked gate. She stated the resident was unattended when she left. She stated a former employee notified the facility the resident was walking down the road several miles away. She said the police had to bring the resident back to the facility. The resident had a history of [REDACTED]. She stated the resident also would say all the time she would be leaving the facility because she did not want to be there.

On 06/11/20 a Past Non Compliance Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to prevent sexual abuse of a cognitively impaired female resident by a male contracted housekeeper on 06/04/20. The Oklahoma State Department of Health was notified and verified the Past Non Compliance IJ. At 2:15p.m., the Administrator was notified of the Past Non Compliance IJ. Based on record review and interview, it was determined the facility failed to ensure: ~ one (#1) of three sampled residents was free from sexual abuse; and ~ one (#2) of three sampled residents was free from intimidation with resulting mental anguish. Resident #1 was sexually abused by a male contracted housekeeper. Resident #2 witnessed the sexual abuse of resident #1 from a housekeeper contracted by the facility. The facility identified 80 residents who resided in the facility. Findings: A policy and procedure titled, Abuse Prevention Program, revised December 2016, documented: Policy Statement Our resident have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual . 1. Resident #1 had [DIAGNOSES REDACTED]. A care plan, revised on 12/02/19, documented the resident would wander about the facility at times with disorganized thinking. She had a history of [REDACTED]. A quarterly assessment, dated 04/09/20, documented the resident's cognition was moderately impaired and she required supervision with her activities of daily living. The assessment further documented the resident was administered antipsychotic, antianxiety and hypnotic medications all seven days of the look back period. An incident report, dated 06/04/20, documented resident #2 reported to the nurse she had seen a male housekeeper and resident #1 engaged in sexual activity. The nurse immediately secured resident #1 and began to search for the male housekeeper. An assessment was performed on the resident and she was sent to the ER to be evaluated and treated. It was documented the police, APS, administrator, DON, physician and family were notified. The facility conducted an investigation which included interviews, record collection, and follow-up care. A police report statement by LPN #1, dated 06/04/20, documented, .At approx 2000 (8:00 p.m.) (resident #2) reported to me that she witnessed the floor tech (housekeeper) having sex with (resident #1) in an empty room. She said that her (resident #1's) pants/panties were on the floor and he was penetrating her from the back. She (resident #2) informed me that he knew she had witnessed it and was trying to intimidate her into keeping quiet . A police report statement by LPN #2, documented, .I was with another charge nurse when the resident (resident #2) was narating (sic) what she saw the alleged employee having sex with female resident who is mentally challenged . A police report statement by CNA #1, documented, .On 6-4-2020 was standing in office when I over heard (housekeeper) on the phone saying we can have sex up here I have a private room . A police report statement by resident #2, dated 06/04/20, documented, .I was approaching my room (room #deleted) I opened my door and turned and he saw me see him fornicating with (resident #1). I saw her position and her panties down. He quickly stopped and zipped up. I continued standing in hall way and after he left (resident #1) came out of room looking dazed. I continued to follow him on hall to TV room. He stared at me because I sat down and stared at him. He asked me if something was wrong. I said you know. He said he didn't know. I said You know. Do you want me to say in front of everybody? He walked away but with an intimating (sic) stare. I said I'm not scared of you . On 06/05/20, the housekeeping contract was annulled and items removed, ~ all staff were in-serviced on Abuse and Neglect policy, ~ all staff were in-serviced on gossip/hippa/company business, ~ counseling services were notified for consult of involved residents and offered to all residents if requested, ~ all personnel files were audited, ~ reviewed/revised policies and procedures to include annual background checks on all employees on their hire date, ~ policy implemented to have staff member in attendance with any outside vendors working short term in direct resident care areas, ~ a QA meeting was held to address background checks related to contracted staff and implementation of resulting policies, ~ a policy was implemented to have outside vendors in facility greater than eight hours a day and in direct resident care areas will have background checks performed, and ~ a policy related to medical personnel, including but not limited to, hospice services will have contracts updated to facilitate the request to have background checks available upon request of the facility and all former employees will have repeat background checks upon rehire. A physician assistant's note, dated 06/08/20, documented resident #1 had stated she no longer felt safe since the alleged assault. The decision was made to start counseling for the resident. The facility was advised to review the facility's policy with the resident on her rights of self-defense, protection due to threat, and act of physical harm toward her. On 06/11/20 at 9:45 a.m., the administrator stated the housekeeper had been employed with the housekeeping company the facility had contracted to provide housekeeping services. The incident occurred on the housekeeper's second day in the facility. The administrator stated they were unaware the housekeeping company had not run a background check or ensured the housekeeper's application was accurate. The administrator stated, We trusted their hiring practices were ethical. At 11:25 a.m., resident #1 was asked if she could recall the incident which had occurred between her and the housekeeper. She stated the first time he pulled out his ding-a-ling. The resident stated she was unsure what he was doing to her the next time. But, she stated, I didn't like it. Resident #1 stated when (resident #2) came she (resident #1) and the housekeeper were having sex. Resident #1 was asked if she felt safe. She stated, she was a little scared he might find her. At 11:33 a.m., resident #2 was asked if she could recall the incident that had occurred between the housekeeper and resident #1. She stated yes, she had gone to open the door of her room and heard skin on skin smacking together. She turned and saw the housekeeper fornicating with resident #1 in the empty room across the hall. He had her bent over with her pants and panties on the ground. Resident #2 stated he had made eye contact with her and stopped. When he had come out of the room he went to the lobby. Resident #1 then came out and stated to resident #2 that she had thought the housekeeper was mad at her. Resident #2 stated it was about control and she felt resident #1 was not capable of having given consent. 2. Resident #2 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 04/23/20, documented the resident's cognition was moderately impaired and she required supervision with activities of daily living. The assessment further documented the resident was administered antipsychotic and antidepressant medications all seven days of the look back period. An incident report, dated 06/04/20, documented resident #2 reported to the nurse she had seen a male housekeeper and resident #1 engaged in sexual activity. The report documented the investigation conducted by the facility included interviews, record collection, and follow-up care. A police report statement by resident #2, dated 06/04/20, documented, .I was approaching my room (room # deleted) I opened my door and turned and he saw me see him fornicating with (resident #1's name). I saw her position and her panties down. He quickly stopped and zipped up. I continued standing in hall way and after he left (resident #1's name) came out of room looking dazed. I continued to follow him on hall to TV room. He stared at me because I sat down and stared at him. He asked me if something was wrong. I said you know. He said he didn't know. I said You know. Do you want me to say in front of everybody? He walked away but with an intimating (sic) stare. I said I'm not scared of you . On 06/05/20, counseling services were notified for consult of involved residents and offered to all residents if requested. A physician assistant's note, dated 06/08/20, documented resident #2 reported recently witnessing another resident being sexually assaulted. The situation plays over and over in her mind at times when she walks past the room where it reportedly happened. The decision was made to start counseling as soon as possible. Staff was to monitor for the need for medication changes. On 06/11/20 at 11:33 a.m., resident #2 was asked if she could recall the incident that had occurred between the housekeeper and resident #1. She stated yes, she had gone to open the door of her room and heard skin on skin smacking together. She turned and saw the housekeeper fornicating with resident #1. He had her bent over with her pants and panties on the ground. Resident #2 stated he had made eye contact with her and stopped. When he had come out of the room he went to the lobby. In the lobby, resident #2 stated the housekeeper continued to stare and try to intimidate her. He asked her if something was wrong and stated he had not done anything. Resident #2 stated she had told the housekeeper he had not scared her and she would announce it to everyone. Resident #2 stated she had been a victim when someone had tried to do the same thing to her in the past. As the resident spoke she had begun to shift in her chair and wrap her sweater tightly around her. She stated she would not let it happen. Resident #2 stated it was about control and she felt resident #1 was not capable of having given consent.

On 06/11/20 a Past Non Compliance Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to implement their abuse policies and procedures to prevent sexual abuse of a cognitively impaired female resident by a male contracted housekeeper on 06/04/20. The Oklahoma State Department of Health was notified and verified the Past Non Compliance IJ. At 2:15p.m., the Administrator was notified of the Past Non Compliance IJ. Based on record review and interviews, it was determined the facility failed to implement their abuse policies and procedures to: ~ prevent abuse for two (#1 & #2) of three sampled residents reviewed for abuse; and ~ ensure screening was conducted on one (#1) of one contracted staff who was reviewed. Resident #1 was sexually abused by a male contracted housekeeper. Resident #2 witnessed the sexual abuse of resident #1 from a housekeeper contracted by the facility. The facility identified 80 residents who resided in the facility. Findings: A policy and procedure titled, Abuse Prevention Program, revised December 2016, documented: Policy Statement Our resident have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. 2. Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has: a. Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law . A policy and procedure titled, Abuse Investigation and Reporting, revised July 2017, documented: .Policy Interpretation and Implementation Role of the Investigator 1. The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; i. Interview other residents to whom the accused employee provides care or services . 1. Resident #1 had [DIAGNOSES REDACTED]. An incident report, dated 06/04/20, documented resident #2 reported to the nurse she had seen a male housekeeper and resident #1 engaged in sexual activity. The nurse immediately secured resident #1 and began to search for the male housekeeper. An assessment was performed on the resident and she was sent to the ER to be evaluated and treated. It was documented the police, APS, administrator, DON, physician and family were notified. The facility conducted an investigation which included interviews, record collection, and follow-up care. A police report statement by LPN #1, dated 06/04/20, documented, .At approx 2000 (8:00 p.m.) (resident #2) reported to me that she witnessed the floor tech (housekeeper) having sex with (resident #1) in an empty room. She said that her (resident #1's) pants/panties were on the floor and he was penetrating her from the back. She (resident #2) informed me that he knew she had witnessed it and was trying to intimidate (sic)her into keeping quiet . On 06/05/20, the housekeeping contract was annulled and items removed, ~ all staff were in-serviced on Abuse and Neglect policy, ~ all staff were in-serviced on gossip/hippa/company business, ~ counseling services were notified for consult of involved residents and offered to all residents if requested, ~ all personnel files were audited, ~ reviewed/revised policies and procedures to include annual background checks on all employees on their hire date, ~ policy implemented to have staff member in attendance with any outside vendors working short term in direct resident care areas, ~ a QA meeting was held to address background checks related to contracted staff and implementation of resulting policies, ~ a policy was implemented to have outside vendors in facility greater than eight hours a day and in direct resident care areas will have background checks performed, and ~ a policy related to medical personnel, including but not limited to, hospice services will have contracts updated to facilitate the request to have background checks available upon request of the facility and all former employees will have repeat background checks upon rehire. A physician assistant's note, dated 06/08/20, documented resident #1 had stated she no longer felt safe since the alleged assault. The decision was made to start counseling for the resident. The facility was advised to review the facility's policy with the resident on her rights of self-defense, protection due to threat, and act of physical harm toward her. At 11:25 a.m., resident #1 was asked if she could recall the incident which had occurred between her and the housekeeper. She stated the first time he pulled out his ding-a-ling. The resident stated she was unsure what he was doing to her the next time. But, she stated, I didn't like it. The resident stated when (resident #2) came she (resident #1) and the housekeeper were having sex. Resident #1 was asked if she felt safe. She stated, she was a little scared he might find her. 2. Resident #2 had [DIAGNOSES REDACTED]. An incident report, dated 06/04/20, documented resident #2 reported to the nurse she had seen a male housekeeper and resident #1 engaged in sexual activity. The report documented the investigation conducted by the facility which included interviews, record collection, and follow-up care. A police report statement by resident #2, dated 06/04/20, documented, .I was approaching my room (room #) I opened my door and turned and he saw me see him fornicating with (resident #1's name). I saw her position and her panties down. He quickly stopped and zipped up. I continued standing in hall way and after he left (resident #1's name) came out of room looking dazed. I continued to follow him on hall to TV room. He stared at me because I sat down and stared at him. He asked me if something was wrong. I said you know. He said he didn't know. I said You know. Do you want me to say in front of everybody? He walked away but with an intimating stare. I said I'm not scared of you . A physician assistant's note, dated 06/08/20, documented resident #2 reported recently witnessing another resident being sexually assaulted. The situation plays over and over in her mind at times when she walks past the room where it reportedly happened. The decision was made to start counseling as soon as possible. Staff was to monitor for the need for medication changes. On 06/11/20 at 11:33 a.m., resident #2 was asked if she could recall the incident that had occurred between the housekeeper and resident #1. She stated yes, she had gone to open the door of her room and heard skin on skin smacking together. She turned and saw the housekeeper fornicating with resident #1. He had her bent over with her pants and panties on the ground. Resident #2 stated he had made eye contact with her and stopped. When he had come out of the room he went to the lobby. In the lobby, resident #2 stated the housekeeper continued to stare and try to intimidate her. He asked her if something was wrong and stated he had not done anything. Resident #2 stated she had told the housekeeper he had not scared her and she would announce it to everyone. Resident #2 stated she had been a victim when someone had tried to do the same thing to her in the past. As the resident spoke she had begun to shift in her chair and wrap her sweater tightly around her. She stated she would not let it happen. Resident #2 stated it was about control and she felt resident #1 was not capable of having given consent. 3. An incident report, dated 06/04/20, documented resident #2 reported to the nurse she had seen a male housekeeper and resident #1 engaged in sexual activity. The nurse immediately secured resident #1 and began to search for the male housekeeper. It was documented the police, APS, administrator, DON, physician and family were notified. The facility conducted an investigation which included interviews, record collection, and follow-up care. A police report statement by resident #2, dated 06/04/20, documented, .I was approaching my room (room #) I opened my door and turned and he saw me see him fornicating with (resident #1's name). I saw her position and her panties down. He quickly stopped and zipped up. I continued standing in hall way and after he left (resident #1's name) came out of room looking dazed. I continued to follow him on hall to TV room. He stared at me because I sat down and stared at him. He asked me if something was wrong. I said you know. He said he didn't know. I said You know. Do you want me to say in front of everybody? He walked away but with an intimating stare. I said I'm not scared of you . On 06/11/20 at 9:45 a.m., the administrator stated the housekeeper had been employed with the housekeeping company the facility had contracted to provide housekeeping services. The incident occurred on the housekeeper's second day in the facility. The administrator stated they were unaware the housekeeping company had not run a background check or ensured the housekeeper's application was accurate. The administrator stated, We trusted their hiring practices were ethical. At 12:20 p.m., the administrator reported the housekeeper had a child abuse charge and larceny charges on his criminal background check. The housekeeper was arrested following the incident on 06/04/20.

Based on observation, record review and interviews, it was determined the facility failed to ensure residents were protected from resident to resident abuse for three (#4, 5 and #6) of three sampled residents reviewed for abuse. Resident #4 resided on the memory care unit and had a history of [REDACTED]. Resident #5 and #6 were pushed aggressively to the ground by resident #4. Resident #6 received a fracture as a result of the incident and resident #5 experienced increased pain. The facility identified 27 residents who resided in the secured unit. Findings: The facility's policy and procedure for, Abuse Prevention Program, documented, .Our residents have the right to be free from abuse, neglect .Implementation .our facility is committed to protecting our residents from abuse by anyone including .other residents . The facility's policy and procedure for, Reporting Abuse to State Agencies and other Entities/Individuals, documented, .All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies . 1. Resident #4 had [DIAGNOSES REDACTED]. An annual assessment, dated 04/19/19, documented the resident's cognition was intact and he had physical behaviors toward other residents. A behavior progress note, dated 05/29/19 at 7:56 p.m., documented, Resident witnessed walking past another resident and pulling the chair out as the resident was about to sit down, causing resident to fall on floor. when (Resident #4) was asked why he did it, his response was I don't know when asked if he knew he could've hurt other resident his response was so . A behavior progress note, dated 07/26/19 at 6:08 p.m., documented, .res cont to have adverse behaviors. res cursing at other residents and staff, continues to turn tv while others are watching tv. while attempting to redirect resident and educate on appropriate behavior, resident shouts vulgar obscenity and turns tv off and walks to room . A second behavior note at 9:14 p.m., documented, .res kicking at other resident when they walk by him. attempted to educate resident on proper behavior for common area. resident acknowledged understanding, apologized, but continued to try and trip other residents that passed by. when resident was asked why behavior was occurring, resident stated they are in my way attempted to educate resident again. resident refused to participate in conversation. A behavior progress note, dated 07/28/19 at 5:00 p.m., documented, .resident attempted to trip another resident multiple times. redirected resident from behavior. resident began to follow staff around shouting devil A second behavior note, at 7:30 p.m., documented, .resident continues to antagonize other residents. res attempted to trip another resident, turning off television while others are watching, and walking away smiling. when resident was asked why this behavior was occurring, resident stated because I don't want to watch that. resident was educated on rules of common areas. resident acknowledged understanding., but behavior continued. resident was asked to go to his room and watch what he wanted. resident refused to comply . The care plan, last updated 07/30/19, documented, Focus: The resident is/has potential to be physically aggressive (hitting/kicking). He has a dx of dementia with behavior, [MEDICAL CONDITIONS], anxiety . Goal: The resident will not harm self or others through the review date . Interventions: administer medications as ordered. Monitor for side effects and effectiveness. Psychiatric/psychogeriatic consult as indicated . There were no additional interventions to address the resident's behaviors. A behavior progress note, dated 08/05/19 at 6:00 p.m., documented, .resident showing s/s of extreme agitation. resident cursing and throwing chairs in the direction of other residents. resident invading other residents person space to point middle finger at them and tell them they were on crack resident was educated about behavior, continues to have adverse behaviors A second note, at 7:03 p.m., documented, .Resident continues to have adverse behaviors continues throwing things at other residents. staff attempted to escort resident away from common area. resident began to get physically violent with staff. dr .notified. new orders received [MEDICATION NAME] 1 mg gel q 4hrs prn x 3 days, [MEDICATION NAME] 234mg subq Q 30days. resident refuses to take any meds . A quarterly assessment, dated 10/16/19, documented the resident's cognition was intact and had no physical behaviors towards other residents during the look back period. A behavior note, dated 12/08/19 at 7:45 p.m., documented, .Resident slamming room door, and yelling and cussing. Agitated that a confused resident keeps attempting to enter his room A nurse's note, dated 01/18/20 at 9:00 p.m., documented, AT APPROXIMATELY 2100 (9:00 p.m.) RESIDENT INITIATED PHYSICAL AGGRESSION TOWARDS ANOTHER RESIDENT EVIDENCED BY RESIDENT PUSHING OTHER RESIDENT ACROSS THE DINING ROOM FLOOR WHICH RESULTED IN RESIDENT FALLING BACKWARDS ONTO FLOOR. NURSING STAFF IMMEDIATELY INTERVENED BY SEPARATING RESIDENTS. RESIDENT ASSESSED FROM HEAD TO TOE NO INJURIES NOTED . A report to the Oklahoma State Department of Health, documented both residents (Resident #4 and #5) were counseled about the altercation with limited understanding and will be on increased monitoring per policy. Staff was in serviced on awareness of escalating signs of behaviors, continue to monitor and follow current care plan. The report was sent to the department on 01/20/20 at 4:39 p.m., almost two days after the incident occurred. There was no documentattion of increased monitroing of the residents after the incident occured. A nurse's note, dated 02/05/20 at 1:50 p.m., documented, RESIDENT AT APPROX 1330 (1:30 p.m.) WAS SPEAKING WITH CMA, RESIDENT AT THIS TIME STATED HE COULD KNOCK HER HEAD OFF. ATTEMPTED TO REDIRECT VERBALLY THIS NURSE WITH CMA. RESIDENT CONT TO BE AGITATED AND WENT ROOM. AT APPROX 1340 (1:40 p.m.) THIS NURSE CALLED TO HALLWAY IN HALL 500; RESIDENT FROM RM 516B (Resident #6) WAS AMBULATING DOWN HALLWAY WHEN THIS RESIDENT AMBULATED BY RES RM 516B (Resident #6) .AND TOOK WALKER TO ROOM AND LEFT WALKER THEN CAME BACK TO HALLWAY AND REMOVED RES 516B (Resident #6) HER WALKER FROM HER, AND PUSHED RESIDENT 516B (Resident #6) .INTO THE WALL MAKING RESIDENT HIT HER HEAD, AND SKIN TEARS NOTED . A nurse's note at 2:35 p.m., documented, RESIDENT CONT TO BE ONE ON ONE AT THIS TIME, RESIDENT BECAME AGGRESSIVE WITH CNA, AND ATTEMPTED TO CHOKE HER WITH BOTH HANDS, CONT TO SCRATCH HER AND TOOK BEDSIDE COMMODE AND THREW URINE AT HER. N.O. TO SEND RESIDENT TO ER FOR PSYCH AND BEHAVIORAL EVAL.911 CALLED AT THIS TIME . A nurse's note at 2:55 p.m., documented, POLICE DEPT ARRIVED WITH FIRE DEPT, AWAITING ARRIVAL OF EMS . A nurse's note at 3:10 p.m., documented, EMT ARRIVED AT THIS TIME; RESIDENT AMBULATED TO HIS ROOM AND ATTEMPTED TO BARRACADE (sic) HIMSELF IN THE ROOM; MOVING HIS BED TO THE DOORWAY; CNA ASSISTED REMOVING BED FROM DOORWAY AFTER GOING THRU BATHROOM THAT IS CONJOINED WITH OTHER ROOM. RESIDENT OUT OF FACILITY ON GURNEY . A nurse's note, dated 02/05/20 at 8:04 p.m., documented, Resident back at facility at 1945 (7:45 p.m.). Resident in restraints at time of arrival. No new orders . A nurse's note, dated 02/07/20 at 8:30 p.m., documented, Resident back at facility at 2030 (8:30 p.m.) in handcuffs at time of arrival . Nurse's notes, dated 02/07/20 through 02/12/20, documented the resident was one on one supervision due to the incident between him and Resident #6. On 02/10/20 at 6:08 p.m., LPN #1 stated resident #4 was currently one on one due to having aggressive behaviors towards Resident #6. She then stated he had pushed resident #6 causing her to fracture her leg. The resident was observed with the one on one supervision throughout the evening observations on 02/10/20. A nurse's note, dated 02/12/20, documented the resident had been transfered out of the facility to a psychatric unit. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An incident report, dated 02/05/20 at 1:40 p.m., documented, Called to hallway on hall 500 .resident sitting on floor on bottom; Resident unable to communicate what had happened. Skin tear noted to left elbow, wrist, and hand .injuries observed .skin tear left elbow .wrist .left hand back .mental status oriented to person .Resident in room [ROOM NUMBER] (Resident #4) pulled rolling walker out from resident, and pushed resident into wall .No other injuries noted Resident is RM 507 (Resident #4) previously stated 'I will knock her head off .Cameras reviewed .(Resident #4) had walked by the resident in hallway, and put walker in RM 507 (Resident #4 room) .then came back down hall and pulled rolling walker out from this resident .(Resident #4) pushed resident into wall making resident hit head, and skin tears noted .N.O. to send resident to ER for eval and tx . A nurse's note, dated 02/05/20 at 1:45 p.m., documented, .called to hallway on hall 500 .resident sitting on floor in hallway skin tear noted to left elbow, wrist, and hand. No other injuries noted .Resident is RM 507 (Resident #4) previously stated 'I will knock her head off .Cameras reviewed .(Resident #4) had walked by the resident in hallway, and put walker in RM 507 (Resident #4 room) .then came back down hall and pulled rolling walker out from this resident .(Resident #4) pushed resident into wall making resident hit head, and skin tears noted .N.O. to send resident to ER for eval and tx . A nurse's note at 2:15 p.m., documented the resident was transported to the emergency room for an evaluation and treatment. A nurse's note, dated 02/05/20 at 10:07 p.m., documented, .Resident returned to facility at 2000 (8:00 p.m.). No new orders, just papers on s/s of a concussion. Steri-strips on left hand, very unsteady gait, refused snack . A nurse's note, dated 02/06/20 at 1:53 p.m., documented, .new order from .ortho .stat ua, cbc, cmp, ekg . A nurse's note, dated 02/06/20 at 2:29 p.m., documented, .Report from daughter femur fracture .stat lab, EKG faxed to (Name deleted doctor) pending if she is a candidate for surgery . A nurse's note, dated 02/07/20 at 12:40 p.m., documented, .Resident has change of condition, spo2 88%@RA. Start oxygen therapy @2L .increased agitation with pain. Dr. (Name deleted orthopedic surgeon) office called informed to transfer out . On 02/10/20 at 6:08 p.m., LPN #1 stated resident #4 was currently one on one due to having aggressive behaviors towards other residents. She then stated he had pushed resident #6 causing her to fracture her leg. The resident was observed with the one on one supervision throughout the evening observations on 02/10/20. On 02/11/20 at 10:58 a.m., a family member of resident #6 stated the resident was pushed by resident #4 which caused her femur to fracture. She stated prior to the incident, her mother was walking around the facility by herself and now she can not get up and walk. She further stated the resident was awaiting to see if she was a candidate for surgery because she was very lethargic. She emphasized again she was no longer able to walk. At 1:35 p.m., the ADON stated she saw the incident on 02/05/20, between resident #4 and #6 on the video camera. She stated resident #6 was coming up the hall and the other resident took his walker to his room then came back out of the room. She stated he approached resident #6, took her walker and took his whole body slamming her back into the wall. She stated the resident went out to be checked for a concussion and came back to the facility. She then stated the resident had an orthopedic appointment after the incident and a fractured femur was found. The ADON stated prior to this incident the resident was able to walk with her walker and had no problems getting around. She stated after she came back she would not walk and complained of pain which she never did in the past. She then stated the resident's oxygen saturation dropped and was very tired so the orthopedic surgeon said to send her out to the hospital. She was asked if Resident #4 had a history of [REDACTED]. She stated he had been known to trip, kick and be aggressive with other residents, but she had never personally observed it. 3. Resident #5 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/08/19, documented the resident's cognition was severely impaired and was able to ambulate without any assistive devices such as a walker or cane. An incident report, dated 01/18/20 at 9:00 p.m., documented, .incident location dining room .description .at approximately 2100 (9:00 p.m.) resident received physical aggression from another resident (Resident #4) found lying supine in dining area complaining of lower back pain, bilateral hip pain, pain in rib area .resident unable to describe altercations . A nurse's note, dated 01/19/20 at 1:59 a.m., documented, Res was sent out toER on ,[DATE] shift, d/t res to res altercation. Res was knocked down to his back by another res and was sent out to ER for eval following this. Res has returned to his room on memory care unit via gerney(sic) .Res c/o back pain upon returning, med with his prn [MEDICATION NAME] for this at this time .New orders from ER, include rest, ice, f/u with pcp and Tylenol every 4 hrs as needed. Res is already taking [MEDICATION NAME] TID routine and prn if needed . A report to the Oklahoma State Department of Health, documented both residents were counseled about the altercation with limited understanding and will be on increased monitoring per policy. Staff was in serviced on awareness of escalating signs of behaviors, continue to monitor and follow current care plan. The report was sent to the department on 01/20/20 at 4:39 p.m., almost two days after the incident occurred. On 02/11/20 at 1:35 p.m., the ADON was asked if Resident #4 had a history of [REDACTED]. She stated he had been known to trip, kick and be aggressive with other residents, but she had never personally observed it. She was asked if she was aware of the incident between resident #4 and #5 that occurred on 01/18/20. She stated the resident went up to Resident #5 and pushed him very hard and he fell to the ground. She confirmed the resident sustained [REDACTED]. She stated the residents were not being protected from resident #4 and confirmed there were no interventions to protect residents on the care plan. On 02/11/20 at 4:00 p.m., CNA #1 stated she was not aware if resident #4 had aggressive behaviors. She then stated she had only been there two months. On 02/12/20 at 10:50 a.m., the DON stated the resident does have physical aggression at times toward other residents. She stated the resident's cognition was intact and was aware of what he was doing. She then looked through the care plan and stated she would address the physical aggression much more in the care plan. She stated we protect the resident's because the employees are aware of his aggressive behavior. She was made aware of the lack of knowledge by the employees working with him. She stated the new employees provably are not aware of the problem because of the lack of the care plan. She then stated she could not say the facility protected the residents and followed their abuse policy for protecting residents.

Based on observation, record review and interviews, it was determined the facility failed to have adequate staff to ensure residents were protected from abuse for three (#4, 5 and #6) of three sampled residents reviewed for abuse. The facility identified 74 residents who resided in the facility, 27 of them on the secured unit. Findings: 1. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual assessment, dated 04/19/19, documented the resident's cognition was intact and he had physical behaviors toward other residents. A behavior progress note, dated 05/29/19 at 7:56 p.m., documented, Resident witnessed walking past another resident and pulling the chair out as the resident was about to sit down, causing resident to fall on floor. when [Resident #4] was asked why he did it, his response was I don't know when asked if he knew he could've hurt other resident his response was so . A behavior progress note, dated 07/26/19 at 6:08 p.m., documented, .res cont to have adverse behaviors. res cursing at other residents and staff, continues to turn tv while others are watching tv. while attempting to redirect resident and educate on appropriate behavior, resident shouts vulgar obscenity and turns tv off and walks to room . A second behavior note at 9:14 p.m., documented, .res kicking at other resident when they walk by him. attempted to educate resident on proper behavior for common area. resident acknowledged understanding, apologized, but continued to try and trip other residents that passed by. when resident was asked why behavior was occurring, resident stated they are in [MEDICATION(S)] attempted to educate resident again. resident refused to participate in conversation. A behavior progress note, dated 07/28/19 at 5:00 p.m., documented, .resident attempted to trip another resident multiple times. redirected resident from behavior. resident began to follow staff around shouting devil A second behavior note, at 7:30 p.m., documented, .resident continues to antagonize other residents. res attempted to trip another resident, turning off television while others are watching, and walking away smiling. when resident was asked why this behavior was occurring, resident stated because I don't want to watch that. resident was educated on rules of common areas. resident acknowledged understanding., but behavior continued. resident was asked to go to his room and watch what he wanted. resident refused to comply . The care plan, last updated 07/30/19, documented, Focus: The resident is/has potential to be physically aggressive (hitting/kicking). He has a dx of dementia with behavior, [CONDITION(S)], [CONDITION(S)], anxiety . Goal: The resident will not harm self or others through the review date . Interventions: administer medications as ordered. Monitor for side effects and effectiveness. Psychiatric/psychogeriatic consult as indicated . There were no additional interventions to address the resident's behaviors. A behavior progress note, dated 08/05/19 at 6:00 p.m., documented, .resident showing s/s of extreme agitation. resident cursing and throwing chairs in the direction of other residents. resident invading other residents person space to point middle finger at them and tell them they were on crack resident was educated about behavior, continues to have adverse behaviors A second note, at 7:03 p.m., documented, .Resident continues to have adverse behaviors continues throwing things at other residents. staff attempted to escort resident away from common area. resident began to get physically violent with staff. dr .notified. new orders received [MEDICATION(S)] 1 mg gel q 4hrs prn x 3 days, [MEDICATION(S)] 234mg subq Q 30days. resident refuses to take any meds . A quarterly assessment, dated 10/16/19, documented the resident's cognition was intact and had no physical behaviors towards other residents during the look back period. A behavior note, dated 12/08/19 at 7:45 p.m., documented, .Resident slamming room door, and yelling and cussing. Agitated that a confused resident keeps attempting to enter his room A nurse's note, dated 01/18/20 at 9:00 p.m., documented, AT APPROXIMATELY 2100 [9:00 p.m.] RESIDENT INITIATED PHYSICAL AGGRESSION TOWARDS ANOTHER RESIDENT EVIDENCED BY RESIDENT PUSHING OTHER RESIDENT ACROSS THE DINING ROOM FLOOR WHICH RESULTED IN RESIDENT FALLING BACKWARDS ONTO FLOOR. NURSING STAFF IMMEDIATELY INTERVENED BY SEPARATING RESIDENTS. RESIDENT ASSESSED FROM HEAD TO TOE NO INJURIES NOTED . A report to the Oklahoma State Department of Health, documented both residents (Resident #4 and #5) were counseled about the altercation with limited understanding and will be on increased monitoring per policy. Staff was in serviced on awareness of escalating signs of behaviors, continue to monitor and follow current care plan. The report was sent to the department on 01/20/20 at 4:39 p.m., almost two days after the incident occurred. There was no documentattion of increased monitroing of the residents after the incident occured. A review of the daily assignment sheet, dated 01/18/20 for the 3:00 p.m. through 11:00 p.m. shift, documented only two direct care staff were working in the secured unit at the time of the incident. A nurse's note, dated 02/05/20 at 1:50 p.m., documented, RESIDENT AT APPROX 1330 [1:30 p.m.] WAS SPEAKING WITH CMA, RESIDENT AT THIS TIME STATED HE COULD KNOCK HER HEAD OFF. ATTEMPTED TO REDIRECT VERBALLY THIS NURSE WITH CMA. RESIDENT CONT TO BE AGITATED AND WENT ROOM. AT APPROX 1340 [1:40 p.m.] THIS NURSE CALLED TO HALLWAY IN HALL 500; RESIDENT FROM RM 516B [Resident #6] WAS AMBULATING DOWN HALLWAY WHEN THIS RESIDENT AMBULATED BY RES RM 516B [Resident #6] .AND TOOK WALKER TO ROOM AND LEFT WALKER THEN CAME BACK TO HALLWAY AND REMOVED RES 516B [Resident #6] HER WALKER FROM HER, AND PUSHED RESIDENT 516B .INTO THE WALL MAKING RESIDENT HIT HER HEAD, AND SKIN TEARS NOTED . A review of the daily assignment sheet, dated 02/05/20 for the 7:00 a.m. through 3:00 p.m. shift, documented only two direct care staff were working in the secured unit at the time of the incident. A nurse's note at 2:35 p.m., documented, RESIDENT CONT TO BE ONE ON ONE AT THIS TIME, RESIDENT BECAME AGGRESSIVE WITH CNA, AND ATTEMPTED TO CHOKE HER WITH BOTH HANDS, CONT TO SCRATCH HER AND TOOK BEDSIDE COMMODE AND THREW URINE AT HER. N.O. TO SEND RESIDENT TO ER FOR PSYCH AND BEHAVIORAL EVAL.911 CALLED AT THIS TIME . A nurse's note at 2:55 p.m., documented, POLICE DEPT ARRIVED WITH FIRE DEPT, AWAITING ARRIVAL OF EMS . A nurse's note at 3:10 p.m., documented, EMT ARRIVED AT THIS TIME; RESIDENT AMBULATED TO HIS ROOM AND ATTEMPTED TO BARRACADE [sic] HIMSELF IN THE ROOM; MOVING HIS BED TO THE DOORWAY; CNA ASSISTED REMOVING BED FROM DOORWAY AFTER GOING THRU BATHROOM THAT IS CONJOINED WITH OTHER ROOM. RESIDENT OUT OF FACILITY ON GURNEY . A nurse's note, dated 02/05/20 at 8:04 p.m., documented, Resident back at facility at 1945 [7:45 p.m.]. Resident in restraints at time of arrival. No new orders . A nurse's note, dated 02/07/20 at 8:30 p.m., documented, Resident back at facility at 2030 [8:30 p.m.] in handcuffs at time of arrival . Nurse's notes, dated 02/07/20 through 02/12/20, documented the resident was one on one supervision due to the incident between him and Resident #6. On 02/10/20 at 6:08 p.m., LPN #1 stated resident #4 was currently one on one due to having aggressive behaviors towards Resident #6. She then stated he had pushed resident #6 causing her to fracture her leg. The resident was observed with the one on one supervision throughout the evening observations on 02/10/20. A nurse's note, dated 02/12/20, documented the resident had been transfered out of the facility to a psychatric unit. 2. Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An incident report, dated 02/05/20 at 1:40 p.m., documented, Called to hallway on hall 500 .resident sitting on floor on bottom; Resident unable to communicate what had happened. Skin tear noted to left elbow, wrist, and hand .injuries observed .skin tear left elbow .wrist .left hand back .mental status oriented to person .Resident in room [ROOM NUMBER] [Resident #4] pulled rolling walker out from resident, and pushed resident into wall .No other injuries noted Resident is RM 507 [Resident #4] previously stated 'I will knock her head off .Cameras reviewed .[Resident #4] had walked by the resident in hallway, and put walker in RM 507 [Resident #4 room] .then came back down hall and pulled rolling walker out from this resident .[Resident #4] pushed resident into wall making resident hit head, and skin tears noted .N.O. to send resident to ER for eval and tx . A nurse's note, dated 02/05/20 at 1:45 p.m., documented, .called to hallway on hall 500 .resident sitting on floor in hallway skin tear noted to left elbow, wrist, and hand. No other injuries noted .Resident is RM 507 [Resident #4] previously stated 'I will knock her head off .Cameras reviewed .[Resident #4] had walked by the resident in hallway, and put walker in RM 507 [Resident #4 room] .then came back down hall and pulled rolling walker out from this resident .[Resident #4] pushed resident into wall making resident hit head, and skin tears noted .N.O. to send resident to ER for eval and tx . A review of the daily assignment sheet, dated 02/05/20 for the 7:00 a.m. through 3:00 p.m. shift, documented only two direct care staff were working in the secured unit at the time of the incident. A nurse's note at 2:15 p.m., documented the resident was transported to the emergency room for an evaluation and treatment. A nurse's note, dated 02/05/20 at 10:07 p.m., documented, .Resident returned to facility at 2000 [8:00 p.m.]. No new orders, just papers on s/s of a concussion. Steri-strips on left hand, very unsteady gait, refused snack . A nurse's note, dated 02/06/20 at 1:53 p.m., documented, .new order from .ortho .stat ua, cbc, cmp, ekg . A nurse's note, dated 02/06/20 at 2:29 p.m., documented, .Report from daughter femur fracture .stat lab, EKG faxed to [Name deleted doctor] pending if she is a candidate for surgery . A nurse's note, dated 02/07/20 at 12:40 p.m., documented, .Resident has change of condition, spo2 88%@RA. Start oxygen therapy @2L .increased agitation with pain. Dr. [Name deleted orthopedic surgeon] office called informed to transfer out . 3. Resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 10/08/19, documented the resident's cognition was severely impaired and was able to ambulate without any assistive devices such as a walker or cane. An incident report, dated 01/18/20 at 9:00 p.m., documented, .incident location dining room .description .at approximately 2100 [9:00 p.m.] resident received physical aggression from another resident [Resident #4] found lying supine in dining area complaining of lower back pain, bilateral hip pain, pain in rib area .resident unable to describe altercations . A nurse's note, dated 01/19/20 at 1:59 a.m., documented, Res was sent out toER on ,d+[DATE] shift, d/t res to res altercation. Res was knocked down to his back by another res and was sent out to ER for eval following this. Res has returned to his room on memory care unit via gerney[sic] .Res c/o back pain upon returning, med with his prn [MEDICATION(S)] for this at this time .New orders from ER, include rest, ice, f/u with pcp and Tylenol every 4 hrs as needed. Res is already taking [MEDICATION(S)] TID routine and prn if needed . A review of the daily assignment sheet, dated 01/18/20 for the 3:00 p.m. through 11:00 p.m. shift, documented only two direct care staff were working in the secured unit at the time of the incident. On 02/12/20 9:36 a.m., the ADON confirmed the number of staff working on the secured unit on 01/18/20 and 02/05/20 when the resident altercations happened. She stated there was not enough staff in the secured unit if there were only two staff. She stated the secured unit was very active and there needed to be at least three CNAs during the day and evening shift. At 9:45 a.m., LPN #3 confirmed she remembered only herself and one other working on 01/18/20 on the evening shift. She then stated there were not enough staff in the secured unit and it was hard to monitor and keep track of all the residents. On 02/12/20 at 10:50 a.m., the DON stated the resident does have physical aggression at times toward other residents. She stated the resident's cognition was intact and was aware of what he was doing. She was asked if two direct care staff working on the floor was enough to provide the necessary care and services. She stated the unit was very active and two direct care staff was not enough.

Based on observation, record review and interviews, it was determined the facility failed to ensure residents were free of neglect for two (#3 and #6) three sampled residents reviewed for medically related social services. Resident #3 had a [MEDICAL CONDITION] stent placed in 03/2019 with no follow up appointments being made by the facility to have it removed as ordered by the physician. The stent remained in and calcified. When the stent was attempted to be removed almost six months later, it broke causing the resident to require a surgical procedure. The resident experienced pain at a level of eight when urinating with the stent in. Findings: The Abuse Prevention Program policy, dated 08/2006, documented, Policy statement .Our residents have the right to be free from abuse, neglect .Our facility is committed to protecting our residents from abuse . The Reporting Abuse to Facility Management policy, last revised 12/2013, documented, .To help with the recognition of incidents of abuse, the following definitions of abuse are provided .Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/24/19, documented the resident's cognition was intact, required one person extensive asssistance with dressing, toilet use, and personal hygiene. The assessment further documented the resident had a Foley catheter and was continent of bowels. The resident received scheduled pain medication, PRN pain medication, and had frequent pain during the last five days of the look back period of the assessment. The resident's worse pain was a five on a scale of one to ten. A nurse's note, dated 03/29/19 at 9:14 a.m., documented, Alerted by CMA that resident was c/o severe pain in left flank area. CMA had administered pain medication approx. 30 mins prior with no effect. Resident stated that pain was 8/10. Resident stated has hx of kidney stones. Contacted Dr (Name deleted), order received to send to ER to eval and treat .transferred to (Name deleted) Medical Center . A second nurse's note at 2:34 p.m. documented, Resident admitted to (Name deleted) medical center for bladder infection and kidney stone . Contacted (Name deleted) Medical Center and spoke to (Name deleted), confirmed is being admitted . Discharge instructions from the hospital, dated 03/30/19, documented the resident was to have a follow up with Dr. (Name deleted urologist) as an outpatient in one week due to the [MEDICAL CONDITION] stent for the kidney stones. A nurse's note, dated 03/30/19 at 8:30 p.m., documented, Resident came back from hospital, transported by EMSA with new orders; [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME], an opioid pain medication) 5-325 mg per tab PO every for 7 days .Resident no longer has Foley uses Urinal, voiding reddish urine with traces of clots. Resident is able to voice needs, aware of changes, pharmacy notified to send med. There was no documentation in the clinical record the facility had made the appointment with the urologist after he was discharged from the hospital on [DATE]. A nurse's note, dated 08/28/19 at 6:50 p.m., documented, Resident complained pain at his lower back, has stent for his kidney sometimes (sic) ago. Dr ordered him out to hospital for evaluation . An emergency room visit, dated 08/28/19, documented the resident was seen for flank pain and a [MEDICAL CONDITION] stent that was retained. The discharge instructions from the emergency room was for the resident to been seen by a urologist the next day for his stent. A nurse's note, dated 08/28/19 at 11:20 p.m., documented, Resident came back to facility via medride accompanied by his father . There was no documentation the facility had contacted the urologist for an appointment on the [MEDICAL CONDITION] stent as instructed by the emergency room . A note from the urologist office, dated 09/05/19 at 10:21 a.m., documented, .Father called today with concerns stating that (Resident) still had stint from his surgery in (MONTH) .I then called the nursing home asking them why they hadn't called and made an appointment to our office to have it removed .person I talked to couldn't give me an answer. I stated to have them bring him here today at 245 (2:45 p.m.) to attempt to remove it. They said they will try nursing home just called and said that they weren't for sure they could get him here today. I stated that this should have been taking out several months ago but no one called from your facility and she said yes I know we just lost paper work . A nurse's note dated 09/16/19 at 4:59 p.m., documented, Resident returned from Nephrology appointment status [REDACTED]. Dr. (Name deleted) has given orders and instructions for surgery on 09/23 (09/23/19) to have stent completely removed. Will have pretesting call and give orders for preop testing prior to that visit. physician's orders [REDACTED]. On 09/17/19 at 1:41 p.m., the office manager for the urologist stated the [MEDICAL CONDITION] stent was placed on 03/30/19 and the resident was discharged with instructions to be seen within a week for a follow up and removal of the stent. She then stated that appointment was never made by the facility. She confirmed that the stent should only be in place two weeks until all kidney stones are passed. She confirmed the resident had been seen on 08/28/19 at the emergency room because of the pain and the resident had discharge instruction to come in for an appointment the next day. She then stated, The facility never called to get him in for an appointment. When asked how the resident finally got an appointment made, she stated a family member called the office concerned that the stent was still in place on 09/05/19 and she researched the residents history and called the facility. She stated the facility was asked to bring him in on the same day to get the stent removed. She then stated the facility said they could not bring him because they did not have transportation for them. She confirmed when she called and spoke with the facility that they had not scheduled the necessary appointments, the facility response was they misplaced the paperwork and did not know about the appointments. She was asked why the resident was scheduled for surgery. She stated when the resident finally came in on 09/16/19 to have the stent removed it broke off. She was asked what caused the stent to be removed. She stated the doctor confirmed the stent had broken off because it was calcified in. She was asked to describe the resident prior to and after the attempted removal of the stent in her office. She stated the resident had a hard time while in the office and was very uncomfortable. She stated the resident did not complain of pain, but his facial expressions indicated he was in a lot of pain. On 09/17/19 at 2:00 p.m., the resident stated his stent had been in since (MONTH) and should have been removed no longer then three months after it was placed. He stated he was in pain when he twisted and especially when he urinates. He stated the pain he experienced because of the stent still being in was between five and eight on a scale of 1-10. He stated the pain was always an eight when he urinated because he had to push. He stated he had been to the hospital because of the pain last week and he went about two weeks ago. He then stated, I don't know why they did not get me an appointment to remove it, but now I have to go in for a surgery. During the interview the resident was observed to twist to his right then left and had a grimace on his face. He confirmed that when he just moved, his pain level was about a five on a scale of 1-10. On 09/18/19 at 9:55 a.m., LPN #1 stated she knew the resident had not been seen at the urologist like he should. She stated she had spoken with the resident's attending physician about the stent still being in a few weeks ago when he asked, but thought the appointment had been made. She stated she works at night and he usually came in the evening after all day time nurses were gone. She then stated, The stent was already suppose to be out. At 10:15 a.m., the social service director stated discharge papers and instructions went to the charge nurse when the resident returned from the hospital or any appointment. If there was a follow up appointment, nursing staff would provide the paperwork and information to her. She stated she did not know about the resident needing an appointment the next day in (MONTH) and had never seen the discharge papers until today. She confirmed the resident did not get an appointment the next day like he should. When asked about a call to the facility on [DATE] from the urologist office, she stated they had spoken with her and was told to bring him in ASAP because the stent had been in too long. She stated they could not transport him there and was not able to make arrangements for him to be transported on the same day. She confirmed the resident now had surgery scheduled on 09/23/19 as a result of the stent breaking. At 10:30 a.m., the DON stated it was too quick of a notice to get the resident there the same day. She stated the facility van was not wheelchair accessible so that was not an option to get him there on 09/05/19. The DON confirmed the resident's appointments were not made for a follow up in (MONTH) and again in (MONTH) and that there was no documentation in the clinical record to support the facility had even attempted to make the appointments. 2. Resident #6 had [DIAGNOSES REDACTED]. A review of the clinical record contained documentation the resident was to bee seen for an appointment on 08/29/19. The appointment sheet documented it had been canceled. On 09/18/19 at 1:20 p.m., the resident's spouse stated the resident was supposed to have had a mammogram in July, but that had been canceled by the facility. He stated at times appointments are missed because transportation never showed up to get his wife. He stated he never knew why the appointments for the mammogram were canceled because her [MEDICAL CONDITION] doctor wanted them to evaluate her for a treatment. At 1:36 p.m., the social service director stated the resident had been missing some appointments but there was no documentation in the clinical record to indicate why. She stated she just started about a month previous as the social service director. She confirmed in the appointment binders there were no sheets for any missed appointments in July. At 1:45 p.m., the breast center employee stated the facility had canceled four mammogram appointments in (MONTH) on 07/05/19, 07/11/19, 07/23/19 and 07/25/19. She stated there were no notes as to why the facility had canceled the appointments. At 1:58 p.m., the social service director stated there was no documentation in the social service progress notes as to why the appointments had been canceled by the facility. At 2:05 p.m., the DON stated if it was not in PCC, then it was not documented. She stated she would look and see if she could locate any documentation on the missed appointments for the mammogram. No further documentation was provided. On 09/19/19 at 1:05 p.m., the administrator stated abuse was anytime rights were violated, or neglected. She then stated the missed medical appointments were neglectful.

Based on observation, record review, and interviews, it was determined the facility failed to ensure residents appointments were made and kept for two (#3 and #6) of three sampled residents reviewed for medically realted social services. Resident #3 had a [MEDICAL CONDITION] stent placed in 03/2019 with no follow up appointments being made by the facility to have it removed. The stent remained in and calcified. When the stent was attempted to be removed almost six months later, it broke causing the resident to need a surgical procedure. The resident experienced pain at a level of eight when urinating with the stent in. Findings: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/24/19, documented the resident's cognition was intact, required one person extensive asssistance with dressing, toilet use, and personal hygiene. The assessment further documented the resident had a Foley catheter and was continent of bowels. The resident received scheduled pain medication, PRN pain medication, and had frequent pain during the last five days of the look back period of the assessment. The resident's worse pain was a five on a scale of one to ten. A nurse's note, dated 03/29/19 at 9:14 a.m., documented, Alerted by CMA that resident was c/o severe pain in left flank area. CMA had administered pain medication approx. 30 mins prior with no effect. Resident stated that pain was 8/10. Resident stated has hx of kidney stones. Contacted Dr (Name deleted), order received to send to ER to eval and treat .transferred to (Name deleted) Medical Center . A second nurse's note at 2:34 p.m. documented, Resident admitted to (Name deleted) medical center for bladder infection and kidney stone . Contacted (Name deleted) Medical Center and spoke to (Name deleted), confirmed is being admitted . Discharge instructions from the hospital, dated 03/30/19, documented the resident was to have a follow up with Dr. (Name deleted urologist) as an outpatient in one week due to the [MEDICAL CONDITION] stent for the kidney stones. A nurse's note, dated 03/30/19 at 8:30 p.m., documented, Resident came back from hospital, transported by EMSA with new orders; [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME], an opioid pain medication) 5-325 mg per tab PO every for 7 days .Resident no longer has Foley uses Urinal, voiding reddish urine with traces of clots. Resident is able to voice needs, aware of changes, pharmacy notified to send med. There was no documentation in the clinical record the facility had made the appointment with the urologist after he was discharged from the hospital on [DATE]. A nurse's note, dated 08/28/19 at 6:50 p.m., documented, Resident complained pain at his lower back, has stent for his kidney sometimes (sic) ago. Dr ordered him out to hospital for evaluation . An emergency room visit, dated 08/28/19, documented the resident was seen for flank pain and a [MEDICAL CONDITION] stent that was retained. The discharge instructions from the emergency room was for the resident to been seen by a urologist the next day for his stent. A nurse's note, dated 08/28/19 at 11:20 p.m., documented, Resident came back to facility via medride accompanied by his father . There was no documentation the facility had contacted the urologist for an appointment on the [MEDICAL CONDITION] stent as instructed by the emergency room . A note from the urologist office, dated 09/05/19 at 10:21 a.m., documented, .Father called today with concerns stating that (Resident) still had stint from his surgery in (MONTH) .I then called the nursing home asking them why they hadn't called and made an appointment to our office to have it removed .person I talked to couldn't give me an answer. I stated to have them bring him here today at 245 (2:45 p.m.) to attempt to remove it. They said they will try nursing home just called and said that they weren't for sure they could get him here today. I stated that this should have been taking out several months ago but no one called from your facility and she said yes I know we just lost paper work . A nurse's note dated 09/16/19 at 4:59 p.m., documented, Resident returned from Nephrology appointment status [REDACTED]. Dr. (Name deleted) has given orders and instructions for surgery on 09/23 (09/23/19) to have stent completely removed. Will have pretesting call and give orders for preop testing prior to that visit. physician's orders [REDACTED]. On 09/17/19 at 1:41 p.m., the office manager for the urologist stated the [MEDICAL CONDITION] stent was placed on 03/30/19 and the resident was discharged with instructions to be seen within a week for a follow up and removal of the stent. She then stated that appointment was never made by the facility. She confirmed that the stent should only be in place two weeks until all kidney stones are passed. She confirmed the resident had been seen on 08/28/19 at the emergency room because of the pain and the resident had discharge instruction to come in for an appointment the next day. She then stated, The facility never called to get him in for an appointment. When asked how the resident finally got an appointment made, she stated a family member called the office concerned that the stent was still in place on 09/05/19 and she researched the residents history and called the facility. She stated the facility was asked to bring him in on the same day to get the stent removed. She then stated the facility said they could not bring him because they did not have transportation for them. She confirmed when she called and spoke with the facility that they had not scheduled the necessary appointments, the facility response was they misplaced the paperwork and did not know about the appointments. She was asked why the resident was scheduled for surgery. She stated when the resident finally came in on 09/16/19 to have the stent removed it broke off. She was asked what caused the stent to be removed. She stated the doctor confirmed the stent had broken off because it was calcified in. She was asked to describe the resident prior to and after the attempted removal of the stent in her office. She stated the resident had a hard time while in the office and was very uncomfortable. She stated the resident did not complain of pain, but his facial expressions indicated he was in a lot of pain. On 09/17/19 at 2:00 p.m., the resident stated his stent had been in since (MONTH) and should have been removed no longer then three months after it was placed. He stated he was in pain when he twisted and especially when he urinates. He stated the pain he experienced because of the stent still being in was between five and eight on a scale of 1-10. He stated the pain was always an eight when he urinated because he had to push. He stated he had been to the hospital because of the pain last week and he went about two weeks ago. He then stated, I don't know why they did not get me an appointment to remove it, but now I have to go in for a surgery. During the interview the resident was observed to twist to his right then left and had a grimace on his face. He confirmed that when he just moved, his pain level was about a five on a scale of 1-10. On 09/18/19 at 9:55 a.m., LPN #1 stated she knew the resident had not been seen at the urologist like he should. She stated she had spoken with the resident's attending physician about the stent still being in a few weeks ago when he asked, but thought the appointment had been made. She stated she works at night and he usually came in the evening after all day time nurses were gone. She then stated, The stent was already suppose to be out. At 10:15 a.m., the social service director stated discharge papers and instructions went to the charge nurse when the resident returned from the hospital or any appointment. If there was a follow up appointment, nursing staff would provide the paperwork and information to her. She stated she did not know about the resident needing an appointment the next day in (MONTH) and had never seen the discharge papers until today. She confirmed the resident did not get an appointment the next day like he should. When asked about a call to the facility on [DATE] from the urologist office, she stated they had spoken with her and was told to bring him in ASAP because the stent had been in too long. She stated they could not transport him there and was not able to make arrangements for him to be transported on the same day. She confirmed the resident now had surgery scheduled on 09/23/19 as a result of the stent breaking. At 10:30 a.m., the DON stated it was too quick of a notice to get the resident there the same day. She stated the facility van was not wheelchair accessible so that was not an option to get him there on 09/05/19. The DON confirmed the resident's appointments were not made for a follow up in (MONTH) and again in (MONTH) and that there was no documentation in the clinical record to support the facility had even attempted to make the appointments. 2. Resident #6 had [DIAGNOSES REDACTED]. A review of the clinical record contained documentation the resident was to bee seen for an appointment on 08/29/19. The appointment sheet documented it had been canceled. On 09/18/19 at 1:20 p.m., the resident's spouse stated the resident was supposed to have had a mammogram in July, but that had been canceled by the facility. He stated at times appointments are missed because transportation never showed up to get his wife. He stated he never knew why the appointments for the mammogram were canceled because her [MEDICAL CONDITION] doctor wanted them to evaluate her for a treatment. At 1:36 p.m., the social service director stated the resident had been missing some appointments but there was no documentation in the clinical record to indicate why. She stated she just started about a month previous as the social service director. She confirmed in the appointment binders there were no sheets for any missed appointments in July. At 1:45 p.m., the breast center employee stated the facility had canceled four mammogram appointments in (MONTH) on 07/05/19, 07/11/19, 07/23/19 and 07/25/19. She stated there were no notes as to why the facility had canceled the appointments. At 1:58 p.m., the social service director stated there was no documentation in the social service progress notes as to why the appointments had been canceled by the facility. At 2:05 p.m., the DON stated if it was not in PCC, then it was not documented. She stated she would look and see if she could locate any documentation on the missed appointments for the mammogram. No further documentation was provided.

On 09/28/15, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure hazardous chemicals were stored securely out of reach to residents on the locked dementia care unit. The IJ situation was verified with the Oklahoma State Department of Health (OSDH). At 12:50 p.m., the administrator and DON were notified of the existence of the IJ. At 2:17 p.m., an acceptable plan of removal was received. The facility's plan of removal documented: Immediate Action to Correct IJ 1. Storage closet was locked on 500 hall immediately, until the lock can be replaced. 2. Lock located on the East side of 500 hall, will be replaced today with a lock that cannot be left unlocked; self locking style. It will be completed by 09/28/2015 by 15:00 (3:00 p.m.). 3. Dangerous chemicals found in the storage closet; (EZ Off, Ant Killer, and Super germicidal wipes) have been removed on 09/28/15 at 13:00 (1:00 p.m.). 4. Maintenance director will personally check the rest of the 15 additional storage closets in the facility to assure there are no other dangerous chemicals in them. Self locking locks will be installed on all storage closets to replace locks that can be left unlocked. This will be completed by 09/28/15 by 17:00 (5:00 p.m.). 5. In-service all RNs, LPNs, CMAs, CNAs, Housekeeping, Laundry, MDS, SSW, Activities, (sic) Office, therapy and administration staff today on: a) No chemicals can be kept in the facility, accessible to residents at any time. No chemicals may be brought in from the outside, the only chemicals allowed are those purchased by the facility for use in housekeeping, laundry, dietary and nursing. Each department head is responsible for securing their chemicals. This includes EZ Off, ant killers and super germicidal wipes. b) Keeping storage rooms locked at all times when not in use. The charge nurse for each hall will check the storage closet each shift to assure it is locked for two weeks and randomly thereafter. Maintenance will check the closet doors monthly to assure that the door closes easily and does not bind in such a way as to prevent the lock from latching. All in-services and corrections will be completed by 09/29/15 10:00 AM. The IJ was removed on 09/29/15 at 7:45 a.m., when all components of the plan of removal had been completed. The deficient practice remained at a pattern with no actual harm with the potential for more than minimal harm. Based on observations, record review, staff interviews, review of MSDS and review of facility policy and procedures, it was determined the facility failed to ensure: a. hazardous chemicals were securely stored out of the reach of residents for one (Hall 500 linen closet) of one linen closet observed on the Hall 500 locked dementia care unit. This had the likelihood to affect eight residents identified by the facility who wandered on the Hall 500 locked dementia care unit. b. a shared resident bathroom was free of accident hazards for one (Hall 400 women's bathroom) of three shared resident bathrooms observed. This had the potential to affect four residents identified by the facility who utilized the Hall 400 women's bathroom. c. a hallway utilized by the residents was maintained in a safe manner to prevent accidents for one (Hall 600) of four resident hallways observed. This had the potential to affect 12 residents identified by the facility who ambulated in the hallways. d. a resident was provided assistance with a transfer in a manner to prevent injury for one (#4) of three sampled residents observed during assistance with a transfer. This had the potential to affect 25 residents identified by the facility who required assistance with a gait belt during a transfer. Findings: A facility policy titled, Safety, documented: Policy Statement .Our facility shall provide a safe and healthful work environment for all employees, residents, and visitors. Therefore, it is the policy of this facility to comply with all applicable governmental health and safety requirements. We expect all employees of this facility to comply with these governmental requirements as well as facility-imposed requirements. Policy Interpretation and Implementation 1. The facility shall verify compliance with all federal, state, and local health and safety regulations . 1. On 09/28/15 at 11:47 a.m., an environmental tour of the Hall 500 locked dementia care unit was conducted. The following observations were made in an unlocked linen closet: An open can of EZ off heavy duty oven cleaner was stored under the sink. An open aerosol can of Terro ant killer was stored under the sink. An opened box of 50 count super sani germicidal wipes was stored on a shelf. The can of Easy Off oven cleaner stated the chemical was harmful if swallowed, may cause eye and skin irritations and use in a well ventilated area. An MSDS sheet for, Easy-Off Oven Cleaner, documented: .Product name .Easy-Off oven cleaner . Hazardous Identification .Danger .Corrosive . Causes burns to skin and eyes on contact .Harmful if swallowed .Avoid contact with eyes, skin, mucous membranes and clothing. DO NOT ingest. Use only adequate ventilation. Avoid breathing spray mist . Potential short term health effects . Eyes .causes burns Skin .causes burns . Ingestion .harmful if swallowed . Signs and symptoms .The product causes burns of eyes, skin and mucous membranes . The can of Terro ant killer stated harmful if swallowed, use in a well ventilated area and may cause skin and eye irritation. The box of super sani germicidal wipes stated harmful if swallowed and may cause eye and skin irritation. An MSDS sheet for Super Sani-Cloth Germicidal Disposable Wipes documented: .DANGER Causes irreversible eye damage. Do not get in eyes or on clothing. Avoid contact with skin . This product is a 'Hazardous Chemical' as defined by the OSHA Hazard Communication Standard . At 12:20 p.m., the linen closet remained unlocked. Residents were observed to ambulate the hall where the closet was located. On 09/28/15 at 12:22 p.m., LPN #4 was asked if there were any residents who wandered and enter into closed rooms. He stated there were eight residents who wandered. He stated there were three who wandered more frequently. He then stated one resident required one on one supervision for wandering. He stated we just try and keep a closer eye on them. At 12:45 p.m., the linen closet door remained unlocked. At 12:48 p.m., the linen closet door was observed to be locked. On 09/29/15 at 9:33 a.m., CNA #1 was asked if any residents wander on the dementia care unit. He stated there are three to four residents who wander. He was asked if the residents have been observed to open closed doors and wander in. He stated, Yes. They open doors so we have to keep an eye on them. At 9:36 a.m., CNA #2 was asked if any residents wander on the dementia care unit. He stated several residents wander. He further stated the residents have been observed to wander in and out of rooms and open closed doors. On 09/30/15 at 11:37 a.m., maintenance supervisor #2 was asked why the linen closet was left unlocked. He stated a nurse had gone into the room and then came out without locking the door back. He stated the door required a key to unlock it. He further stated you need to turn the lock on the inside before closing the door or it would not lock. 2. On 09/28/15 at 2:15 p.m., a tour of the environment was conducted. The following observation was made: The shared women's bathroom on hall 400 was observed. The bottom of the inside of the door had metal flashing. The metal flashing was loose and gaping open. The edges of the metal were sharp and exposed. At 2:16 p.m., maintenance supervisor #2 stated he needed to fix the door. On 09/30/15 at 11:37 a.m., maintenance supervisor #1 and #2 were notified of the observation in the women's shared bathroom on hall 400. They acknowledged the concerns. On 10/01/15 at 12:50 p.m., the administrator was notified of the observation. He acknowledged the concerns. 3. On 09/28/15 at 2:10 p.m., a tour of the environment was conducted. There was a large piece of concrete observed missing between resident hall 600 and the entry ways. The hole was approximately six inches wide by ten inches in length. At 2:11 p.m., a resident was observed to ambulate over the piece of missing concrete. On 09/30/15 at 11:37 a.m., maintenance supervisor #1 and #2 were notified of the observation. Maintenance supervisor #2 stated he was aware of the missing concrete and he needed to find a contractor to fix the hole. On 10/01/15 at 12:50 p.m., the administrator was notified of the observations. He acknowledged the concerns. 4. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 07/28/15, documented the resident was severely impaired in cognitive skills for daily decision making. He required total assistance from staff with transfers. On 09/29/15 at 10:58 a.m., CNA #3 and CNA #4 were observed as they assisted the resident with a transfer from his geri chair to his bed. They knocked on the resident's door and entered the room. They provided privacy and donned clean gloves. CNA #3 and #4 then positioned the geri chair close to the resident's bedside. The CNA's then positioned themselves in front of the resident. CNA # 3 then placed his right hand under the resident's arm pit. CNA #4 placed her left hand under the resident's arm pit. The CNA's then lifted the resident up by lifting under the resident's armpits. They lifted the resident to a standing position, pivoted the resident over the bed and sat him down. The resident was nonweight bearing. They then assisted the resident to a supine position in his bed. At 11:10 a.m., CNA #3 and #4 were asked how they ensure residents are transferred in a safe manner. CNA #4 stated they use a gait belt during transfers. CNA #4 was observed with a gait belt around her waist. She was asked if there was a reason she did not use her gait belt to transfer the resident. She stated, No. I wasn't thinking. They were asked if they could injure a resident if they provided transfer assistance by lifting a resident under their armpits. CNA #3 stated, Oh, yes. On 09/29/15 at 4:00 p.m., the DON was asked how should staff ensure residents are transferred in a manner to prevent injury. She stated, They have to use their gait belt. She was then asked if it was acceptable to lift a nonweight bearing resident under the armpits and transfer them. She stated, Never. She was notified of the observation. She stated, Ok.

On 12/01/14, an Immediate Jeopardy situation was determined to exist due to the facility's failure to complete a thorough investigation of resident #1's suspicious injury of unknown origin which occurred on 11/17/14 due to an altercation with resident #16. Additional injuries were sustained on 11/25/14 which resulted from a second altercation with resident #16. On 12/01/14, the Oklahoma State Department of Health was notified and verified the Immediate Jeopardy situation. At 5:00 p.m., the Administrator and Director of Nursing were notified of the Immediate Jeopardy situation. At 8:40 p.m., an acceptable plan of removal was received. The Plan of removal documented the following: "Plan of Removal Claim of Immediate Jeopardy December 1, 2014 1. One staff member will be designated as a 'monitor' for the Dementia Unit to observe the common area and hallway; particularly when other staff members are providing care to residents in their rooms or in the shower room. This person will be referred to as the 'monitor'. Charge Nurse will be responsible to ensure that a monitor is designated and in-place for all shifts. A facility wide in-service to include Nursing (RN/LPN, CMA, C NA's (sic)) Housekeeping, Dietary, Maintenance, and Activities staff that may work on Hall 500/Dementia Unit as a monitor will be educated by noon, [DATE] about the new Abuse Investigations Policy, protecting resident and new procedure on monitoring residents. Staff members will not work on Dementia Unit until they have completed mandatory in-service, either in person or via telephone with witness. 2. Administrator and Department Heads (medical Records, Maintenance, Dietary, MDS Nurses, Activities, DON, and Business Office Manager) have been educated on the attached new Abuse Investigations Policy as potentially being investigators by [DATE]; 2300 (11:00 p.m.) hours. A modification was made whereby the Administrator will appoint a member of management to investigate alleged incidents. All were given the referenced policy to ready and follow. 3. A facility wide in-service to include Nursing (RN/LPN, CMA, C NA's (sic)), Housekeeping, Dietary, Maintenance, and Activities staff will be called in for mandatory In-Service and then sign that they have been educated on the new Abuse Investigations Policy and new procedure on monitoring residents on Dementia Unit. Staff will be encouraged to continue reporting any suspected abuse. Specifically, Staff will be told that an investigating officer will be assigned to conduct investigations. Nursing (RN/LPN, CMA, C NA's (sic)), Housekeeping, Dietary, Maintenance, And Activities Staff may be educated about the new Abuse Investigations Policy and new procedures on monitoring residents via telephone with a witness or in person. Facility staff to include Nursing (RN/LPN, CMA, C NA's (sic)), Housekeeping, Dietary, Maintenance, and Activities staff will be in-serviced by noon, [DATE] about new Abuse Investigations Policy, protecting residents and having a monitor in place to protect residents by being able to call for help. Staff members will not work until they have completed mandatory in-service, either in person or via telephone with witness. 4. All residents on Dementia Unit will be assessed by 2200 (10:00 p.m.) [DATE] for any suspicious injury. Should any be found, each will follow the new Abuse Investigations Policy to be investigated in an attempt to determine cause of injury. 5. Residents with assaultive behaviors will be identified in order to focus the assigned monitor. This is to be completed by 2300 (11:00 p.m.), [DATE]." On 12/02/14 at 3:30 p.m., the Immediate Jeopardy situation was removed after all components of the plan of removal had been completed. The deficient practice remained at an isolated level of actual harm. Based on clinical record review, staff interviews and review of facility policy and procedures, it was determined the facility failed to: a. conduct a thorough investigation of a suspicious injury of unknown origin for one (#1) of three sampled residents whose clinical records were reviewed for injuries of unknown origin; and b. conduct a thorough investigation of an allegation of sexual assault for one (#15) of 14 sampled residents whose records were reviewed for abuse. This resulted in actual harm to resident #1 who received an injury of unknown origin which was not properly investigated. Resident #1 had bruising to his right upper arm and right lower leg from an altercation with resident #16, including an area that appeared as a suspicious mouth sized buise. Approximately eight days later resident #1 was assaulted again by resident #16 and received bruising to his right pinky finger, right side of the head, and abrasions to his left shoulder and right hip. After this incident, resident #16 admitted to hitting, biting and pushing the resident down. This also resulted in an Immediate Jeopardy situation to resident's safety on the hall 500 locked unit due to the facility's failure to conduct thorough investigations for injuries of unknown origin. This had to potential to affect all 88 residents who resided in the facility. Findings: A facility policy titled, Abuse Investigations, documented: "Policy Statement All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Policy Interpretation and Implementation 1. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident... 3. the individual conducting the investigation will, as a minimum... c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate)... g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors... j. Review all events leading up to the alleged incident. 4. The following guidelines will be used when conducting interviews: a. Each interview will be conducted separately and in a private location... 8. The individual in charge of the investigation will consult daily with the Administrator concerning the progress/findings of the investigation. 9. The Administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation... 15. Inquiries concerning abuse reporting and investigation should be referred to the Administrator or to the Director of Nursing Services." 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 09/25/14, documented the resident had severe cognitive impairment. He did not require staff assistance with transfers and ambulation. A comprehensive assessment, dated 10/15/14, documented the resident had moderate cognitive impairment. He did not require staff assistance with transfers and ambulation. A nurse's note, dated 11/17/14 at 2:15 p.m., documented, "Resident was noted to have bruising to right upper arm and right lower inner leg. Bruising to right leg is noted below the knee to the left of inner calf. Reported to (Dr. name omitted) and (DON) at 11:45 a.m. Bruising reported to resident's sister (name omitted) at 1:52 p.m. Resident denies any complaints of pain or discomfort." At 2:15 p.m., a nurse's note documented, Resident is unable to inform staff of ideology (sic) of bruising. Resident verbalizes 'Oh that came from my pacemaker.' A nurse's note, dated 11/19/14 at 11:30 a.m., documented, "Resident is given a shower by hospice CNA and is noted to have bruising noted to upper right arm to right elbow. Bruising is a darker purplish color and it appear to be a bruise noted to right forearm that has a line bruising noted to middle of bruise. Bruise to right forearm appears to be an ellipse shape... Hospice nurse spoke with resident about possible harm from another resident or his roommate. Resident continues to deny that anybody is hitting him. Resident is informed by Hospice nurse that his room will be changed. Resident verbalizes 'Oh thank you, thank you.' Resident appears to be relieved when informed of room change." A nurse's note, dated 11/19/14 at 11:30 a.m., documented, "Room changed from 508 B to room [ROOM NUMBER] B. Resident is continuously redirected to room [ROOM NUMBER] B." A hospice document, titled, Visit Note Report, documented: "...Visit date... 11/19/14... Visit Type... Hospice RN... In-Home Time...Began... 12:35 PM... Completed... 1:14 PM... Assessment... No distress, but bruising noted to the right upper arm that has worsened since last week and a small mouth size bruise to the right lower forearm... Analysis... Observed the bruising on the right arm that appears to have worsened. Staff reports that roommate does have some anger issues at times and that roommate has a history of being combative towards other residents... Plan... Spoke with the DON and Administrator regarding this issue and they did agree to move patient to another room. Hospice HHA did assist with this transfer. Will continue to observe for further bruising or injury..." A nurse's note, dated 11/24/14 at 12:15 p.m., documented, "Resident's sister here to visit with this resident. Resident's sister verbalizes 'I told the prayer team members at church that my brother (resident #1) has some bruising, and what appears to be a bite mark on his right arm. The nursing staff moved him into another room for his protection'... This nurse informed (resident #1 sister) that resident's bruising and possible bite mark to right arm was reported to State Department of Health.... (named sister) verbalizes that resident (resident #1) told her it was (resident #16). This resident was removed from previous room [ROOM NUMBER] B and previous roommate (resident #16)... This resident is continuously redirected back to room [ROOM NUMBER] B." A nurse's note, dated 11/24/14 at 9:00 p.m., documented, "Resident cont (continues) on observation R/T (related to) Res/Res altercation. (no) behaviors noted this shift..." A nurse's note, dated 11/25/14 at 2:55 p.m., documented, "This resident is noted to be sitting in the floor with his left leg up under him. This resident verbalized 'that other resident (resident #16) pushed me down, because he just does not like me.' This resident was in other resident's room in 508 when other resident pushed him down. This resident is noted to have a bluish bruise to his right pinky finger with [MEDICAL CONDITION], an abrasion to left shoulder back and an abrasion to right lower back with some [MEDICAL CONDITION] noted. Resident also appears to have an [MEDICAL CONDITION] hardened area to right side of head. Area to right side of head is a bluish color. This resident denies knowing the origin of hematoma to right side of head and right pinky finger. Resident's (named physician) is informed at 1:38 p.m. and resident's sister (name omitted) is informed at 1:39 p.m." A nurse's note, dated 11/25/14 at 2:55 p.m., documented, "Police here to question resident at 3:00 pm. (Ambulance service) called at 3:11 pm and arrived at 3:25 pm to transfer this resident to hospital for an evaluation and treatment orders written and faxed for transfer to emergency room for evaluation and treatment rt (related to) hematoma to right side of head." 2. Resident #16 was admitted to the facility with [DIAGNOSES REDACTED]. A comprehensive assessment, dated 10/10/14, documented the resident was cognitively intact. He did not require assistance from staff with transfers and ambulation. A care plan, dated 10/16/14, documented, "Focus... Restraints...I have dx of senile dementia and have short term memory issues... Interventions... (named resident #16) has a hx of poor impulse control and having quick anger episodes. He is very territorial and when others wander in his room, he lashes out. A barrier has been placed on his door to distract wanderers..." A nurse's note, dated 11/19/14 at 12:55 p.m., documented, "...observed this res push another res...for walking behind this res who was sitting (at) dining table. the res stood up (and) pushed res... will cont to observe res (and) re-direct d/t neg Bx (behavior) (and) (increased) agitation. Reported neg Bx to DON..." A nurse's note, dated 11/24/14 at 1:00 p.m., documented, "(Resident #1) verbalizes that this resident bit him on right forearm. Other Resident verbalized this to his sister (name omitted). Other resident was moved to another room [ROOM NUMBER] B after it was reported to (named nursing home) staff by hospice CNA of bruising and possible bite mark to arm, leg and forearm. Other resident (Resident #1) was moved on 11-19-14." A nurse's note, dated 11/25/14 at 9:00 p.m., documented, "Resident is noted by CNA staff to be going into another resident's room (Resident #1) and (Resident #6) in 503 B. CNA encourages resident to go back to his room [ROOM NUMBER] B and this resident appears to get upset and agitated. This resident verbalizes that other resident (Resident #1) was in his room. CNA redirected both residents to their own rooms." A nurse's note, dated 11/25/14 at 3:35 p.m., documented, "This resident sitting in living room watching television. No distress or discomfort is noted at 1314 (1:14 p.m.). CNA informs this nurse that another resident (resident #1) was sitting in this resident's room on the floor next to the bed and in front of the night stand. Other resident (Resident #1) was sitting on his left leg and verbalized '(Resident #16) pushed me down because he does not like me.' Staff asked this resident how other resident (Resident #1) got onto the floor. This resident verbalizes 'he crapped on my floor, I pushed him down, and I cleaned up the crap'..." An Oklahoma State Department of Health incident report form, dated 11/17/14, documented, "...(checked box) Final... Part B... Resident was found to have bruising noted to right upper arm and right lower leg. Right lower leg bruising is noted below the knee to the left of inner calf. Room has been evaluated for trip hazards and non (sic) exist. Will continue to provide a safe environment for all residents... Part C... Investigation could not determine how bruising occurred, however, (Resident #1's) roommate was moved to a different room to try and rule out the possibility that his roommate could have caused bruising. Will continue to monitor and provide a safe environment..." A fax confirmation, dated 11/21/14 at 12:17 p.m., confirms the Oklahoma State Department of Health incident report was faxed to the Oklahoma State Department of Health. An Oklahoma State Department of Health incident report form, dated 11/17/14, documented, "...(marked) Final... Part B... Per reported incident of 11-17-14, resident (resident #1) was found to have bruising noted to right upper arm and right lower leg, originally of unknown origin. (Resident #16) is roommate of (Resident #1). (Resident #1) was interviewed by day shift L.P.N. and hospice R.N., but did not provide explanation of bruising. (Resident #1) was moved to another room to attempt to rule out (Resident #16) as the cause of the bruising. This was originally reported as an injury of unknown origin. Shortly after 11:00 a.m., on 11-24-14 (Resident #1) was interviewed by his sister, (name omitted). (Resident #1) stated to his sister that '(Resident #16)' had been the cause of his bruising. (Resident #1) has been removed from the room occupied by (Resident #16) and (Resident #16) remains in a room without a roommate... Part C... Allegation of abuse is substantiated on Resident/Roommate (Resident #16). (Resident #16) was immediate (sic) referred and admitted to the (facility name omitted) after he testified to physicians that he was pushing, hitting and hurting Resident (Resident #1)..." A fax confirmation, dated 11/26/14 at 12:18 p.m., confirms the Oklahoma State Department of Health incident report was faxed to the Oklahoma State Department of Health. A Jones Police Department voluntary statement written by LPN #3, dated 11/25/14 at 1:15 p.m., documented, "...This resident was sitting on his left leg in room [ROOM NUMBER] next to the bed and in front of night stand. (Resident #1) verbalized 'that another resident (Resident #16) pushed him down because he just does not like me.' (Resident #1) is noted to have bruising to right pinky and to right side of head (of hairline) Right pinky and right side of head are a bluish color with some [MEDICAL CONDITION] noted. (Resident #1) is also noted to have an abrasion to left shoulder and an abrasion to right lower back with some [MEDICAL CONDITION] also noted to right lower back." A Police Department document titled Incident/Offense Report, dated 11/23/14, documented, "On 11-23-14 at approximately 1430 (2:30 p.m.) hours, (officer name omitted) advised me that he needed me to go to (named nursing home address) and make contact with (Resident #1) about an assault... I observed a circular bruise on his right arm and he told me that he had a pace maker taken out from there. I made contact with the nursing staff and was advised that (Resident #1) had dementia very bad and is unable comprehend many things. I was advised by the staff that there was an altercation between (Resident #1) and his old roommate (Resident #16). I was advised that since the altercation they are no longer roommates..." A Police Department document titled Incident/Offense Report, dated 11/25/14, documented, On 11/25/2014 at or about 1418 2:18 p.m.) hrs. I was contacted by (name omitted)... to inform police of an assault at the (named nursing home)... I immediately drove to the (named nursing home) to make contact with the alleged victim, (Resident #1).... I informed (LPN #3) for the reason of my visit and she showed me to (Resident #1) (sic) room. (Resident #1) would not talk to me at first as he seemed confused at my presence and when asked him about a bite mark on his Right Arm he said, (sic) (Resident #16) pushed me down.(sic) I also saw a fresh abrasion on the back of his Left Shoulder, a swollen Right Pinkie finger and a lump on the Right side of his forehead. When I asked (Resident #1) how he had gotten the injuries he would only say, (sic) (Resident #16) pushed me down.(sic)..." An Oklahoma State Department of Health incident report form, dated 11/26/14, documented, "...(checked box) Combined Initial and Final... Incident type... (checked box) Allegations of Abuse/Mistreatment... Part B... (Resident #1) was found on floor on his old room, Rm 508 with an abrasion to left shoulder blade area and [MEDICAL CONDITION] and abrasion to right side above hip area.... Resident stated that Resident (Resident #16) pushed him down. Resident was sent to hospital for further evaluation based on Sister/POA's insistence... Resident (Resident #1) had previously been reported as having bruising of unknown origin, on 11/25/14 Resident (Resident #16) admitted to pushing resident (Resident #1) down, hitting and biting him previously... Part C... Investigation substantiates abuse of (Resident #1) by his demented roommate, (Resident #16)..." On 12/01/14 at 10:30 a.m., photographs were obtained from the local police department. The photographs included injuries resident #1 had sustained. (named police officer) stated the photographs were taken on 11/25/14. The following photographs were reviewed for resident #1: A blue colored bruise was reviewed on his right temporal area of his head. A blue colored bruise was reviewed on his right pinky finger. A yellow and purple elliptical bruise was reviewed on his right lower forearm. A straight purple bruise was observed just above the elliptical bruise. A bright red abrasion was reviewed on his upper right hip. On 12/01/14 at 3:35 p.m., LPN #3 was asked if the facility had ever interviewed her or asked her for a statement related the resident's injury of unknown origin. She stated she was not interviewed and was not asked for a witness statement. The only statement she gave was for the police. At 4:20 p.m., the administrator was asked if he had conducted the investigation, from 11/17/14, of injury of unknown origin. He stated an investigation had been initiated and any allegation of abuse was unsubstantiated due to being unable to find what had happened. He then stated resident #1 and resident #16 were separated as roommates to rule out the roommate as the cause of the injuries. He then stated it was not until resident #1's sister talked to him that the facility knew resident #16 had caused the suspicious bruise and then resident #16 admitted he had assaulted resident #1. He was then asked about the investigation of the suspicious injury of unknown origin. He stated he thought the nurse's had interviewed him and was not sure if the DON had been involved during the interview process. He then was asked if he had interviewed staff in regards to the suspicious injury of unknown origin on resident #1. He stated he thought the DON did. At 4:35 p.m., the DON was asked if the staff were interviewed about the suspicious injury of unknown origin. She stated the staff were talked to and no one reported seeing anything. She was asked if the interviews with staff were documented. She acknowledged the interviews were not documented. She was asked if resident's were interviewed. She stated the residents were not interviewed. She was then asked what preventions were put in place to prevent a recurrence of altercations between the residents. She stated the facility did not suspect resident #16 until the sister of resident #1 informed them. She stated they initially moved resident #1 to another room due to the administrator suspected resident #16. She denied any other types of prevention or inservices conducted for suspicious injuries of unknown origin. On 12/05/14 at 10:40 a.m., the DON was asked who normally investigates injuries of unknown origins. She stated the administrator completes the state [MEDICATION NAME]. She then stated bruises are not investigated unless the bruise is suspicious in appearance. 3. Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. A facility incident report, dated 09/05/14 at 4:00 p.m., documented, "...Person involved: (named resident #15)... Describe exactly what happened...Resident told secretary that her vagina was paining her, asked what cause is. She said 'man did it'. Nurse examined her and found no bruise, trauma, redness... Additional comments and/or steps taken to prevent recurrences: Monitored (named resident #17) closely and ensured he did not come close to (named resident #15)..." A nurse's note, dated 09/05/14 at 9:30 p.m., documented, "At about 4 pm, secretary told nurse that resident told her that her (resident's) vagina was hurting. Asked what caused it, resident told her 'man did it.' Nurse assessed her in presence of a female CNA...There was no redness, trauma, or discharge from her vagina. Nurse notified DON and Dr about the situation. Dr gave order to send resident to hospital for evaluation. Resident have (sic) history of [MEDICAL CONDITION] and depression. She was acting manic and anxious. Nurse also called the Administrator; police was (sic) called and they came for investigation. Resident told police that she want (sic) to talk to him in private, at this time nurse and other nurse from hall 500 were told to leave. Resident could not tell when the rape occurred, one time she said it was 1950. Resident was sent to hospital via (ambulance). She left facility by 9 pm." An emergency department note, dated 09/05/14 at 9:40 p.m., documented, "...Comments: (named nursing home) sent (named resident #15) for sexual assault exam but since she is dementia (sic), (named hospital) would not perform exam even with consent from (named nursing home) administrator..." An emergency department report, dated 09/05/14 at 10:23 p.m., documented, "...Addendum...Patient unable to undergo sexual assault exams as patient without (sic) power of attorney or person to call for consent....Patient with somehow dubious history of assault as reportedly suffered assault many years ago and will occasionally report abuse related to prior history. Police have been notified..." A nurse's note, dated 09/06/14 at 4:00 a.m., documented, "Resident arrived back to facility c (ambulance service) at (3:13 a.m.) Transferred back to room...Assessment done upon arrival (no) injury noted. Res was very happy to be back to facility, smiling..." A social service note, dated 09/06/14 at 10:20 a.m., documented, "(named resident) communicated to two different people that she had been hurt by a man and was bleeding from her female parts. She was examined by nurse and there was no evidence of any bleeding or trauma. (named resident) had told me x 1 year ago that she was raped and it took further communication with her to know that she was reflecting on the rape and made it seem like she had just been raped. Perhaps Aug or Sept is the anniversary of her being raped and she relives it. She identified resident (named resident #17) as the man that hurt her. (named resident #17) has been monitored and (named resident #15) was sent to ER for examination. ER refused to examine her as they determined she was not competent to make an informed consent. I was called and gave consent but hospital refused to accept my consent for her. We do not have any evidence to indicate she has been touched or harmed in any way. Her allegation was reported and investigated as required. Police were also called to report her allegation." An OSDH incident report, dated 09/05/14 and submitted via fax to the OSDH on 09/11/14, documented, "...(checked box) Final... ...Incident Date: 09/05/14... Incident Location: Rm 403?... Resident(s)/Client(s) Involved: (named resident #15 and #17)... Incident Type: ...(checked box) Physical Harm... Notifications Made: ...(checked boxes) Physician, Family, DHS: Adult Protective Services, Local Law Enforcement... Description of Incident: ...(named resident #15) reported that a man had hurt her and that she was bleeding from her female parts. She was immediately examined and nurse found no evidence of any bleeding or trauma to her. MD contacted and MD wanted her sent our for examination. (named resident #15) was sent out to ER but ER determined that she was demented and could not give informed consent for sexual assault examination. Administrator gave consent however hospital refused to acknowledge that consent as (named resident #15) has no other family or POA. (named resident #15) had reported (1 year ago) that she was raped and made it seem like it just happened. We belive that (named resident #15) was raped in the past and perhaps Aug or Sep is the anniversary of such trauma. We have been monitoring (named resident #17) as that is whom (named resident #15) identified as a man that hurt her. (named resident #17) has not been seen on (named resident #15) hall nor anywhere around her at all. We belive that (named resident #15) is being manic during the last several days and are also requesting a review/adjustment of her medications... Part C For 5 day and final reports, please include a summary of the investigation (include investigative actions, findings and causative factors) and corrective measures implemented to prevent recurrence... Investigation as complete as we can get it. Hospital refused to examine (named resident #15) due to her dementia and not being able to provided informed consent for sexual assault exam. Hospital stated that she had no injury but may have had a history of [REDACTED]. Police did not have any other evidence to indicate otherwise and (named resident #17) could not even identify (named resident #15). Will continue to have residents separated as (named resident #17) lives on a different hall" A quarterly assessment, dated 09/15/14, documented the resident was moderately impaired in cognitive skills for daily decision making. She was independent with transfers, ambulation and eating. She required extensive assistance from staff with bathing. A social service note, dated 09/23/14, documented, "...Resident had an episode where she accused another resident of rape. Resident was sent to hospital for necessary exam. For several reasons outlined in the facility investigation it is believed the rape did not actually occur. Investigation did not reveal any actual harm. By report this resident accuses some one of rape periodically. Resident, by report, was raped once some time ago..." A physician's progress note, dated 09/25/14, documented, "...Had c/o sexual assault (and) sent to (named emergency room )..." A care plan, dated 01/06/14 and last updated 10/01/14, documented, "Problems: Miscellaneous... Goals: I will be free from injury thru next review... Interventions: ...(written in) 10/01/14...(named resident) has hx of reporting 'rape' has been investig each time (and) no specifics have been verified. Will cont to treat (and) eval each claim as they occur. Each claim to be invest..." On 12/04/14 at 10:10 a.m., the DON was asked what action is taken for an allegation of abuse or neglect to ensure the allegation is thoroughly investigated. She stated, "Assess the patient. Notify the doctor with results. Also, take statements from the accused, accuser, any staff that might know something. We also may interview other residents. Just depends." She was then asked if she was aware of any other accusations of sexual assault prior to September 2014. She stated, "I was aware of her having claims of an assault years ago. I'm not aware of any claims prior to September or since I have worked here." She was asked how long she has been employed with the facility. She stated she has worked at the facility for two years. She was then asked to review the resident's nursing notes, facility incident report and state reportable incident report. She was asked if the facility had conducted any staff or resident interviews during their investigation. She stated, "I know there were statements taken. You probably need to talk with (named administrator). He would have them." On 12/04/14 at 10:15 a.m., the social service director was asked if he was aware of any other incidents of sexual assault allegations made by the resident. He stated, "She hasn't claimed rape since I've been here." He was asked how long he has been employed by the facility. He stated, "Since April." At 10:20 a.m., the administrator was asked if he had taken staff and resident statements as part of his investigation of the sexual assault allegation by resident #15. He stated, "I know we got statements from staff and residents. I will go look for them." At 11:00 a.m., the administrator was asked if he had located any statements from staff or residents for the investigation of sexual assault. He stated, "I've contacted the police department. He's on his way with the report. There is a statement in the report they have from the DHS investigator." He was asked if this statement was part of the facility investigation or part of the police investigation. He stated the police interviewed the DHS investigator and he thought the statement would help our investigation. He was then asked if he had located any statements taken by the facility as part of the facility investigation. He stated, "Whatever we have is included in the state reportable. We did take statements from staff and residents. I know we did it." On 12/04/14 at 11:15 a.m., resident #17 was asked if the facility had ever interv

On 12/01/14, an Immediate Jeopardy situation was determined to exist due to the facility's failure to follow their abuse policies and procedures to ensure a thorough investigation was completed for a suspicious injury of unknown origin for resident #1 which occurred on 11/17/14 due to an altercation with resident #16. Resident #1 sustained additional injuries on 11/25/14 due to a second altercation with resident #16. On 12/01/14, the Oklahoma State Department of Health was notified and verified the Immediate Jeopardy situation. At 5:00 p.m., the Administrator and Director of Nursing were notified of the Immediate Jeopardy situation. At 8:40 p.m., an acceptable plan of removal was received. The Plan of removal documented the following: "Plan of Removal Claim of Immediate Jeopardy December 1, 2014 1. One staff member will be designated as a 'monitor' for the Dementia Unit to observe the common area and hallway; particularly when other staff members are providing care to residents in their rooms or in the shower room. This person will be referred to as the 'monitor'. Charge Nurse will be responsible to ensure that a monitor is designated and in-place for all shifts. A facility wide in-service to include Nursing (RN/LPN, CMA, C NA's (sic)) Housekeeping, Dietary, Maintenance, and Activities staff that may work on Hall 500/Dementia Unit as a monitor will be educated by noon, [DATE] about the new Abuse Investigations Policy, protecting resident and new procedure on monitoring residents. Staff members will not work on Dementia Unit until they have completed mandatory in-service, either in person or via telephone with witness. 2. Administrator and Department Heads (medical Records, Maintenance, Dietary, MDS Nurses, Activities, DON, and Business Office Manager) have been educated on the attached new Abuse Investigations Policy as potentially being investigators by [DATE]; 2300 (11:00 p.m.) hours. A modification was made whereby the Administrator will appoint a member of management to investigate alleged incidents. All were given the referenced policy to ready and follow. 3. A facility wide in-service to include Nursing (RN/LPN, CMA, C NA's (sic)), Housekeeping, Dietary, Maintenance, and Activities staff will be called in for mandatory In-Service and then sign that they have been educated on the new Abuse Investigations Policy and new procedure on monitoring residents on Dementia Unit. Staff will be encouraged to continue reporting any suspected abuse. Specifically, Staff will be told that an investigating officer will be assigned to conduct investigations. Nursing (RN/LPN, CMA, C NA's (sic)), Housekeeping, Dietary, Maintenance, And Activities Staff may be educated about the new Abuse Investigations Policy and new procedures on monitoring residents via telephone with a witness or in person. Facility staff to include Nursing (RN/LPN, CMA, C NA's (sic)), Housekeeping, Dietary, Maintenance, and Activities staff will be in-serviced by noon, [DATE] about new Abuse Investigations Policy, protecting residents and having a monitor in place to protect residents by being able to call for help. Staff members will not work until they have completed mandatory in-service, either in person or via telephone with witness. 4. All residents on Dementia Unit will be assessed by 2200 (10:00 p.m.) [DATE] for any suspicious injury. Should any be found, each will follow the new Abuse Investigations Policy to be investigated in an attempt to determine cause of injury. 5. Residents with assaultive behaviors will be identified in order to focus the assigned monitor. This is to be completed by 2300 (11:00 p.m.), [DATE]." On 12/02/14 at 3:30 p.m., the Immediate Jeopardy situation was removed after all components of the plan of removal had been completed. The deficient practice remained at an isolated level of actual harm. Based on clinical record review, staff interviews and review of facility policy and procedures, it was determined the facility failed to implement their abuse policies and procedures to: a. conduct a thorough investigation of a suspicious injury of unknown origin for one (#1) of three sampled residents whose clinical records were reviewed for injuries of unknown origin; and b. conduct a thorough investigation of an allegation of sexual assault for one (#15) of 14 sampled residents whose records were reviewed for abuse. This resulted in actual harm to resident #1 who received an injury of unknown origin which was not properly investigated. Resident #1 had bruising to his right upper arm and right lower leg from an altercation with resident #16, including an area that appeared as a suspicious mouth sized buise. Approximately eight days later resident #1 was assaulted again by resident #16 and received bruising to his right pinky finger, right side of the head, and abrasions to his left shoulder and right hip. After this incident, resident #16 admitted to hitting, biting and pushing the resident down. This also resulted in an Immediate Jeopardy situation to resident's safety on the hall 500 locked unit due to the facility's failure to implement their abuse policies and procedures to conduct thorough investigations for injuries of unknown origin. This had to potential to affect all 88 residents who resided in the facility. Findings: A facility policy titled, Abuse Investigations, documented: "Policy Statement All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Policy Interpretation and Implementation 1. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident... 3. the individual conducting the investigation will, as a minimum... c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate)... g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors... j. Review all events leading up to the alleged incident. 4. The following guidelines will be used when conducting interviews: a. Each interview will be conducted separately and in a private location... 8. The individual in charge of the investigation will consult daily with the Administrator concerning the progress/findings of the investigation. 9. The Administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation... 15. Inquiries concerning abuse reporting and investigation should be referred to the Administrator or to the Director of Nursing Services." 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 09/25/14, documented the resident had severe cognitive impairment. He did not require staff assistance with transfers and ambulation. A comprehensive assessment, dated 10/15/14, documented the resident had moderate cognitive impairment. He did not require staff assistance with transfers and ambulation. A nurse's note, dated 11/17/14 at 2:15 p.m., documented, "Resident was noted to have bruising to right upper arm and right lower inner leg. Bruising to right leg is noted below the knee to the left of inner calf. Reported to (Dr. name omitted) and (DON) at 11:45 a.m. Bruising reported to resident's sister (name omitted) at 1:52 p.m. Resident denies any complaints of pain or discomfort." At 2:15 p.m., a nurse's note documented, Resident is unable to inform staff of ideology (sic) of bruising. Resident verbalizes 'Oh that came from my pacemaker.' A nurse's note, dated 11/19/14 at 11:30 a.m., documented, "Resident is given a shower by hospice CNA and is noted to have bruising noted to upper right arm to right elbow. Bruising is a darker purplish color and it appear to be a bruise noted to right forearm that has a line bruising noted to middle of bruise. Bruise to right forearm appears to be an ellipse shape... Hospice nurse spoke with resident about possible harm from another resident or his roommate. Resident continues to deny that anybody is hitting him. Resident is informed by Hospice nurse that his room will be changed. Resident verbalizes 'Oh thank you, thank you.' Resident appears to be relieved when informed of room change." A nurse's note, dated 11/19/14 at 11:30 a.m., documented, "Room changed from 508 B to room [ROOM NUMBER] B. Resident is continuously redirected to room [ROOM NUMBER] B." A hospice document, titled, Visit Note Report, documented: "...Visit date... 11/19/14... Visit Type... Hospice RN... In-Home Time...Began... 12:35 PM... Completed... 1:14 PM... Assessment... No distress, but bruising noted to the right upper arm that has worsened since last week and a small mouth size bruise to the right lower forearm... Analysis... Observed the bruising on the right arm that appears to have worsened. Staff reports that roommate does have some anger issues at times and that roommate has a history of being combative towards other residents... Plan... Spoke with the DON and Administrator regarding this issue and they did agree to move patient to another room. Hospice HHA did assist with this transfer. Will continue to observe for further bruising or injury..." A nurse's note, dated 11/24/14 at 12:15 p.m., documented, "Resident's sister here to visit with this resident. Resident's sister verbalizes 'I told the prayer team members at church that my brother (resident #1) has some bruising, and what appears to be a bite mark on his right arm. The nursing staff moved him into another room for his protection'... This nurse informed (resident #1 sister) that resident's bruising and possible bite mark to right arm was reported to State Department of Health.... (named sister) verbalizes that resident (resident #1) told her it was (resident #16). This resident was removed from previous room [ROOM NUMBER] B and previous roommate (resident #16)... This resident is continuously redirected back to room [ROOM NUMBER] B." A nurse's note, dated 11/24/14 at 9:00 p.m., documented, "Resident cont (continues) on observation R/T (related to) Res/Res altercation. (no) behaviors noted this shift..." A nurse's note, dated 11/25/14 at 2:55 p.m., documented, "This resident is noted to be sitting in the floor with his left leg up under him. This resident verbalized 'that other resident (resident #16) pushed me down, because he just does not like me.' This resident was in other resident's room in 508 when other resident pushed him down. This resident is noted to have a bluish bruise to his right pinky finger with [MEDICAL CONDITION], an abrasion to left shoulder back and an abrasion to right lower back with some [MEDICAL CONDITION] noted. Resident also appears to have an [MEDICAL CONDITION] hardened area to right side of head. Area to right side of head is a bluish color. This resident denies knowing the origin of hematoma to right side of head and right pinky finger. Resident's (named physician) is informed at 1:38 p.m. and resident's sister (name omitted) is informed at 1:39 p.m." A nurse's note, dated 11/25/14 at 2:55 p.m., documented, "Police here to question resident at 3:00 pm. (Ambulance service) called at 3:11 pm and arrived at 3:25 pm to transfer this resident to hospital for an evaluation and treatment orders written and faxed for transfer to emergency room for evaluation and treatment rt (related to) hematoma to right side of head." 2. Resident #16 was admitted to the facility with [DIAGNOSES REDACTED]. A comprehensive assessment, dated 10/10/14, documented the resident was cognitively intact. He did not require assistance from staff with transfers and ambulation. A care plan, dated 10/16/14, documented, "Focus... Restraints...I have dx of senile dementia and have short term memory issues... Interventions... (named resident #16) has a hx of poor impulse control and having quick anger episodes. He is very territorial and when others wander in his room, he lashes out. A barrier has been placed on his door to distract wanderers..." A nurse's note, dated 11/19/14 at 12:55 p.m., documented, "...observed this res push another res...for walking behind this res who was sitting (at) dining table. the res stood up (and) pushed res... will cont to observe res (and) re-direct d/t neg Bx (behavior) (and) (increased) agitation. Reported neg Bx to DON..." A nurse's note, dated 11/24/14 at 1:00 p.m., documented, "(Resident #1) verbalizes that this resident bit him on right forearm. Other Resident verbalized this to his sister (name omitted). Other resident was moved to another room [ROOM NUMBER] B after it was reported to (named nursing home) staff by hospice CNA of bruising and possible bite mark to arm, leg and forearm. Other resident (Resident #1) was moved on 11-19-14." A nurse's note, dated 11/25/14 at 9:00 p.m., documented, "Resident is noted by CNA staff to be going into another resident's room (Resident #1) and (Resident #6) in 503 B. CNA encourages resident to go back to his room [ROOM NUMBER] B and this resident appears to get upset and agitated. This resident verbalizes that other resident (Resident #1) was in his room. CNA redirected both residents to their own rooms." A nurse's note, dated 11/25/14 at 3:35 p.m., documented, "This resident sitting in living room watching television. No distress or discomfort is noted at 1314 (1:14 p.m.). CNA informs this nurse that another resident (resident #1) was sitting in this resident's room on the floor next to the bed and in front of the night stand. Other resident (Resident #1) was sitting on his left leg and verbalized '(Resident #16) pushed me down because he does not like me.' Staff asked this resident how other resident (Resident #1) got onto the floor. This resident verbalizes 'he crapped on my floor, I pushed him down, and I cleaned up the crap'..." An Oklahoma State Department of Health incident report form, dated 11/17/14, documented, "...(checked box) Final... Part B... Resident was found to have bruising noted to right upper arm and right lower leg. Right lower leg bruising is noted below the knee to the left of inner calf. Room has been evaluated for trip hazards and non (sic) exist. Will continue to provide a safe environment for all residents... Part C... Investigation could not determine how bruising occurred, however, (Resident #1's) roommate was moved to a different room to try and rule out the possibility that his roommate could have caused bruising. Will continue to monitor and provide a safe environment..." A fax confirmation, dated 11/21/14 at 12:17 p.m., confirms the Oklahoma State Department of Health incident report was faxed to the Oklahoma State Department of Health. An Oklahoma State Department of Health incident report form, dated 11/17/14, documented, "...(marked) Final... Part B... Per reported incident of 11-17-14, resident (resident #1) was found to have bruising noted to right upper arm and right lower leg, originally of unknown origin. (Resident #16) is roommate of (Resident #1). (Resident #1) was interviewed by day shift L.P.N. and hospice R.N., but did not provide explanation of bruising. (Resident #1) was moved to another room to attempt to rule out (Resident #16) as the cause of the bruising. This was originally reported as an injury of unknown origin. Shortly after 11:00 a.m., on 11-24-14 (Resident #1) was interviewed by his sister, (name omitted). (Resident #1) stated to his sister that '(Resident #16)' had been the cause of his bruising. (Resident #1) has been removed from the room occupied by (Resident #16) and (Resident #16) remains in a room without a roommate... Part C... Allegation of abuse is substantiated on Resident/Roommate (Resident #16). (Resident #16) was immediate (sic) referred and admitted to the (facility name omitted) after he testified to physicians that he was pushing, hitting and hurting Resident (Resident #1)..." A fax confirmation, dated 11/26/14 at 12:18 p.m., confirms the Oklahoma State Department of Health incident report was faxed to the Oklahoma State Department of Health. A Jones Police Department voluntary statement written by LPN #3, dated 11/25/14 at 1:15 p.m., documented, "...This resident was sitting on his left leg in room [ROOM NUMBER] next to the bed and in front of night stand. (Resident #1) verbalized 'that another resident (Resident #16) pushed him down because he just does not like me.' (Resident #1) is noted to have bruising to right pinky and to right side of head (of hairline) Right pinky and right side of head are a bluish color with some [MEDICAL CONDITION] noted. (Resident #1) is also noted to have an abrasion to left shoulder and an abrasion to right lower back with some [MEDICAL CONDITION] also noted to right lower back." A Police Department document titled Incident/Offense Report, dated 11/23/14, documented, "On 11-23-14 at approximately 1430 (2:30 p.m.) hours, (officer name omitted) advised me that he needed me to go to (named nursing home address) and make contact with (Resident #1) about an assault... I observed a circular bruise on his right arm and he told me that he had a pace maker taken out from there. I made contact with the nursing staff and was advised that (Resident #1) had dementia very bad and is unable comprehend many things. I was advised by the staff that there was an altercation between (Resident #1) and his old roommate (Resident #16). I was advised that since the altercation they are no longer roommates..." A Police Department document titled Incident/Offense Report, dated 11/25/14, documented, On 11/25/2014 at or about 1418 2:18 p.m.) hrs. I was contacted by (name omitted)... to inform police of an assault at the (named nursing home)... I immediately drove to the (named nursing home) to make contact with the alleged victim, (Resident #1).... I informed (LPN #3) for the reason of my visit and she showed me to (Resident #1) (sic) room. (Resident #1) would not talk to me at first as he seemed confused at my presence and when asked him about a bite mark on his Right Arm he said, (sic) (Resident #16) pushed me down.(sic) I also saw a fresh abrasion on the back of his Left Shoulder, a swollen Right Pinkie finger and a lump on the Right side of his forehead. When I asked (Resident #1) how he had gotten the injuries he would only say, (sic) (Resident #16) pushed me down.(sic)..." An Oklahoma State Department of Health incident report form, dated 11/26/14, documented, "...(checked box) Combined Initial and Final... Incident type... (checked box) Allegations of Abuse/Mistreatment... Part B... (Resident #1) was found on floor on his old room, Rm 508 with an abrasion to left shoulder blade area and [MEDICAL CONDITION] and abrasion to right side above hip area.... Resident stated that Resident (Resident #16) pushed him down. Resident was sent to hospital for further evaluation based on Sister/POA's insistence... Resident (Resident #1) had previously been reported as having bruising of unknown origin, on 11/25/14 Resident (Resident #16) admitted to pushing resident (Resident #1) down, hitting and biting him previously... Part C... Investigation substantiates abuse of (Resident #1) by his demented roommate, (Resident #16)..." On 12/01/14 at 10:30 a.m., photographs were obtained from the local police department. The photographs included injuries resident #1 had sustained. (named police officer) stated the photographs were taken on 11/25/14. The following photographs were reviewed for resident #1: A blue colored bruise was reviewed on his right temporal area of his head. A blue colored bruise was reviewed on his right pinky finger. A yellow and purple elliptical bruise was reviewed on his right lower forearm. A straight purple bruise was observed just above the elliptical bruise. A bright red abrasion was reviewed on his upper right hip. On 12/01/14 at 3:35 p.m., LPN #3 was asked if the facility had ever interviewed her or asked her for a statement related the resident's injury of unknown origin. She stated she was not interviewed and was not asked for a witness statement. The only statement she gave was for the police. At 4:20 p.m., the administrator was asked if he had conducted the investigation, from 11/17/14, of injury of unknown origin. He stated an investigation had been initiated and any allegation of abuse was unsubstantiated due to being unable to find what had happened. He then stated resident #1 and resident #16 were separated as roommates to rule out the roommate as the cause of the injuries. He then stated it was not until resident #1's sister talked to him that the facility knew resident #16 had caused the suspicious bruise and then resident #16 admitted he had assaulted resident #1. He was then asked about the investigation of the suspicious injury of unknown origin. He stated he thought the nurse's had interviewed him and was not sure if the DON had been involved during the interview process. He then was asked if he had interviewed staff in regards to the suspicious injury of unknown origin on resident #1. He stated he thought the DON did. At 4:35 p.m., the DON was asked if the staff were interviewed about the suspicious injury of unknown origin. She stated the staff were talked to and no one reported seeing anything. She was asked if the interviews with staff were documented. She acknowledged the interviews were not documented. She was asked if resident's were interviewed. She stated the residents were not interviewed. She was then asked what preventions were put in place to prevent a recurrence of altercations between the residents. She stated the facility did not suspect resident #16 until the sister of resident #1 informed them. She stated they initially moved resident #1 to another room due to the administrator suspected resident #16. She denied any other types of prevention or inservices conducted for suspicious injuries of unknown origin. On 12/05/14 at 10:40 a.m., the DON was asked who normally investigates injuries of unknown origins. She stated the administrator completes the state [MEDICATION NAME]. She then stated bruises are not investigated unless the bruise is suspicious in appearance. 3. Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. A facility incident report, dated 09/05/14 at 4:00 p.m., documented, "...Person involved: (named resident #15)... Describe exactly what happened...Resident told secretary that her vagina was paining her, asked what cause is. She said 'man did it'. Nurse examined her and found no bruise, trauma, redness... Additional comments and/or steps taken to prevent recurrences: Monitored (named resident #17) closely and ensured he did not come close to (named resident #15)..." A nurse's note, dated 09/05/14 at 9:30 p.m., documented, "At about 4 pm, secretary told nurse that resident told her that her (resident's) vagina was hurting. Asked what caused it, resident told her 'man did it.' Nurse assessed her in presence of a female CNA...There was no redness, trauma, or discharge from her vagina. Nurse notified DON and Dr about the situation. Dr gave order to send resident to hospital for evaluation. Resident have (sic) history of [MEDICAL CONDITION] and depression. She was acting manic and anxious. Nurse also called the Administrator; police was (sic) called and they came for investigation. Resident told police that she want (sic) to talk to him in private, at this time nurse and other nurse from hall 500 were told to leave. Resident could not tell when the rape occurred, one time she said it was 1950. Resident was sent to hospital via (ambulance). She left facility by 9 pm." An emergency department note, dated 09/05/14 at 9:40 p.m., documented, "...Comments: (named nursing home) sent (named resident #15) for sexual assault exam but since she is dementia (sic), (named hospital) would not perform exam even with consent from (named nursing home) administrator..." An emergency department report, dated 09/05/14 at 10:23 p.m., documented, "...Addendum...Patient unable to undergo sexual assault exams as patient without (sic) power of attorney or person to call for consent....Patient with somehow dubious history of assault as reportedly suffered assault many years ago and will occasionally report abuse related to prior history. Police have been notified..." A nurse's note, dated 09/06/14 at 4:00 a.m., documented, "Resident arrived back to facility c (ambulance service) at (3:13 a.m.) Transferred back to room...Assessment done upon arrival (no) injury noted. Res was very happy to be back to facility, smiling..." A social service note, dated 09/06/14 at 10:20 a.m., documented, "(named resident) communicated to two different people that she had been hurt by a man and was bleeding from her female parts. She was examined by nurse and there was no evidence of any bleeding or trauma. (named resident) had told me x 1 year ago that she was raped and it took further communication with her to know that she was reflecting on the rape and made it seem like she had just been raped. Perhaps Aug or Sept is the anniversary of her being raped and she relives it. She identified resident (named resident #17) as the man that hurt her. (named resident #17) has been monitored and (named resident #15) was sent to ER for examination. ER refused to examine her as they determined she was not competent to make an informed consent. I was called and gave consent but hospital refused to accept my consent for her. We do not have any evidence to indicate she has been touched or harmed in any way. Her allegation was reported and investigated as required. Police were also called to report her allegation." An OSDH incident report, dated 09/05/14 and submitted via fax to the OSDH on 09/11/14, documented, "...(checked box) Final... ...Incident Date: 09/05/14... Incident Location: Rm 403?... Resident(s)/Client(s) Involved: (named resident #15 and #17)... Incident Type: ...(checked box) Physical Harm... Notifications Made: ...(checked boxes) Physician, Family, DHS: Adult Protective Services, Local Law Enforcement... Description of Incident: ...(named resident #15) reported that a man had hurt her and that she was bleeding from her female parts. She was immediately examined and nurse found no evidence of any bleeding or trauma to her. MD contacted and MD wanted her sent our for examination. (named resident #15) was sent out to ER but ER determined that she was demented and could not give informed consent for sexual assault examination. Administrator gave consent however hospital refused to acknowledge that consent as (named resident #15) has no other family or POA. (named resident #15) had reported (1 year ago) that she was raped and made it seem like it just happened. We belive that (named resident #15) was raped in the past and perhaps Aug or Sep is the anniversary of such trauma. We have been monitoring (named resident #17) as that is whom (named resident #15) identified as a man that hurt her. (named resident #17) has not been seen on (named resident #15) hall nor anywhere around her at all. We belive that (named resident #15) is being manic during the last several days and are also requesting a review/adjustment of her medications... Part C For 5 day and final reports, please include a summary of the investigation (include investigative actions, findings and causative factors) and corrective measures implemented to prevent recurrence... Investigation as complete as we can get it. Hospital refused to examine (named resident #15) due to her dementia and not being able to provided informed consent for sexual assault exam. Hospital stated that she had no injury but may have had a history of [REDACTED]. Police did not have any other evidence to indicate otherwise and (named resident #17) could not even identify (named resident #15). Will continue to have residents separated as (named resident #17) lives on a different hall" A quarterly assessment, dated 09/15/14, documented the resident was moderately impaired in cognitive skills for daily decision making. She was independent with transfers, ambulation and eating. She required extensive assistance from staff with bathing. A social service note, dated 09/23/14, documented, "...Resident had an episode where she accused another resident of rape. Resident was sent to hospital for necessary exam. For several reasons outlined in the facility investigation it is believed the rape did not actually occur. Investigation did not reveal any actual harm. By report this resident accuses some one of rape periodically. Resident, by report, was raped once some time ago..." A physician's progress note, dated 09/25/14, documented, "...Had c/o sexual assault (and) sent to (named emergency room )..." A care plan, dated 01/06/14 and last updated 10/01/14, documented, "Problems: Miscellaneous... Goals: I will be free from injury thru next review... Interventions: ...(written in) 10/01/14...(named resident) has hx of reporting 'rape' has been investig each time (and) no specifics have been verified. Will cont to treat (and) eval each claim as they occur. Each claim to be invest..." On 12/04/14 at 10:10 a.m., the DON was asked what action is taken for an allegation of abuse or neglect to ensure the allegation is thoroughly investigated. She stated, "Assess the patient. Notify the doctor with results. Also, take statements from the accused, accuser, any staff that might know something. We also may interview other residents. Just depends." She was then asked if she was aware of any other accusations of sexual assault prior to September 2014. She stated, "I was aware of her having claims of an assault years ago. I'm not aware of any claims prior to September or since I have worked here." She was asked how long she has been employed with the facility. She stated she has worked at the facility for two years. She was then asked to review the resident's nursing notes, facility incident report and state reportable incident report. She was asked if the facility had conducted any staff or resident interviews during their investigation. She stated, "I know there were statements taken. You probably need to talk with (named administrator). He would have them." On 12/04/14 at 10:15 a.m., the social service director was asked if he was aware of any other incidents of sexual assault allegations made by the resident. He stated, "She hasn't claimed rape since I've been here." He was asked how long he has been employed by the facility. He stated, "Since April." At 10:20 a.m., the administrator was asked if he had taken staff and resident statements as part of his investigation of the sexual assault allegation by resident #15. He stated, "I know we got statements from staff and residents. I will go look for them." At 11:00 a.m., the administrator was asked if he had located any statements from staff or residents for the investigation of sexual assault. He stated, "I've contacted the police department. He's on his way with the report. There is a statement in the report they have from the DHS investigator." He was asked if this statement was part of the facility investigation or part of the police investigation. He stated the police interviewed the DHS investigator and he thought the statement would help our investigation. He was then asked if he had located any statements taken by the facility as part of the facility investigation. He stated, "Whatever we have is included in the state reportable. We did take st

On 12/01/14 an Immediate Jeopardy situation was determined to exist which jeopardized resident safety related to the facility's failure to provide adequate supervision of residents to prevent resident to resident altercations on the Hall 500 Locked Unit. Resident #16 exhibited assaultive behaviors towards resident #1, which caused injury to resident #1, on two separate occasions over an eight day period. On 12/01/14 the Oklahoma State Department of Health was notified and verified the Immediate Jeopardy situation. At 5:00 p.m., the Administrator and Director of Nursing were notified of the Immediate Jeopardy situation. At 8:40 p.m., an acceptable plan of removal was received. The Plan of removal documented the following: "Plan of Removal Claim of Immediate Jeopardy December 1, 2014 1. One staff member will be designated as a 'monitor' for the Dementia Unit to observe the common area and hallway; particularly when other staff members are providing care to residents in their rooms or in the shower room. This person will be referred to as the 'monitor'. Charge Nurse will be responsible to ensure that a monitor is designated and in-place for all shifts. A facility wide in-service to include Nursing (RN/LPN, CMA, C NA's (sic)) Housekeeping, Dietary, Maintenance, and Activities staff that may work on Hall 500/Dementia Unit as a monitor will be educated by noon, [DATE] about the new Abuse Investigations Policy, protecting resident and new procedure on monitoring residents. Staff members will not work on Dementia Unit until they have completed mandatory in-service, either in person or via telephone with witness. 2. Administrator and Department Heads (medical Records, Maintenance, Dietary, MDS Nurses, Activities, DON, and Business Office Manager) have been educated on the attached new Abuse Investigations Policy as potentially being investigators by [DATE]; 2300 (11:00 p.m.) hours. A modification was made whereby the Administrator will appoint a member of management to investigate alleged incidents. All were given the referenced policy to ready and follow. 3. A facility wide in-service to include Nursing (RN/LPN, CMA, C NA's (sic)), Housekeeping, Dietary, Maintenance, and Activities staff will be called in for mandatory In-Service and then sign that they have been educated on the new Abuse Investigations Policy and new procedure on monitoring residents on Dementia Unit. Staff will be encouraged to continue reporting any suspected abuse. Specifically, Staff will be told that an investigating officer will be assigned to conduct investigations. Nursing (RN/LPN, CMA, C NA's (sic)), Housekeeping, Dietary, Maintenance, And Activities Staff may be educated about the new Abuse Investigations Policy and new procedures on monitoring residents via telephone with a witness or in person. Facility staff to include Nursing (RN/LPN, CMA, C NA's (sic)), Housekeeping, Dietary, Maintenance, and Activities staff will be in-serviced by noon, [DATE] about new Abuse Investigations Policy, protecting residents and having a monitor in place to protect residents by being able to call for help. Staff members will not work until they have completed mandatory in-service, either in person or via telephone with witness. 4. All residents on Dementia Unit will be assessed by 2200 (10:00 p.m.) [DATE] for any suspicious injury. Should any be found, each will follow the new Abuse Investigations Policy to be investigated in an attempt to determine cause of injury. 5. Residents with assaultive behaviors will be identified in order to focus the assigned monitor. This is to be completed by 2300 (11:00 p.m.), [DATE]." On 12/02/14 at 3:30 p.m., the Immediate Jeopardy situation was removed after all components of the plan of removal had been completed. The deficient practice remained at an isolated level of actual harm. Based on clinical record review and staff interviews, it was determined the facility failed to provide adequate supervision to prevent resident to resident altercations for one (#1) of three sampled residents who had a history of [REDACTED]. This resulted in actual harm to resident #1 who received an injury of unknown origin. Resident #1 had bruising to his right upper arm and right lower leg from an altercation with resident #16, including an area that appeared as a suspicious mouth sized buise. Approximately eight days later resident #1 was assaulted again by resident #16 and received bruising to his right pinky finger, right side of the head, and abrasions to his left shoulder and right hip. After this incident, resident #16 admitted to hitting, biting and pushing the resident down. This also resulted in an Immediate Jeopardy situation to resident's safety on the Hall 500 Locked Unit, due to the facility's failure to provide supervision to prevent resident to resident altercations. This had the potential to affect all 30 residents identified by the facility who resided on the Hall 500 Locked Unit. Findings: A facility policy titled Abuse Investigations, documented: "Policy Statement All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Policy Interpretation and Implementation 1. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident... 3. the individual conducting the investigation will, as a minimum... c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate)... g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors... j. Review all events leading up to the alleged incident. 4. The following guidelines will be used when conducting interviews: a. Each interview will be conducted separately and in a private location... 8. The individual in charge of the investigation will consult daily with the Administrator concerning the progress/findings of the investigation. 9. The Administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation... 15. Inquiries concerning abuse reporting and investigation should be referred to the Administrator or to the Director of Nursing Services." 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 09/25/14, documented the resident had severe cognitive impairment. He did not required assistance from staff with transfers and ambulation. A comprehensive assessment, dated 10/15/14, documented the resident had moderate cognitive impairment. He did not require assistance from staff with transfers and ambulation. A nurse's note, dated 11/17/14 at 2:15 p.m., documented, "Resident was noted to have bruising to right upper arm and right lower inner leg. Bruising to right leg is noted below the knee to the left of inner calf. Reported to (Dr. name omitted) and (DON) at 11:45 a.m. Bruising reported to resident's sister (name omitted) at 1:52 p.m. Resident denies any complaints of pain or discomfort." At 2:15 p.m., a nurse's note documented, Resident is unable to inform staff of ideology (sic) of bruising. Resident verbalizes 'Oh that came from my pacemaker.' A nurse's note, dated 11/19/14 at 11:30 a.m., documented, "Resident is given a shower by hospice CNA and is noted to have bruising to upper right arm to right elbow. Bruising is a darker purplish color and it appears to be a bruise noted to right forearm that has a line bruising noted to middle of bruise. Bruise to right forearm appears to be an ellipse shape... Hospice nurse spoke with resident about possible harm from another resident or his roommate. Resident continues to deny that anybody is hitting him. Resident is informed by Hospice nurse that his room will be changed. Resident verbalizes 'Oh thank you, thank you.' Resident appears to be relieved when informed of room change." A nurse's note, dated 11/19/14 at 11:30 a.m., documented, "Room changed from 508 B to room 503 B. Resident is continuously redirected to room 503 B." A hospice document, titled Visit Note Report, documented; "...Visit date... 11/19/14... Visit Type... Hospice RN... In-Home Time...Began... 12:35 PM... Completed... 1:14 PM... Assessment... No distress, but bruising noted to the right upper arm that has worsened since last week and a small mouth size bruise to the right lower forearm... Analysis... Observed the bruising on the right arm that appears to have worsened. Staff reports that room mate does have some anger issues at times and that room mate has a history of being combative towards other residents... Plan... Spoke with the DON and Administrator regarding this issue and they did agree to move patient to another room. Hospice HHA did assist with this transfer. Will continue to observe for further bruising or injury..." A nurse's note, dated 11/24/14 at 12:15 p.m., documented, "Resident's sister here to visit with this resident. Resident's sister verbalizes 'I told the prayer team members at church that my brother (resident #1) has some bruising, and what appears to be a bite mark on his right arm. The nursing staff moved him into another room for his protection.'... This nurse informed (resident #1 sister) that resident's bruising and possible bite mark to right arm was reported to State Department of Health.... (named sister) verbalizes that resident (named resident #1) told her it was (named resident #16). This resident was removed from previous room 508 B and previous roommate (named resident #16)... This resident is continuously redirected back to room 503 B." A nurse's note, dated 11/24/14 at 9:00 p.m., documented, "Resident cont (continues) on observation R/T (related to) Res/Res altercation. (no) behaviors noted this shift..." A nurse's note, dated 11/25/14 at 2:55 p.m., documented, "This resident is noted to be sitting in the floor with his left leg up under him. This resident verbalize 'that other resident (named resident #16) pushed me down, because he just does not like me.' This resident was in other resident's room in 508 when other resident pushed him down. This resident is noted to have a bluish bruise to his right pinky finger with edema, an abrasion to left shoulder back and an abrasion to right lower back with some edema noted. Resident also appears to have an edematous hardened area to right side of head. Area to right side of head is a bluish color. This resident denies knowing the origin of hematoma to right side of head and right pinky finger. Resident's (named physician) is informed at 1:38 p.m. and resident's sister (name omitted) is informed at 1:39 p.m." A nurse's note, dated 11/25/14 at 2:55 p.m., documented, "Police here to question resident at 3:00 pm. (Ambulance service) called at 3:11 pm and arrived at 3:25 pm to transfer this resident to hospital for an evaluation and treatment orders written and faxed for transfer to emergency room for evaluation and treatment rt (related to) hematoma to right side of head." 2. Resident #16 was admitted to the facility with [DIAGNOSES REDACTED]. A comprehensive assessment, dated 10/10/14, documented the resident was cognitively intact. He did require assistance from staff with transfers and ambulation. A care plan, dated 10/16/14, documented, "Focus... Restraints...I have dx of senile dementia and have short term memory issues... Interventions... Has a hx of poor impulse control and having quick anger episodes. He is very territorial and when other wander in his room, he lashes out. A barrier has been placed on his door to distract wanderers..." A nurse's note, dated 11/19/14 at 12:55 p.m., documented, "...observed this res push another res...for walking behind this res who was sitting (at) dining table. The res stood up (and) pushed res... will cont to observe res (and) re-direct d/t neg Bx (behavior) (and) (increased) agitation. Reported neg Bx to DON..." A nurse's note, dated 11/24/14 at 1:00 p.m., documented, "(Resident #1) verbalizes that this resident bit him on right forearm. Other Resident verbalized this to his sister (name omitted). Other resident was moved to another room 503 B after it was reported to (named nursing home) staff by hospice CNA of bruising and possible bite mark to arms, leg and forearm. Other resident (Resident #1) was moved on 11-19-14." A nurse's note, dated 11/25/14 at 9:00 p.m., documented, "Resident is noted by CNA staff to be going into another resident's room (Resident #1) and (Resident #6) in 503 B. CNA encourages resident to go back to his room 508 B and this resident appears to get upset and agitated. This resident verbalizes that other resident (Resident #1) was in his room. CNA redirected both residents to their own rooms." A nurse's note, dated 11/25/14 at 3:35 p.m., documented, "This resident sitting in living room watching television. No distress or discomfort is noted at 1314 (1:14 p.m.). CNA informs this nurse that another resident (resident #1) was sitting in this resident's room on the floor next to the bed and in front of the night stand. Other resident (Resident #1) was sitting on his left leg and verbalized '(Resident #16) pushed me down because he does not like me.' Staff asked this resident how other resident (Resident #1) got onto the floor. This resident verbalizes 'he crapped on my floor, I pushed him down, and I cleaned up the crap'..." An Oklahoma State Department of Health incident report form, dated 11/17/14, documented, "...(checked box) Final... Part B... Resident was found to have bruising noted to right upper arm and right lower leg. Right lower leg bruising is noted below the knee to the left of inner calf. Room has been evaluated for trip hazards and non (sic) exist. Will continue to provide a safe environment for all residents... Part C... Investigation could not determine how bruising occurred, however, (Resident #1's) roommate was moved to a different room to try and rule out the possibility that his roommate could have caused bruising. Will continue to monitor and provide a safe environment..." A fax confirmation, dated 11/21/14 at 12:17 p.m., confirms the Oklahoma State Department of Health incident report was faxed to the Oklahoma State Department of Health. An Oklahoma State Department of Health incident report form, dated 11/17/14, documented, "...(checked box) marked Final... Part B... Per reported incident of 11-17-14, resident (resident #1) was found to have bruising noted to right upper arm and right lower leg, originally of unknown origin. (Resident #16) is roommate of (Resident #1). (Resident #1) was interviewed by day shift L.P.N. and hospice R.N., but did not provide explanation of bruising. (Resident #1) was moved to another room to attempt to rule out (Resident #16) as the cause of the bruising. This was originally reported as an injury of unknown origin. Shortly after 11:00 a.m., on 11-24-14 (Resident #1) was interviewed by his sister, (name omitted). (Resident #1) stated to his sister that '(Resident #16)' had been the cause of his bruising. (Resident #1) has been removed from the room occupied by (Resident #16) and (Resident #16) remains in a room without a roommate... Part C... Allegation of abuse is substantiated on Resident/Roommate (Resident #16). (Resident #16) was immediate (sic) referred and admitted to the (facility name omitted) after he testified to physicians that he was pushing, hitting and hurting Resident (Resident #1)..." A fax confirmation, dated 11/26/14 at 12:18 p.m., confirms the Oklahoma State Department of Health incident report was faxed to the Oklahoma State Department of Health. A Jones Police Department voluntary statement written by LPN #3, dated 11/25/14 at 1:15 p.m., documented, "...This resident was sitting on his left leg in room 508 next to the bed and in front of night stand. (Resident #1) verbalized 'that another resident (Resident #16) pushed him down because he just does not like me.' (Resident #1) is noted to have bruising to right pinky and to right side of head (of hairline) Right pinky and right side of head are a bluish color with some edema noted. (Resident #1 is also noted to have an abrasion to left shoulder and an abrasion to right lower back with some edema also noted to right lower back." A Police Department document titled Incident/Offense Report, dated 11/23/14, documented, "On 11-23-14 at approximately 1430 (2:30 p.m.) hours, (officer name omitted) advised me that he needed me to go to 1100 Georgia Ave and make contact with (Resident #1) about an assault... I observed a circular bruise on his right arm and he told me that he had a pace maker taken out from there. I made contact with the nursing staff and was advised that (Resident #1) had dementia very bad and is unable comprehend many things. I was advised by the staff that there was an altercation between (Resident #1) and his old roommate (Resident #16). I was advised that since the altercation they are no longer roommates..." A Police Department document titled Incident/Offense Report, dated 11/25/14, documented, "...On 11/25/2014 at or about 1418 (2:18 p.m.) hrs. I was contacted by (name omitted)... to inform police of an assault at the (named nursing home)... I immediately drove to the (named nursing home) to make contact with the alleged victim, (Resident #1).... I informed (LPN #3) for the reason of my visit and she showed me to (Resident #1) (sic) room. (Resident #1) would not talk to me at first as he seemed confused at my presence and when asked him about a bite mark on his Right Arm he said, (sic) (Resident #16) pushed me down.(sic) I also saw a fresh abrasion on the back of his Left Shoulder, a swollen Right Pinkie finger and a lump on the Right side of his forehead. When I asked (Resident #1) how he had gotten the injuries he would only say, (sic) (Resident #16) pushed me down. (sic)..." An Oklahoma State Department of Health incident report form, dated 11/26/14, documented, "...(checked box) Combined Initial and Final... Incident type... (checked box) Allegations of Abuse/Mistreatment... Part B... (Resident #1) was found on floor on his old room, Rm 508 with an abrasion to left shoulder blade area and edema and abrasion to right side above hip area.... Resident stated that Resident (Resident #16) pushed him down. Resident was sent to hospital for further evaluation based on Sister/POA's insistence... Resident (Resident #1) had previously been reported as having bruising of unknown origin, on 11/25/14 Resident (Resident #16) admitted to pushing resident (Resident #1) down, hitting and biting him previously... Part C... Investigation substantiates abuse of (Resident #1) by his demented roommate, (Resident #16)..." On 12/01/14 at 10:30 a.m., photographs were obtained from the police department. The photographs included injuries resident #1 had sustained. (named police officer) stated the photographs were taken on 11/25/14. The following photographs were reviewed for resident #1: A blue colored bruise was reviewed on his right temporal area of his head. A blue colored bruise was reviewed on his right pinky finger. A yellow and purple elliptical bruise was reviewed on his right lower forearm. A straight purple bruise was observed just above the elliptical bruise. A bright red abrasion was reviewed on his upper right hip. On 12/01/14 at 3:35 p.m., LPN #3 was asked if the facility maintained sufficient staff to prevent resident to resident altercations on hall 500. She stated, "I think we should have another aide." At 3:40 p.m., CMA #1 was asked if the facility maintained sufficient staff to prevent resident to resident altercations on hall 500. She stated no and they were always short on staff. At 3:41 p.m., LPN #4 was asked if the facility maintained sufficient staff to prevent resident to resident altercations on hall 500. She stated no, we try the best we can. At 3:45 p.m., CNA #3 was asked if the facility maintained sufficient staff to prevent resident to resident altercations. She stated no they need three CNAs for hall 500. At 3:45 p.m., CNA #4 was asked if the facility maintained sufficient staff to prevent resident to resident altercations. She stated no. At 4:20 p.m., the administrator was asked about the investigation, from 11/17/14, of injury of unknown origin. He stated an investigation had been initiated and any allegation of abuse was unsubstantiated due to being unable to find what had happened. He then stated resident #1 and resident #16 were separated as roommates to rule out the roommate as the cause of the injuries. He then stated it was not until resident #1's sister talked to him that the facility knew resident #16 had caused the suspicious bruise and resident #16 admitted he had assaulted resident #1. He was then asked about the investigation of the suspicious injury of unknown origin. He stated he thought the nurse's had interviewed him and was not sure if the DON had been involved during the interview process. He was then asked if he had interviewed staff in regards to the suspicious injury of unknown origin. He stated he thought the DON did. At 4:35 p.m., the DON was asked if the staff were interviewed about the suspicious injury of unknown origin. She stated the staff were talked to and no one reported seeing anything. She was asked if the interviews with staff were documented. She acknowledged the interviews were not documented. She was asked if resident's were interviewed. She stated the residents were not interviewed. She was then asked what preventions were put in place to prevent a reoccurence of altercations between the residents. She stated the facility did not suspect resident #16 until the sister of resident #1 informed them. She stated they initially moved resident #1 to another room due to the administrator suspected resident #16. She denied any other types of prevention or inservices conducted for suspicious injuries of unknown origin. On 12/01/14 at 5:00 p.m., the DON and administrator were informed staff reported they did not feel there was sufficient staff to provide supervision to prevent resident to resident altercations on hall 500. The DON stated she felt there was sufficient staff on hall 500. On 12/02/14 at 2:16 p.m., RN #1 was asked if she was assigned to work hall 500 did she remain on hall 500 throughout her entire shift. She stated she could not always be on hall 500. She then stated there was not enough staff on hall 500 to watch the residents. On 12/05/14 at 10:40 a.m., the DON was asked who normally investigates injuries of unknown origins. She stated the administrator completes the state reportables. She then stated bruises are not investigated unless the bruise is suspicious in appearance.

Based on clinical record review, staff interviews and review of facility policies and procedures, it was determined the facility failed to ensure a resident was free from restraints without a medical reason for the use of the restraint. Mitten restraints were being held on the resident's wrist with the use of duct tape for one (#3) of three sampled residents reviewed for the use of restraints. Improper use of duct tape resulted in actual harm to the resident. This had the potential to affect three residents who utilized restraints as identified by the facility. Findings: A facility policy and procedure, titled Restraint, documented, "Procedure 1. Document alternative measures to restraints that have been utilized and deemed unsuccessful. 2. Complete the Initial Restraint Assessment... 3. Obtain informed consent from the resident (if possible) for the use of the restraint. If the resident is mentally or physically incapable of signing the consent, then a legally responsible party may sign the consent form...Potential risks and benefits of restraint use should be explained to the resident/family... 6. The use/release of the restraint shall be documented every shift on the Restraint Release Record. 7. A Monthly Restraint Assessment will be completed to determine the continued need for the use of the restraint... 8. The use of the restraint must be documented in the resident's Care Plan... 9. Restraint reductions shall be attempted at least two (2) times per year..." Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/02/14, documented, severe cognitive impairment for daily decision making skills. The resident was always incontinent of bowel and bladder. He required extensive assistance with transfers, dressing, hygiene, and bathing. A physician's telephone order, dated 11/20/12, documented, "Attempt to use hand mitt for prevention of res (resident) picking at wounds on 6-2 off q (every) HS (hour of sleep) 10 pm." A nurse's note, dated 03/02/14, documented, "Upon 1st rounds this morning the CNA (certified nursing assistant) (initials omitted) founds (sic) resident c (with) duck (sic) tape wrapped tightly around them. CNA reported to this nurse. This nurse gently removed duck (sic) tape and mittens. Pt (patient) was noted c (with) reddened bruises to B (both) wrist. Pt (patient) was assessed for further injury...appears calm and denies feeling afraid for his safety. Also we did not use mittens on pt (patient) (at) all yesterday (3/1/14). And we did not place mittens on resident prior to leaving last night..." An incident report, dated 03/02/14, documented, "...Pt (patient) noted c (with) mittens on both hands c (with) purple duck (sic) tape wrapped tightly around them. This nurse removed duck (sic) tape and mittens and noted red bruises on B (both) wrists..." A document, dated 03/03/14, titled Report of Nursing Practice Incident, documented, "...was reported to of hand mittens taped on with duck (sic) tape. Nurse (name omitted) was last nurse to of been responsible for resident (resident #3). Bruising to both wrist was found due to tightness of tape and use of mittens." A written statement by CNA #1, dated 03/04/14, documented, "I did put the duct tape on (resident #3) (on Sat (Saturday) night/Sun (Sunday) MORN (morning) 3/1-3/2 on the 10-6 shift) to keep his mittens in place because he was digging in feces and smearing it on the wall (and) bed. He did this multiple times the night before and I did it to prevent it from reoccurring on this night. The nurse (name omitted) (and) she was aware that I had used duct tape instead of paper tape which had been used with prior incidents to keep on his mittens." A written statement by LPN #1, dated 03/05/14, documented, "The CNA (certified nursing assistant) used tape to hold mittens on (resident #3), because he was able to remove them and he would not stop digging in his rectum. I assessed the tape and it was not tight around his wrists, it was moveable." On 07/21/14 at 12:24 p.m., the administrator was asked if he felt the use of duct tape to secure hand mitten restraints was acceptable. He stated, "No." At 1:55 p.m., the director of nursing was asked if the use of duct tape to secure hand mittens was the proper application of a restraint. She stated, "No, not at all." She stated the Velcro on the hand mittens was worn and not holding. She was then asked what would be a good intervention for hand mittens that had worn Velcro. She stated, "Order new ones." She then stated she felt the benefits to utilizing duct tape to secure the hand mittens outweighed the negatives. At 4:00 p.m., the director of nursing was asked if there was documentation of assessments for the use of hand mitten restraints. She stated they did not think the use hand mittens was a restraint. There was no documentation of the hand mittens being monitored as restraints. On 07/23/14 at 12:23 p.m., the primary care physician was asked if use of duct tape to secure hand mittens in place was the proper use of a restraint. He stated, "Nothing is to be used with duct tape on it." At 3:45 p.m., LPN #2 was asked if staff were to utilize duct tape and/or any other tape to secure mitten restraints. He stated, "No." At 3:51 p.m., LPN #3 was asked if staff were to utilize duct tape and/or any other tape to secure mitten restraints. She stated, "No, Velcro." On 07/23/14 at 3:55 p.m., the social services director was asked if staff were to utilize duct tape and/or tape to secure mitten restraints. He stated, "No, not our policy." At 3:55 p.m., LPN #4 was asked if staff were to utilize duct tape and/or any other tape to secure mitten restraints. She stated, "No."

Based on observation, record review, and interview, it was determined the facility failed to prevent one (#1) of one sampled resident who had a history of [REDACTED]. This resulted in injury and actual harm. The facility identified no other residents with behaviors directed toward self harm residing in the open unit. Findings: Resident #1 had [DIAGNOSES REDACTED]. A psychiatric physician's progress note, dated 01/17/12, documented the resident had suicide ideations with a plan and intent. The note further documented she had indicated she planned to break her TV and use the glass to cut her jugular vein. The resident was demanding to be sent out and would commit suicide if not sent to an in-patient hospital. The resident had been residing in the locked unit. Clinical records documented the resident had resided in the facility's locked unit until 02/06/12, due to having been an elopement risk. On this date, the resident was transferred to a room in the open unit. A psychiatric physician's progress note, dated 02/25/12, documented staff had informed him the resident had attempted to escape yesterday because she didn't get to smoke enough. His note documented she was alert and her objective was to be able to smoke outside. The resident's smoking assessment, dated 03/26/12, documented the resident had a history of [REDACTED]. The resident's smoking assessments, dated 04/05/12 and 07/05/12, documented the resident was not able to self extinguish a cigarette. The results of the assessments documented she required minimal supervision. The resident's behavior risk assessments, dated 08/03/12 and 09/28/12, documented the resident was attention seeking and posed a risk of harm to herself and others due to suicide ideation with attempts. A nurse's note dated, 10/21/12 at 7:20 p.m., documented the resident continued to go outside to smoke frequently. A nurse's note dated, 10/23/12 at 6:20 p.m., documented the resident was found by an outside party on 6th Street. A CNA returned the resident to the facility. The annual resident assessment, dated 10/26/12, documented she was cognitively intact. She was able to ambulate with assistance, self-propelled her wheelchair, made herself understood and understood others. A nurse's note dated, 11/23/12 at 11:15 p.m., documented the resident had constantly asked for extra cigarettes and would become angry and tearful when denied the cigarettes. A nurse's note, dated 11/29/12 at 6:15 p.m., documented the resident was yelling and screaming for a cigarette at 6:00 p.m., after having been observed smoking at 5:00 p.m. She had been told her 6:00 p.m., cigarette would be held. A nurse's note dated, 12/04/12 at 7:00 p.m., documented the nurse noted a large contusion on the resident's forehead. The resident stated she had banged her head on a brickwall. The resident stated she had done it because she was mad. She was transferred to a local emergency room . A nurse's note, dated 12/05/12 at 3:15 p.m., documented the resident had been found outside the facility on the road. She was returned to the DON's office for counseling due to behaviors of banging head on the block wall for cigarettes and multiple attempts at elopement. A physician's admission note to a psychiatric facility, dated 12/06/12, documented the resident had been admitted to the hospital due to elopement and increasing self injuries. She was recently admitted to a local emergency room due to banging her head on a block wall resulting in a contusion. She used these self injury behaviors to get her way with staff. A nurse's note, dated 12/31/12 at 2:40 p.m., documented the resident requested a cigarette, per smoking schedule, and self-propelled self to designated smoking area. The resident (no time given) was at the nurse's station demanding another cigarette. The nurse explained the cigarettes were given according to the facility smoking schedule. The resident returned to her room for a breathing treatment. At 4:10 p.m., the nurse documented she heard, "I'm on fire." The resident was found with her dress on fire. The fire was immediately extinguished. The resident had burns to bilateral legs and thumbs. A cigarette lighter was removed from her possession. She was admitted to a local hospital for treatment of [REDACTED]. An incident report, date 12/31/12, documented a resident who resided across the hall from the resident stated he saw her set her dress on fire then yell out, "I'm on fire." It documented a cigarette lighter was removed from her possession. The emergency room physician admission notes, dated 12/31/12, documented the resident had blisters to bilateral lower legs. The burns were documented as first degree burns. The resident was admitted to the hospital's Intensive Care Unit (ICU) unit due to suicidal gestures. On 01/23/13 at 8:30 a.m., resident #2 was interviewed. His room was located directly across from resident #1's room. It was observed his cigarette lighter was sitting on his bedside table. He stated he was an independent smoker. He stated residents who might start a fire are not allowed to keep a lighter. They borrow ours and they don't always return them. He was asked if staff ever stayed with the residents while they smoked. He stated no. At 1:30 p.m., the social services director was asked to explain the facility policy concerning residents who were on minimal supervision for smoking. She stated it meant the resident was not to keep cigarettes on their person or in their room. They did have some residents who were independent smokers, they kept their own cigarettes and lighters. She was asked if the policy documented anything about the minimal supervision residents keeping a lighter. She stated it didn't say anything about a lighter. She was asked if the staff was responsible for supervising the residents while they smoked. She stated no, they didn't have any residents who required supervision while they smoked, except those on the locked unit. She was asked if staff was responsible for assisting the residents to light their cigarettes. She stated no, we give them a cigarette and they get a light from the independent smokers. She was asked how the facility insured the residents who were not allowed to keep a lighter, did not obtain a lighter and cigarettes from the independent smokers. She stated there was no way to prevent it. She was asked if the facility had a suicide prevention policy. She stated no. At 2:00 p.m., the ADON was asked if the facility had a suicide prevention policy for residents who were at risk. He stated no they would just watch them more often, maybe every 15 minutes. He was asked how the facility ensured resident's who were at risk for self harm didn't obtain lighters from other residents. He stated he didn't know what the facility policy was for supervising the resident's who smoked. At 2:10 p.m., LPN #2 was interviewed. She was asked if it was ever determined how the resident obtained the cigarette lighter that she used to set herself on fire. She stated after the fire, resident #5 came to the nurse's station and wanted her cigarette lighter. She informed the staff resident #1 had borrowed her lighter while they were outside smoking. She was asked how the resident's who had only cigarettes and no lighter would light their cigarettes. She stated they get lights from other residents. She added it was not staff's responsibility to supervise resident #1 while she smoked. She was asked if the procedure for resident #1 was that the facility gave her a cigarette then expected her to find a light. She stated yes. On 01/24/13 at 1:20 p.m., resident #6 was interviewed. He stated he was an independent smoker and he was allowed to keep cigarettes and a lighter on his person. He was asked how residents who were not allowed to keep a lighter would light their cigarettes. He stated those residents without a lighter would borrow the independent smokers lighters. He added sometimes the residents did not return the lighter. He was asked if staff ever sat with the residents while they smoked. He said, no. He was asked if he had ever seen staff assist a resident with lighting his/her cigarette. He said he didn't think so. At 2:20 p.m., the consultant nurse was asked why the resident had been transferred from the locked unit to the unlocked unit. She stated the resident had created havoc while she was on the locked unit. She stated the staff reported on many occasions the resident kicked and struck the glass patio doors, activated the fire alarm, and would beat on the exit door. She added, on 02/06/12, the facility had spoken with the resident. The resident promised to cease her behaviors and agreed not to attempt elopements if she was transferred to the unlocked unit. The smoking policy named three outside areas which were designated as outdoor smoking areas for the residents. During the course of the survey residents were observed to be smoking in these areas. Staff was never observed to be present with residents at these times.

Based on observation, record review, and interviews, it was determined the facility failed to assess and implement dietary recommendations to prevent an actual harm of a severe weight loss of 11.5 % in six months for one (#15) of one sampled resident who had a severe weight loss. The resident Census and Condition report dated 08/20/12, documented seven residents had unplanned weight change. Findings: A facility policy documented, "Nursing service is responsible for supervision of nutrition intake, will be aware of the nutritional status of each resident... Nursing service will...observe intake and document acceptance of diet. Nursing service will contact the resident's designated physician when intake of nutrients is less than 75% of normal diet for two consecutive days." A facility policy for "Dietary Service Manager" documented, "...With dietitian, monitors nutritional status of residents using regular assessments, progress notes and dietary care planning." A facility policy for "Job Description Consultant Dietitian" documented, "Directs the functions of the dietary department...Overseas(sic) the nutritional assessment and the nutritional care plan for each resident of the facility. Identifying nutrition needs and counseling with the residents or responsible party." Resident #16 was admitted to the facility with [DIAGNOSES REDACTED]. The "Custom Weight History" for 07/06/11 through 08/14/12, documented the following weights for the resident: 02/12: 182.4 pounds 03/12: 211.0 pounds 04/12: 178.0 pounds 05/12: 173.4 pounds 06/12: 195.0 pounds 07/12: 170.0 pounds 08/12: 161.1 pounds An annual assessment dated [DATE], documented the resident was able to express ideas and wants, understood others and had moderately impaired cognitive skills for daily decision making. The assessment also documented the resident did not reject care, required extensive assistance with transfers, required set up assistance with meals and used a wheelchair for mobility. There was no documentation on the assessment to indicate the resident had weight loss. A care plan dated 02/23/12, documented, "(Resident) eats in assisted dining room. He is on a reg mecha soft diet. His teeth are in poor condition. At risk for altered nutrition/hydration/wt loss. Goals: Will have optimal nutrition/hydration/good oral hygiene and no sig wt loss thru next review. Interventions: diet and snacks as ordered. Monitor all meal % offer alternative if less than 50% eaten. Good oral hygiene. Weigh as ordered, notify MD of sig wt loss/gain. diet consult if ordered. Dental consult if ordered." A "Nutritional Progress Notes" dated 03/15/12, documented, "Wt 178...had slight wt loss within usual wt range." A "Nutritional Progress Notes" dated 04/30/12, documented, "Wt 179 (Resident) wt stable from last month...continues to eat all meals in the assisted dining room will continue to monitor." There was no documentation the facility assessed the resident's weight loss and implemented interventions to prevent a further decline in weight. A quarterly assessment dated [DATE], documented the resident's cognition was intact, required extensive assistance with transfers and extensive assistance with eating. The resident's care plan was updated on 05/29/12, with no changes in the care plan to address the resident's continual weight loss. The resident experienced a severe weight loss of 9.00 % or sixteen pounds in three months from March to June 2012. A "Nutritional Risk Assessment" dated 06/15/12, documented the resident was a high risk for nutrition problems with a score of 12. A score of eight or greater indicates the resident is a high risk. A "Consultant Dietician Recommendations" report dated 06/15/12, documented, "...Recommend: Notify the physician of significant weight change for resident: weight loss 3 month -7.58...weight gain: 1 month +12.46 %. Recommendation: FYI: stable wt X 6 mo BMI 28.9 high..." The recommendation was signed by the physician and the consulting dietician. Prior to June the facility had not notified the physician of the residents weight loss. There was no recommendations or interventions put into place to address the resident's weight loss. A "Weight Loss Risk Assessment Tool" dated 06/26/12, documented the resident was a risk for weight loss with a score of nine. A score between 0 and 15 indicated the resident was at risk. There continued to be no implemented interventions to address the resident's continual weight loss. A "Consultant Dietician Recommendations" report dated 07/13/12, documented, "...Recommend: Notify the physician of significant weight change for resident: weight loss 1 month -12.8%...Recommendation: adding house supplement /c meals TID..." The recommendation was signed by the physician and the consulting dietician. A "Nutritional Progress Notes" dated 07/13/12, documented, "170# (arrow down 25 # X 1 month...Rec: house supplement /c meals TID, notify doc wt (arrow down)...also continue to encourage food/fluids." The resident experienced a severe weight loss of 5.29 % in one one month from July to August 2012. There was no documentation the family or physician had been notified of the severe weight loss. There was no documentation the facility implemented interventions to prevent the continual weight loss. On 08/20/12 at 8:20 a.m., the morning meal service in the assisted dining area was observed. The resident was observed in a geri-chair sitting at a 45 degree angle. When he received his morning meal he did not receive a house supplement. The resident consumed 50% of meal and was not offered a replacement meal. On 08/20/12 at 12:35 p.m., 08/21/12 at 8:25 a.m., and 08/21/12 at 12:28 p.m., the resident was observed receiving his meal tray. During each observation the resident was positioned in a geri-chair at a 45 degree angle. When the resident received his meal no house supplement was provided to him. The resident consumed 25% of of each meal on the 08/21/12. On 08/23/12 at 10:35 a.m., a request was made for the resident to be weighed. CNA #7 was observed taking the resident's geri-chair to get a weight. The weight on the geri-chair, without the resident, recorded 75.8 pounds. CNA #7 then took the geri-chair to the resident's room and transferred the resident into the geri-chair with the assistance from CNA #5. Both CNAs took the resident and placed him on the scale. The weight recorded 237.2 pounds. The aide then subtracted the geri-chair weight. The resident weight recorded 161 pounds. An interview was conducted on 08/23/12 at 9:00 a.m., with the dietary manager regarding the resident's weight loss. She was asked how she handled the months weights for residents. She stated they had been entered into the computer and a list of residents were made to discuss with the consulting dietician. She was asked if the facility discussed resident's weight loss in their QA meetings. She stated, "I have not been part of QA." She then stated, "I can not say if weights are addressed in QA meetings." She was asked if she or anyone had notified the family of the resident's weight loss. She stated, "No, sir." She was asked about the resident's weight and the severe weight loss. She stated, "June was suppose to have a reweigh because we thought the 195 was wrong." She was asked if the reweigh was done and if there was documentation to indicate the 195 pounds was inaccurate. She stated, "No, I didn't document it." She was asked what interventions were put into place to address the resident's severe weight loss. She stated, "Health Shake was just implemented." The dietary manager was asked if the resident received the shake as ordered. She indicated the resident had and when told about the observations she made no comments. She was asked how the facility addressed the resident's continual weight loss which resulted in a severe weight loss. She stated, "The weight loss was not addressed the way it should have." An interview was conducted on 08/23/12 at 9:20 a.m., with the DON regarding the resident's severe weight loss. She was asked how the facility addressed the resident's weight loss. She stated, "We didn't." She was asked if the June weight was accurate or if there was a reweigh. She stated, "I don't know." She was asked who would know if the weight was accurate or if a reweigh was completed. She stated, "The dietary manager." She was asked if the resident received the house supplement health shake as ordered in July. She stated, "Yes, as far as I know." She was made aware of the four meal observations when the house supplements were not provided or offered to the resident. She made no comments. She was asked if the care plan was developed to address the resident's severe weight loss. She stated, "No, it's not addressed or developed on the care plan."

Based on observation, record review and interviews, it was determined the facility failed to have an effective quality assurance program in place to identify problems and implement plans of action to correct deficient practice. The facility failed to identify and implement a plan of action to correct system failures related to assessing and implementing changes for residents who had a severe weight loss. This resulted in an actual harm. The facility also failed to identify a problem with maintenance and housekeeping and implement changes to improve these areas. This had the potential to affect 111 of 111 residents residing in the facility. Findings: A facility policy for, "Quality Assurance-Internal Audit Policy" documented, "A committee of the whole shall be appointed to act as the Quality assurance Team. It shall review and audit all areas of the facility: ...Nursing...security...social services..." 1. The facility failed to identify and implement interventions for a resident who had a severe weight loss over a six month period which resulted in an actual harm. Refer to F-325 and F-157. 2. Refer to F-253 and F-465 for housekeeping and maintenance. An interview was conducted on 08/23/12 at 9:00 a.m., with the dietary manager regarding the resident's weight loss. She was asked how she handled the months weights for residents. She stated they had been entered into the computer and a list of residents was made to discuss with the consulting dietician. She was asked if the facility discussed resident's weight loss in their QA meetings. She stated, "I have not been part of QA." She then stated I can not say if weights were addressed in QA meetings. An interview was conducted on 08/23/12 at 9:20 a.m., with the DON regarding the resident's severe weight loss. She was asked how the facility addressed the resident's weight loss. She stated, "We didn't." She was asked if the facility discussed resident's nutrition needs and weight loss during their QA meetings. She stated, "We have not talked about weights. The only thing we talk about are the problems from the deficiencies." An interview was conducted on 08/23/12 at 10:11 a.m., with the administrator. She was asked if the QA committee discussed weight loss during their meetings. She stated, "I have not done that yet in my committee." She was asked about the QA committee addressing the exterior and interior housekeeping and maintenance concerns. She stated, "We talk about that, but have not been able to get them fixed."

On 06/29/12, an immediate jeopardy was determined to exist in regard to the facility's failure to implement interventions to protect one resident (#1) from another resident (#6) with known inappropriate sexual behaviors. The facility also failed to have a system to identify additional residents with inappropriate sexual behavior. At 2:10 p.m. the Oklahoma State Department of Health confirmed the existence of the immediate jeopardy situation. At 2:29 p.m., the ADM and DON were informed an immediate jeopardy situation existed. On 06/29/12 at 5:20 p.m., an acceptable plan of removal was provided by the administrator. The plan of removal was as followed: "Staff education on abuse policy provided to all staff with focus on protecting residents from harm, investigating allegations of abuse, determining allegations of abuse, reporting allegations of abuse to appropriate agencies and following abuse policy. Completed 06/30/2012 @ 0900. All residents will be screened for inappropriate sexual behaviors, which included any history of behaviors and any precursors that may indicate potential for development of behaviors. Completed 6/30/12 @ 0900 Screens completed by LPN's and RN's. Any resident identified with inappropriate sexual behaviors or patterns will be care planned. Completed 6/30/12 @ 0900 by LPN's and RN. Behavior and medication management is provided monthly and prn by psychologist. Psych certified RN will see identified residents weekly for additional management of behaviors. A quality assurance sub-committee has been established to monitor compliance with facility abuse policy which includes but is not limited to protections of residents, investigations of any allegations, reporting to appropriate agencies including law enforcement, following policy. Sub-committee will meet weekly and review all incidents, allegations of misconduct and any rumors. Sub-committee will provide further training at least quarterly. Ensure abuse policy training with new employees completed with orientation. Completed 6/29/12 @ 3:45. A pre-screening evaluation will be completed prior to all admissions and will include review of: H&P, DOC reports, sex offender registry, medication review, and current caregivers and pre-admission evaluation. Started 6/29/12 and ongoing. Protection of the resident when abuse is alleged or actual will prevent harm to the resident as well as all residents. Protective actions will include but not limited to: Immediate suspension of accused employee with termination pending investigation, removal of resident accused of causing harm with 1 on 1 monitoring during investigation, limitation of care plan to prevent further harm and protect all residents, involvement of law enforcement if criminal act." On 07/05/12 at 6:30 p.m., after reviewing all inservices, care plan updates, and interviews with staff, the administrator was informed the immediacy had been lifted at 11:00 p.m. on 07/03/12, after all inservices had been completed. The deficient practice remained at a scope of actual harm at a pattern, until the facility is able to ensure a system is in place to prevent the deficient practice from reoccurring. Based on record review and interview, it was determined the facility failed to protect an incapacitated female resident (#1) from a male resident (#6) with known inappropriate sexual behaviors. The DON identified two additional allegations of sexual abuse in the past six months. This had the potential to affect 114 of 114 residents residing in the facility. Findings: A facility policy documented, "All occurrences of abuse, neglect, mistreatment, injuries of an unknown source and theft or misappropriation of resident property will be analyzed by the quality assessment and assurance committee to determine if a system changes need to be made... The quality assessment and assurance committee will review all reports during their regularly scheduled meetings." "Abuse means "the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to obtain or maintain physical harm, pain or mental anguish..Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault." Resident #6 was admitted to the facility from another LTC facility with [DIAGNOSES REDACTED]. Nurses' notes from a previous facility dated 12/06/11, 12/07/11, 12/08/11, 12/18/11, 12/21/11 and 01/09/12, documented, "res cont on one on one monitoring this shift by staff member...no inappropriate behavior noted this shift." Facility 'Behavior Monitoring' forms' dated 01/12, 02/12 and 03/12, documented, "behavioral symptom... sexual inappropriate" A nurse's note dated 03/03/12, documented, "10:00 A female res. reported that this res.(#6) entered her bedroom & fondled her breast. The female resident told him to stop & she came to report incident to staff... DON, Dr and Son notified. Son reported that this resident has had this type of incident occur in the past." A quarterly assessment dated [DATE], documented the resident was severely impaired in cognition, able to make his needs known, was able to understand and be understood. The assessment further documented the resident was independent with all ADL's except required assistance with bathing. A care plan last updated 04/18/12, documented, "Res has DX of depression and takes [MEDICATION NAME], cont w POC. Goals, res will have no side effects of antidepressant use thru next review. Interventions, {arrow up} [MEDICATION NAME] to 30 mg po qd." The care plan was not developed to include interventions for the residents known sexual behaviors and sexual inappropriateness. A facility 'Behavior Monitoring' form dated 04/12 and 05/12, documented, "behavorial symptom... sexual inappropriate." Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. An "H & P" dated 02/14/12, documented, "...The patient is nonverbal secondary to [MEDICAL CONDITION] as as child..." An admission assessment dated [DATE] and a quarterly assessment dated [DATE], documented the resident had unclear speech, rarely understood others, rarely was understood by others, and was severely impaired in cognitive skills for daily decision making. The assessment also documented the resident was totally dependent on staff for transfers, dressing, eating, personal hygiene and bathing. The "Care Area Assessment Psychosocial Well-Being" dated 03/27/12, documented, "Diseases and Condition that may impede ability to interact with others: mental [MEDICAL CONDITION] documentation: {Resident) has DX TBI at a young age, MR, and mood disorder. She is unable to communicate..." The "Care Area Assessment Activities of Daily Living (ADLs) - Functional Status Worksheet" dated 03/27/12, documented, "{Resident) was admitted to facility from (Name deleted) hospital DX dysphagia, TBI, MR...She is unable to communicate needs and her vision is poor...." A care plan dated 04/02/12, documented, "Problem: (Resident) is dependent on staff for daily needs. She is non-verbal, except for screaming at times.... Problem: (Resident has DX of dysphagia, TBI, MR...She is unable to communicate needs...Goals: (Resident) will be free of injury..." An incident report dated 06/01/12, documented, "CNA called nurse to resident's room where we observed a large bruise too left side & hip area. ROM normal for resident 0 s/s of pain...steps to prevent recurrence: told staff to monitor closely..." A report to the OSDH dated 06/01/12, documented, "...relevant resident history: Res Dx...severe intellectual disability, dysphagia, TBI. Resi is non-verbal, and has decreased cognitive status R/T DX... corrective measures implemented to prevent recurrence: Staff inserviced to make sure alarms and floor mat in place in room beside bed and to monitor resident closely and frequently..." An "Incident/Accident Report" dated 06/19/12, documented, "Person involved: (Res #6/Res #1) date of incident/accident: 06/15/12, time of incident 1730 (5:30 p.m.)...location of incident: Rm 410...describe what exactly happened: Res (#6) seen exiting Rm 410. Res (#1) had diaper on but pulled to side. (#1) was quiet, not upset acting. (#6) pants were up & zipped..." A signed statement dated 06/15/12, from LPN #5 documented, "At around 1730 (5:30 p.m.) the CMA called out for (LPN #1) from (Res #1) Rm. I went down to (Res #1) Rm and observed her on her R-side on the soft safety mat beside her bed. Her clothes-gown and diaper were on her. On her bed we observed a wet spot toward the middle-it was a clearish mucous like substance, the sheet was removed and the mattress underneath it was also wet in the same area..." A signed statement dated 06/15/12, from CNA #5 documented, "The CMA (#1) was on her way down to room [ROOM NUMBER]...and she seen (Res #6) (the resident) come out her room. As she was entering she called down for the nurse (LPN #1) and said (Res #1) on the floor. She put herself on the floor as soon as (CMA #1) entered the room. So myself..and the nurse (LPN #1) and other co-worker were checking her out. Her clothes was still on & untapped on one side...in the process of getting her onto her bed I...had grabbed her pad to straighten it and I had touched some slimy sticky stuff as I leaned on her bed it was on her pad. And it was not thickened liquids..." A signed statement dated 06/15/12, from CMA #1 documented, "I went down the hall to (Res #1) room and (Res #6) was coming out of her room. As I entered her depends was pulled to the side she raised up and put her head down on her mat and her knees and there was what looked like semen on the pad..." A signed statement dated 06/15/12, from LPN #1 documented, "CMA...called this nurse to room [ROOM NUMBER] where she said she saw resident (#6) come out of room where we witnessed resident (#1) lying on her R side on matt (sp). Her brief was half on and pulled to the side...I assessed her injury there were none. CNA (#5) placed her hand on bed to fix pad. When she felt semen on her hand. I moved pad & sheet more to discover more...I then went to resident (#6) room and asked him what he was doing in that room. He stated no and thank you mam. Called DON...who stated to move resident to another room for her safety which we did and to monitor (Res #6)." A note dated 06/19/12 at 2:00 p.m., from CMA #1 documented, "Interviewed employee re incident. CMA stated (Res #1) was in bed sitting up rolling onto mat on floor. She was not yelling or upset/anxious. She stated she did not know if anything happened...stated that (Resident) diaper was pulled to side & there was a substance on the pad that she felt looked like semen (wet & sticky)." The note was signed by the administrator and DON. A note dated 06/19/12, from LPN #1 documented, "Stated that CMA reported to her that (Res #6) was leaving (Res #1) room. Questioned charge nurse re semen, stated there was a clear sticky substance on the pad." The note was signed by the administrator and DON. A note dated 06/20/12, documented, "(Res #6) was transferred to 500 hall, locked unit d/t increased wandering and increased supervision." There was no documentation in the resident's clinical record regarding the sexual abuse. Facility staff were asked to provide nurses' notes which included the day of the incident. None were provided prior to the completion of this investigation. The incident report and signed statements did not document resident #1's and resident #6's family and physician had been notified of the 06/15/12, incident. There was no documentation to indicate the OSDH and local law enforcement had been notified of the sexual abuse. The nurses' notes in the clinical for resident #6 ended on 06/13/12 and resumed again on 06/19/12. When surveyors asked for the missing notes and documentation none were provided before the end of the investigation. A nurse's note dated 06/22/12, for resident #6 documented, "1:00 p.m., received T.O. for stat labs for psych admission to (local psych hospital), r/t sexual hx, 0 sexual bx noted or observed this shift wctm." A nurse's note dated 06/22/12, on the 2-10 shift for resident #6 documented, "faxed all info to (local psych hospital) (face sheet, MAR, H&P, labs) called other facility 3 x's - 0 call returned this shift. A nurse's note dated 06/24/12 at 6:00 p.m., for resident #6 documented, "Res has had 0 neg bx nstead (sic) this shift, res brother informed this CN that res discharging in AM to home after informed of pending placement for psych eval at (local psych hospital) D.O.N. informed." The resident care plan did not address the resident's history and previous incidents of being sexually inappropriate. An interview was conducted on 06/29/12 at 12:44 p.m., with the DON and administrator. They were asked if there was any documentation in either residents clinical record for the sexual abuse incident that occurred on 06/15/12. The DON and administrator stated it would be in the nurses' notes. They were asked what the inappropriate behaviors were for resident #6. The DON stated, 'There are none unless they are charted." They were asked about the behavior monitoring sheets and additional documentation that indicated the resident was sexually inappropriate. The administrator stated, "It was reported that he had been masturbating more." She then indicated there had been an incident in March where the resident grabbed another resident's breast. They were asked if the care plan was developed to address the resident's inappropriate sexual behavior. The DON stated, "No, it's not on the care plan." They were asked if the inappropriate behavior should be addressed on the care plan. The DON stated, "Yes, so staff will know what to do." They were asked if the incident was reported to the local law enforcement and to the OSDH. The administrator and DON stated, "It wasn't reported." The administrator then stated, "The police should have been notified and a rape kit should have been done." They were asked who was responsible for ensuring a complete and through investigation was completed. The administrator stated, 'The charge nurse and then the DON and myself." They were asked what type of investigation occurred in response to the 06/15/12, incident. The administrator stated, "Allegation of sexual abuse." The DON was asked what the facility policy and procedure were for allegations of abuse. She stated, "Protect the residents, investigate and report criminal acts to the police and notify the health department within 24 hours." She was asked if the policy was followed. She stated, "No, the policy was not followed." She was asked when the facility incident report had been filled out. The administrator stated on 06/19/12 (four days after the incident). The administrator was asked who was responsible for screening new admissions and to ensure it was reported to the proper authorities. The administrator stated, "I do all the screenings myself and No, they were not. I take full responsibility for it."

On 06/29/12, an immediate jeopardy was determined to exist in regard to the facility's failure to thoroughly investigate allegations of resident to resident sexual abuse; act upon findings, report the incident to the local law enforcement and the Oklahoma State Department of Health. At 2:10 p.m. the Oklahoma State Department of Health confirmed the existence of the immediate jeopardy situation. At 2:29 p.m., the ADM and DON were informed an immediate jeopardy situation existed. On 06/29/12 at 5:20 p.m., an acceptable plan of removal was provided by the ADM. The plan of removal was as followed: "Staff education on abuse policy provided to all staff with focus on protecting residents from harm, investigating allegations of abuse, determining allegations of abuse, reporting allegations of abuse to appropriate agencies and following abuse policy. Completed 06/30/2012 @ 0900. All residents will be screened for inappropriate sexual behaviors, which included any history of behaviors and any precursors that may indicate potential for development of behaviors. Completed 6/30/12 @ 0900 screens completed by LPN's and RN's. Any resident identified with inappropriate sexual behaviors or patterns will be care planned. Completed 6/30/12 @ 0900 by LPN's and RN. Behavior and medication management is provided monthly and PRN by psychologist. Psych certified RN will see identified residents weekly for additional management of behaviors. A quality assurance sub-committee has been established to monitor compliance with facility abuse policy which includes but is not limited to protections of residents, investigations of any allegations, reporting to appropriate agencies including law enforcement , following policy. Sub-committee will meet weekly and review all incidents, allegations of misconduct and any rumors. Sub-committee will provide further training at least quarterly. Ensure abuse policy training with new employees completed with orientation. Completed 6/29/12 @ 3:45. A pre-screening evaluation will be completed prior to all admissions and will include review of : H&P, DOC reports, sex offender registry, medication review, and current caregivers and pre-admission evaluation. Started 6/29/12 and ongoing. Protection of the resident when abuse is alleged or actual will prevent harm to the resident as well as all residents. Protective actions will include but not limited to: Immediate suspension of accused employee with termination pending investigation, removal of resident accused of causing harm with 1 on 1 monitoring during investigation, limitation of care plan to prevent further harm and protect all residents, involvement of law enforcement if criminal act." On 07/05/12 at 6:30 p.m., after reviewing all in-services, care plan updates, and interviews with staff, the ADM was informed the immediacy had been lifted at 11:00 p.m. on 07/03/12, after all in-services had been completed. The deficient practice remained at a scope of actual harm at a pattern, until the facility is able to ensure a system is in place to prevent the deficient practice from reoccurring. Based on record review and interview, it was determined the facility failed to thoroughly investigate resident to resident sexual abuse involving resident #1 and resident #6, act upon investigative findings, notify the local law enforcement and report an allegation of sexual abuse to the Oklahoma State Department of Health for one of three abuse investigations reviewed. The DON identified two additional allegations of sexual abuse in the past six months. This had the potential to affect 114 of 114 residents residing in the facility. Findings: A facility policy documented, "All occurrences of abuse, neglect, mistreatment, injuries of an unknown source and theft or misappropriation of resident property will be analyzed by the quality assessment and assurance committee to determine if a system changes need to be made... The quality assessment and assurance committee will review all reports during their regularly scheduled meetings." "Abuse means "the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to obtain or maintain physical harm, pain or mental anguish...sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault." A facility form titled, "Abuse Policy and Procedure," documented, "It is the policy of (facility) that the residents of this facility will be free of abuse, neglect, mistreatment...Incidents of abuse, neglect...will be reported immediately to the Oklahoma Department of Health, the appropriate State Board Registry, and ...In addition (facility) will implement a requirement that all reports of abuse have written interviews and findings...Initial reports will be made to the OSDH within 12 hours of the incident...An initial written report will be made within 5 working days...The final results of all investigations are reported...within five (5) working days of completion of the investigation." A facility form titled, "Preventing Resident Abuse" documented, "Our facility will not condone any form of resident abuse and will continually monitor our facility's...to assist in preventing resident abuse....Assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict or neglect...involving attending physicians and the Medical Director when findings of abuse have been determined." A facility form titled, "Administrative Policies and Procedures Resident Abuse, Neglect and Misappropriation of Property" documented, "when actions by a demented person to a resident constitutes inappropriate behavior, the facility will take steps to protect the resident from further incident according to the resident's plan of care...All employees of a nursing facility are mandated reporters of resident abuse...must report any and all incidents...licensed nurse should report his/her findings to the administrator and/or physician as soon as possible...and receive instructions for notification of the resident's responsible party." Resident #6 was admitted to the facility from another LTC facility with [DIAGNOSES REDACTED]. Nurses' notes from a previous facility dated 12/06/11, 12/07/11, 12/08/11, 12/18/11, 12/21/11 and 01/09/12, documented, "res cont on one on one monitoring this shift by staff member...no inappropriate behavior noted this shift." Facility 'Behavior Monitoring' forms' dated 01/12, 02/12 and 03/12, documented, "behavioral symptom... sexual inappropriate" A nurse's note dated 03/03/12, documented, "10:00 A female res. reported that this res.(#6) entered her bedroom & fondled her breast. The female resident told him to stop & she came to report incident to staff... DON, Dr and Son notified. Son reported that this resident has had this type of incident occur in the past." A quarterly assessment dated [DATE], documented the resident was severely impaired in cognition, able to make his needs known, was able to understand and be understood. The assessment further documented the resident was independent with all ADL's except required assistance with bathing. A care plan last updated 04/18/12, documented, "Res has DX of depression and takes [MEDICATION NAME], cont w POC. Goals, res will have no side effects of antidepressant use thru next review. Interventions, {arrow up} [MEDICATION NAME] to 30 mg po qd." The care plan was not developed to include interventions for the residents known sexual behaviors and sexual inappropriateness. A facility 'Behavior Monitoring' form dated 04/12 and 05/12, documented, "behavorial symptom... sexual inappropriate." Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. An "H & P" dated 02/14/12, documented, "...The patient is nonverbal secondary to [MEDICAL CONDITION] as as child..." An admission assessment dated [DATE] and a quarterly assessment dated [DATE], documented the resident had unclear speech, rarely understood others, rarely was understood by others, and was severely impaired in cognitive skills for daily decision making. The assessment also documented the resident was totally dependent on staff for transfers, dressing, eating, personal hygiene and bathing. The "Care Area Assessment Psychosocial Well-Being" dated 03/27/12, documented, "Diseases and Condition that may impede ability to interact with others: mental [MEDICAL CONDITION] documentation: {Resident) has DX TBI at a young age, MR, and mood disorder. She is unable to communicate..." The "Care Area Assessment Activities of Daily Living (ADLs) - Functional Status Worksheet" dated 03/27/12, documented, "{Resident) was admitted to facility from (Name deleted) hospital DX dysphagia, TBI, MR...She is unable to communicate needs and her vision is poor...." A care plan dated 04/02/12, documented, "Problem: (Resident) is dependent on staff for daily needs. She is non-verbal, except for screaming at times.... Problem: (Resident has DX of dysphagia, TBI, MR...She is unable to communicate needs...Goals: (Resident) will be free of injury..." An incident report dated 06/01/12, documented, "CNA called nurse to resident's room where we observed a large bruise too left side & hip area. ROM normal for resident 0 s/s of pain...steps to prevent recurrence: told staff to monitor closely..." A report to the OSDH dated 06/01/12, documented, "...relevant resident history: Res Dx...severe intellectual disability, dysphagia, TBI. Resi is non-verbal, and has decreased cognitive status R/T DX... corrective measures implemented to prevent recurrence: Staff inserviced to make sure alarms and floor mat in place in room beside bed and to monitor resident closely and frequently..." An "Incident/Accident Report" dated 06/19/12, documented, "Person involved: (Res #6/Res #1) date of incident/accident: 06/15/12, time of incident 1730 (5:30 p.m.)...location of incident: Rm 410...describe what exactly happened: Res (#6) seen exiting Rm 410. Res (#1) had diaper on but pulled to side. (#1) was quiet, not upset acting. (#6) pants were up & zipped..." A signed statement dated 06/15/12, from LPN #5 documented, "At around 1730 (5:30 p.m.) the CMA called out for (LPN #1) from (Res #1) Rm. I went down to (Res #1) Rm and observed her on her R-side on the soft safety mat beside her bed. Her clothes-gown and diaper were on her. On her bed we observed a wet spot toward the middle-it was a clearish mucous like substance, the sheet was removed and the mattress underneath it was also wet in the same area..." A signed statement dated 06/15/12, from CNA #5 documented, "The CMA (#1) was on her way down to room [ROOM NUMBER]...and she seen (Res #6) (the resident) come out her room. As she was entering she called down for the nurse (LPN #1) and said (Res #1) on the floor. She put herself on the floor as soon as (CMA #1) entered the room. So myself..and the nurse (LPN #1) and other co-worker were checking her out. Her clothes was still on & untapped on one side...in the process of getting her onto her bed I...had grabbed her pad to straighten it and I had touched some slimy sticky stuff as I leaned on her bed it was on her pad. And it was not thickened liquids..." A signed statement dated 06/15/12, from CMA #1 documented, "I went down the hall to (Res #1) room and (Res #6) was coming out of her room. As I entered her depends was pulled to the side she raised up and put her head down on her mat and her knees and there was what looked like semen on the pad..." A signed statement dated 06/15/12, from LPN #1 documented, "CMA...called this nurse to room [ROOM NUMBER] where she said she saw resident (#6) come out of room where we witnessed resident (#1) lying on her R side on matt (sp). Her brief was half on and pulled to the side...I assessed her injury there were none. CNA (#5) placed her hand on bed to fix pad. When she felt semen on her hand. I moved pad & sheet more to discover more...I then went to resident (#6) room and asked him what he was doing in that room. He stated no and thank you mam. Called DON...who stated to move resident to another room for her safety which we did and to monitor (Res #6)." A note dated 06/19/12 at 2:00 p.m., from CMA #1 documented, "Interviewed employee re incident. CMA stated (Res #1) was in bed sitting up rolling onto mat on floor. She was not yelling or upset/anxious. She stated she did not know if anything happened...stated that (Resident) diaper was pulled to side & there was a substance on the pad that she felt looked like semen (wet & sticky)." The note was signed by the administrator and DON. A note dated 06/19/12, from LPN #1 documented, "Stated that CMA reported to her that (Res #6) was leaving (Res #1) room. Questioned charge nurse re semen, stated there was a clear sticky substance on the pad." The note was signed by the administrator and DON. A note dated 06/20/12, documented, "(Res #6) was transferred to 500 hall, locked unit d/t increased wandering and increased supervision." There was no documentation in the resident's clinical record regarding the sexual abuse. Facility staff were asked to provide nurses' notes which included the day of the incident. None were provided prior to the completion of this investigation. The incident report and signed statements did not document resident #1's and resident #6's family and physician had been notified of the 06/15/12, incident. There was no documentation to indicate the OSDH and local law enforcement had been notified of the sexual abuse. The nurses' notes in the clinical for resident #6 ended on 06/13/12 and resumed again on 06/19/12. When surveyors asked for the missing notes and documentation none were provided before the end of the investigation. A nurse's note dated 06/22/12, for resident #6 documented, "1:00 p.m., received T.O. for stat labs for psych admission to (local psych hospital), r/t sexual hx, 0 sexual bx noted or observed this shift wctm." A nurse's note dated 06/22/12, on the 2-10 shift for resident #6 documented, "faxed all info to (local psych hospital) (face sheet, MAR, H&P, labs) called other facility 3 x's - 0 call returned this shift. A nurse's note dated 06/24/12 at 6:00 p.m., for resident #6 documented, "Res has had 0 neg bx nstead (sic) this shift, res brother informed this CN that res discharging in AM to home after informed of pending placement for psych eval at (local psych hospital) D.O.N. informed." The resident care plan did not address the resident's history and previous incidents of being sexually inappropriate. An interview was conducted on 06/29/12 at 12:44 p.m., with the DON and administrator. They were asked if there was any documentation in either residents clinical record for the sexual abuse incident that occurred on 06/15/12. The DON and administrator stated it would be in the nurses' notes. They were asked what the inappropriate behaviors were for resident #6. The DON stated, 'There are none unless they are charted." They were asked about the behavior monitoring sheets and additional documentation that indicated the resident was sexually inappropriate. The administrator stated, "It was reported that he had been masturbating more." She then indicated there had been an incident in March where the resident grabbed another resident's breast. They were asked if the care plan was developed to address the resident's inappropriate sexual behavior. The DON stated, "No, it's not on the care plan." They were asked if the inappropriate behavior should be addressed on the care plan. The DON stated, "Yes, so staff will know what to do." They were asked if the incident was reported to the local law enforcement and to the OSDH. The administrator and DON stated, "It wasn't reported." The administrator then stated, "The police should have been notified and a rape kit should have been done." They were asked who was responsible for ensuring a complete and through investigation was completed. The administrator stated, 'The charge nurse and then the DON and myself." They were asked what type of investigation occurred in response to the 06/15/12, incident. The administrator stated, "Allegation of sexual abuse." The DON was asked what the facility policy and procedure were for allegations of abuse. She stated, "Protect the residents, investigate and report criminal acts to the police and notify the health department within 24 hours." She was asked if the policy was followed. She stated, "No, the policy was not followed." She was asked when the facility incident report had been filled out. The administrator stated on 06/19/12 (four days after the incident). The administrator was asked who was responsible for screening new admissions and to ensure it was reported to the proper authorities. The administrator stated, "I do all the screenings myself and No, they were not. I take full responsibility for it."

On 06/29/12, an immediate jeopardy was determined to exist in regard to the facility's failure to implement the facility abuse policy to protect an incapacitated female resident from a resident with known sexual behaviors; thoroughly investigate and report allegations of resident to resident sexual abuse, report criminal activity to the local law enforcement, and report the abuse to the Oklahoma State Department of Health. At 2:10 p.m. the Oklahoma State Department of Health confirmed the existence of the immediate jeopardy situation. At 2:29 p.m., the ADM and DON were informed an immediate jeopardy situation existed. On 06/29/12 at 5:20 p.m., an acceptable plan of removal was provided by the administrator. The plan of removal was as followed: "Staff education on abuse policy provided to all staff with focus on protecting residents from harm, investigating allegations of abuse, determining allegations of abuse, reporting allegations of abuse to appropriate agencies and following abuse policy. Completed 06/30/2012 @ 0900 All residents will be screened for inappropriate sexual behaviors, which included any history of behaviors and any precursors that may indicate potential for development of behaviors. Completed 6/30/12 @ 0900 Screens completed by LPN's and RN's. Any resident identified with inappropriate sexual behaviors or patterns will be care planned. Completed 6/30/12 @ 0900 by LPN's and RN. Behavior and medication management is provided monthly and prn by psychologist. Psych certified RN will see identified residents weekly for additional management of behaviors. A quality assurance sub-committee has been established to monitor compliance with facility abuse policy which includes but is not limited to protections of residents, investigations of any allegations, reporting to appropriate agencies including law enforcement, following policy. Sub-committee will meet weekly and review al incidents, allegations of misconduct and any rumors. Sub-committee will provide further training at least quarterly. Ensure abuse policy training with new employees completed with orientation. Completed 6/29/12 @ 3:45. A pre-screening evaluation will be completed prior to all admissions and will include review of : H&P, DOC reports, sex offender registry, medication review, and current caregivers and pre-admission evaluation. Started 2/29/12 and ongoing. Protection of the resident when abuse is alleged or actual will prevent harm to the resident as well as all residents. Protective actions will include but not limited to: Immediate suspension of accused employee with termination pending investigation, removal of resident accused of causing harm with 1 on 1 monitoring during investigation, limitation of care plan to prevent further harm and protect all residents, involvement of law enforcement if criminal act." On 07/05/12 at 6:30 p.m., after reviewing all inservices, care plan updates, and interviews with staff, the administrator was informed the immediacy had been lifted at 11:00 p.m. on 07/03/12, after all inservices' had been completed. The deficient practice remained at a scope of actual harm at a pattern, until the facility is able to ensure a system is in place to prevent the deficient practice from recurring. Based on record review and interviews, it was determined the facility failed to implement their abuse policy and procedure for protecting residents from sexual abuse, completed thorough investigation, report to the Oklahoma State Department of Health, report to local law enforcement criminal activity for one of three abuse investigations reviewed. This had the potential to affect 114 of 114 residents residing in the facility. The DON identified two additional allegations of sexual abuse in the past six months. Findings: A facility policy documented, "All occurrences of abuse, neglect, mistreatment, injuries of an unknown source and theft or misappropriation of resident property will be analyzed by the quality assessment and assurance committee to determine if a system changes need to be made... The quality assessment and assurance committee will review all reports during their regularly scheduled meetings." "Abuse means "the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to obtain or maintain physical harm, pain or mental anguish...sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault." A facility form titled, "Abuse Policy and Procedure," documented, "It is the policy of (facility) that the residents of this facility will be free of abuse, neglect, mistreatment...Incidents of abuse, neglect...will be reported immediately to the Oklahoma Department of Health, the appropriate State Board Registry, and ...In addition (facility) will implement a requirement that all reports of abuse have written interviews and findings...Initial reports will be made to the OSDH within 12 hours of the incident...An initial written report will be made within 5 working days...The final results of all investigations are reported...within five (5) working days of completion of the investigation." A facility form titled, "Preventing Resident Abuse" documented, "Our facility will not condone any form of resident abuse and will continually monitor our facility's...to assist in preventing resident abuse....Assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict or neglect...involving attending physicians and the Medical Director when findings of abuse have been determined." A facility form titled, "Administrative Policies and Procedures Resident Abuse, Neglect and Misappropriation of Property" documented, "when actions by a demented person to a resident constitutes inappropriate behavior, the facility will take steps to protect the resident from further incident according to the resident's plan of care...All employees of a nursing facility are mandated reporters of resident abuse...must report any and all incidents...licensed nurse should report his/her findings to the administrator and/or physician as soon as possible...and receive instructions for notification of the resident's responsible party." Resident #6 was admitted to the facility from another LTC facility with [DIAGNOSES REDACTED]. Nurses' notes from a previous facility dated 12/06/11, 12/07/11, 12/08/11, 12/18/11, 12/21/11 and 01/09/12, documented, "res cont on one on one monitoring this shift by staff member...no inappropriate behavior noted this shift." Facility 'Behavior Monitoring' forms' dated 01/12, 02/12 and 03/12, documented, "behavioral symptom... sexual inappropriate" A nurse's note dated 03/03/12, documented, "10:00 A female res. reported that this res.(#6) entered her bedroom & fondled her breast. The female resident told him to stop & she came to report incident to staff... DON, Dr and Son notified. Son reported that this resident has had this type of incident occur in the past." A quarterly assessment dated [DATE], documented the resident was severely impaired in cognition, able to make his needs known, was able to understand and be understood. The assessment further documented the resident was independent with all ADL's except required assistance with bathing. A care plan last updated 04/18/12, documented, "Res has DX of depression and takes [MEDICATION NAME], cont w POC. Goals, res will have no side effects of antidepressant use thru next review. Interventions, {arrow up} [MEDICATION NAME] to 30 mg po qd." The care plan was not developed to include interventions for the residents known sexual behaviors and sexual inappropriateness. A facility 'Behavior Monitoring' form dated 04/12 and 05/12, documented, "behavorial symptom... sexual inappropriate." Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. An "H & P" dated 02/14/12, documented, "...The patient is nonverbal secondary to [MEDICAL CONDITION] as as child..." An admission assessment dated [DATE] and a quarterly assessment dated [DATE], documented the resident had unclear speech, rarely understood others, rarely was understood by others, and was severely impaired in cognitive skills for daily decision making. The assessment also documented the resident was totally dependent on staff for transfers, dressing, eating, personal hygiene and bathing. The "Care Area Assessment Psychosocial Well-Being" dated 03/27/12, documented, "Diseases and Condition that may impede ability to interact with others: mental [MEDICAL CONDITION] documentation: {Resident) has DX TBI at a young age, MR, and mood disorder. She is unable to communicate..." The "Care Area Assessment Activities of Daily Living (ADLs) - Functional Status Worksheet" dated 03/27/12, documented, "{Resident) was admitted to facility from (Name deleted) hospital DX dysphagia, TBI, MR...She is unable to communicate needs and her vision is poor...." A care plan dated 04/02/12, documented, "Problem: (Resident) is dependent on staff for daily needs. She is non-verbal, except for screaming at times.... Problem: (Resident has DX of dysphagia, TBI, MR...She is unable to communicate needs...Goals: (Resident) will be free of injury..." An incident report dated 06/01/12, documented, "CNA called nurse to resident's room where we observed a large bruise too left side & hip area. ROM normal for resident 0 s/s of pain...steps to prevent recurrence: told staff to monitor closely..." A report to the OSDH dated 06/01/12, documented, "...relevant resident history: Res Dx...severe intellectual disability, dysphagia, TBI. Resi is non-verbal, and has decreased cognitive status R/T DX... corrective measures implemented to prevent recurrence: Staff inserviced to make sure alarms and floor mat in place in room beside bed and to monitor resident closely and frequently..." An "Incident/Accident Report" dated 06/19/12, documented, "Person involved: (Res #6/Res #1) date of incident/accident: 06/15/12, time of incident 1730 (5:30 p.m.)...location of incident: Rm 410...describe what exactly happened: Res (#6) seen exiting Rm 410. Res (#1) had diaper on but pulled to side. (#1) was quiet, not upset acting. (#6) pants were up & zipped..." A signed statement dated 06/15/12, from LPN #5 documented, "At around 1730 (5:30 p.m.) the CMA called out for (LPN #1) from (Res #1) Rm. I went down to (Res #1) Rm and observed her on her R-side on the soft safety mat beside her bed. Her clothes-gown and diaper were on her. On her bed we observed a wet spot toward the middle-it was a clearish mucous like substance, the sheet was removed and the mattress underneath it was also wet in the same area..." A signed statement dated 06/15/12, from CNA #5 documented, "The CMA (#1) was on her way down to room [ROOM NUMBER]...and she seen (Res #6) (the resident) come out her room. As she was entering she called down for the nurse (LPN #1) and said (Res #1) on the floor. She put herself on the floor as soon as (CMA #1) entered the room. So myself..and the nurse (LPN #1) and other co-worker were checking her out. Her clothes was still on & untapped on one side...in the process of getting her onto her bed I...had grabbed her pad to straighten it and I had touched some slimy sticky stuff as I leaned on her bed it was on her pad. And it was not thickened liquids..." A signed statement dated 06/15/12, from CMA #1 documented, "I went down the hall to (Res #1) room and (Res #6) was coming out of her room. As I entered her depends was pulled to the side she raised up and put her head down on her mat and her knees and there was what looked like semen on the pad..." A signed statement dated 06/15/12, from LPN #1 documented, "CMA...called this nurse to room [ROOM NUMBER] where she said she saw resident (#6) come out of room where we witnessed resident (#1) lying on her R side on matt (sp). Her brief was half on and pulled to the side...I assessed her injury there were none. CNA (#5) placed her hand on bed to fix pad. When she felt semen on her hand. I moved pad & sheet more to discover more...I then went to resident (#6) room and asked him what he was doing in that room. He stated no and thank you mam. Called DON...who stated to move resident to another room for her safety which we did and to monitor (Res #6)." A note dated 06/19/12 at 2:00 p.m., from CMA #1 documented, "Interviewed employee re incident. CMA stated (Res #1) was in bed sitting up rolling onto mat on floor. She was not yelling or upset/anxious. She stated she did not know if anything happened...stated that (Resident) diaper was pulled to side & there was a substance on the pad that she felt looked like semen (wet & sticky)." The note was signed by the administrator and DON. A note dated 06/19/12, from LPN #1 documented, "Stated that CMA reported to her that (Res #6) was leaving (Res #1) room. Questioned charge nurse re semen, stated there was a clear sticky substance on the pad." The note was signed by the administrator and DON. A note dated 06/20/12, documented, "(Res #6) was transferred to 500 hall, locked unit d/t increased wandering and increased supervision." There was no documentation in the resident's clinical record regarding the sexual abuse. Facility staff were asked to provide nurses' notes which included the day of the incident. None were provided prior to the completion of this investigation. The incident report and signed statements did not document resident #1's and resident #6's family and physician had been notified of the 06/15/12, incident. There was no documentation to indicate the OSDH and local law enforcement had been notified of the sexual abuse. The nurses' notes in the clinical for resident #6 ended on 06/13/12 and resumed again on 06/19/12. When surveyors asked for the missing notes and documentation none were provided before the end of the investigation. A nurse's note dated 06/22/12, for resident #6 documented, "1:00 p.m., received T.O. for stat labs for psych admission to (local psych hospital), r/t sexual hx, 0 sexual bx noted or observed this shift wctm." A nurse's note dated 06/22/12, on the 2-10 shift for resident #6 documented, "faxed all info to (local psych hospital) (face sheet, MAR, H&P, labs) called other facility 3 x's - 0 call returned this shift. A nurse's note dated 06/24/12 at 6:00 p.m., for resident #6 documented, "Res has had 0 neg bx nstead (sic) this shift, res brother informed this CN that res discharging in AM to home after informed of pending placement for psych eval at (local psych hospital) D.O.N. informed." The resident care plan did not address the resident's history and previous incidents of being sexually inappropriate. An interview was conducted on 06/29/12 at 12:44 p.m., with the DON and administrator. They were asked if there was any documentation in either residents clinical record for the sexual abuse incident that occurred on 06/15/12. The DON and administrator stated it would be in the nurses' notes. They were asked what the inappropriate behaviors were for resident #6. The DON stated, 'There are none unless they are charted." They were asked about the behavior monitoring sheets and additional documentation that indicated the resident was sexually inappropriate. The administrator stated, "It was reported that he had been masturbating more." She then indicated there had been an incident in March where the resident grabbed another resident's breast. They were asked if the care plan was developed to address the resident's inappropriate sexual behavior. The DON stated, "No, it's not on the care plan." They were asked if the inappropriate behavior should be addressed on the care plan. The DON stated, "Yes, so staff will know what to do." They were asked if the incident was reported to the local law enforcement and to the OSDH. The administrator and DON stated, "It wasn't reported." The administrator then stated, "The police should have been notified and a rape kit should have been done." They were asked who was responsible for ensuring a complete and through investigation was completed. The administrator stated, 'The charge nurse and then the DON and myself." They were asked what type of investigation occurred in response to the 06/15/12, incident. The administrator stated, "Allegation of sexual abuse." The DON was asked what the facility policy and procedure were for allegations of abuse. She stated, "Protect the residents, investigate and report criminal acts to the police and notify the health department within 24 hours." She was asked if the policy was followed. She stated, "No, the policy was not followed." She was asked when the facility incident report had been filled out. The administrator stated on 06/19/12 (four days after the incident). The administrator was asked who was responsible for screening new admissions and to ensure it was reported to the proper authorities. The administrator stated, "I do all the screenings myself and No, they were not. I take full responsibility for it." The DON was asked what the facility policy and procedure was for allegations of abuse and investigation of abuse. She stated, "Protect the residents; investigate and report criminal acts to the police and notify the health department within 24 hours." She was asked if the policy was followed. She stated, "No, the policy was not followed."

On 07/02/12, an immediate jeopardy was determined to exist in regard to the facility's failure to have supervision to prevent injuries caused by resident to resident altercations between cognitively impaired residents residing in a secured unit. At 2:20 p.m., the Oklahoma State Department Of Health confirmed the existence of the immediate jeopardy situation. At 2:40 p.m., the ADM and DON were informed an immediate jeopardy situation existed. On 07/02/12 at 4:38 p.m., an acceptable plan of removal was provided by the ADM. "The two identified residents have been placed on 1 on 1 pending transfer to impatient psych facility. Two extra employees will be staffed to accommodate the 1 on 1 until transfer to inpatient psych facility. 7/2/12 @ 1540. Secured unit residents have been evaluated for resident to resident altercations. Behavior risk assessments have been completed. Actual and potential behaviors have been identified using behavior risk assessment. Behavior modification plans have been developed and implemented with care plan. 7/2/12 @ 2200. Preadmission behavioral screening will be completed to identify actual and history of behaviors. To be completed prior to admission starting 7/2/12. Resident to resident abuse policy has been developed and implemented. 7/2/12 @ 1550. Special care unit staff in serviced on resident to resident abuse policy. 7/2/12@2330 QA sub-committee will be reviewing all incident reports and allegations of Resident to Resident altercations/abuse weekly. QA sub-committee developed 6/29/12 @ 1545." On 07/05/12 at 6:30 p.m., after reviewing all inservices, care plan updates, and interviews with staff, the ADM was informed the immediacy had been lifted at 11:00 p.m. on 07/03/12, after all inservices had been completed. The deficient practice remained at a scope of actual harm at a pattern, until the facility is able to ensure a system is in place to prevent the deficient practice from recurring. Based on observation, record review and interviews, it was determined the facility: A. failed to ensure residents were free of resident to resident altercations for two (#3 and #8) of three sampled residents residing in the facility secured unit and, B. failed to monitor a resident to prevent reoccurrence of falls and or accidents for one (#2) of three sampled residents who resided in a secured unit. This had the potential to affect 28 Residents who Resided in the secured unit. Findings: A. Resident to resident altercations on the secured unit: 1. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An incident report dated 02/18/12, documented, "Incident date 02/18/12, incident time 0330 (3:30 a.m.) incident location 503 B, event: Res to res event; injury: 0 marks but c/o back pain, initial actions: Resident education...describe what happened and assessment and intervention: Res in male res room & took coat & clothes. Male res. woke up & yelled at res to get out but refused. Male res hitting her on the back (arrow up). CNA (Name deleted) in room and able to remove (Res #3) out of room... Notes: Staff educated to monitor residents closely and redirect to their own rooms." The resident's identified on the incident report were resident #3 and #9. The daily Staffing Schedule for the 11:00 p.m. through 7:00 a.m. shift, the shift in which the incident occurred, documented two certified nurse aides were working in the secured unit at the time of the incident. It also documented there was one charge nurse floating between halls 100, 200 and 500. An incident report dated 02/22/12, documented, "Incident date 02//22/12, incident time 2230 (10:30 p.m.) incident location hallway, event: Res to res event; injury: no injury, initial actions: staff education and Resident education...describe what happened staff member witnessed (Res #3) and another resident (#8) becoming physical /c punching to the arms and abdomen, staff redirected (Res) stated 0 pain or discomfort will cont. to monitor..." The daily Staffing Schedule for the 3:00 p.m. through 11:00 p.m. shift, the shift in which the incident occurred, documented two certified nurse aides were working in the secured unit at the time of the incident. There also was one certified medication aide and one charge nurse who were covering halls 100, 200 and 500. An initial assessment dated [DATE], documented the resident had short and long term memory problems, was severely impaired in cognitive skills for daily decision making and was delusional. The assessment documented the resident as independent with transfers, ambulation and eating. The assessment also documented she had physical and verbal behavior symptoms directed toward others. These behavior symptoms put other residents at risk for physical injury, intruded on the privacy of others and disrupted care. The care area assessment summary dated 02/29/12, documented the resident's behavioral symptoms would be care planned. The care area assessment worksheet dated 02/29/12, documented, "Analysis of findings: chart review/admit notes (Resident) has a dx of schizophrenia-bipolar-she is awake most of shift going in and out of other residents rooms...will care plan for less than 3 episodes of behaviors per week through next review... (Res) has DX of dementia w/ behaviors, schizophrenia, bipolar. She is hard to redirect. She is orientated to self. She is delusion in speech. At risk for poor communication. Will care plan...She does not sit still for long..." The assessment did not address the resident wandered. A care plan dated 03/02/12, documented, "Problems: (Res) is a new admit to facility. She has DX of schizo, dementia, Alzh, Bipolar, HTN, DM, depression and psychosis. She is awake most of the night, going in and out of other Res rooms. She is at risk for further decline. Goals: (Res) will function within her current level and have no further decline in cog status... Interventions: Use cues and reminders as needed for day to day activities. Reorient res to room as needed. Administer medications as ordered. Psych RN svs for assessment and observation. Therapeutic teaching as needed. Explain all procedures using simple commands, pleasant tone and repeat as necessary... Problem...she is hard to redirect. She is orientated to self. She is delusional in speech. At risk for poor communication and not getting needs met. Goal: staff to anticipate thru next review. Interventions: Use short phrases, speak clearly, repeat if necessary. monitor resident for changes in LOC, gait, balance. Redirect, reorient as needed. Ask short questions and allow ample time for (Res) to express any needs she may have..." The care plan did not address the resident's behaviors of physical and verbal altercations with other residents as indicated on the initial assessment. An incident report dated 04/08/12, documented, "Incident date 04/08/12, incident time 0620 (6:20 a.m.), describe what happened: envolved (sic) in a res to res confrontation, walked into his room struck him in the face leaving a small laceration above Lt eye...steps taken to prevent recurrence: Res encouraged to stay out of fell ow residents rooms. She verbalized understanding (wanders...)" A report sent to the Oklahoma State Department of Health for the incident documented, "Res (#3) was redirected by staff with success. Res was placed on Q 30 minute visual checks. Res was educated about behaviors and entering residents rooms. Verbalized understanding. Physician notified of behaviors, no new orders received at this time. Will continue to monitor. There had been no prior incidence of aggression between these two residents. Staff inserviced on keeping up with residents where abouts on the hall." The daily Staffing Schedule for the 11:00 p.m. through 7:00 a.m. shift, the shift in which the incident occurred, documented two certified nurse aides were working in the secured unit at the time of the incident. It also documented there was one charge nurse that was covering halls 100, 200 and 500. An incident report dated 04/09/12, documented, "Incident date 04/09/12, time of incident 2040 (8:40 p.m.), exact location of incident: dining room...Resident was attacked by another resident /c laceration to her (L) side face..." There were no documented steps or interventions on the incident report to prevent recurrence of the event. The residents identified in the incident report were resident #3 and resident #8. A report sent to the Oklahoma State Department of Health for the incident documented, "Resi (#8) counseled about appropriate behavior, verbalized understanding, resident placed on Q 30 minute visual checks. Staff informed to keep residents apart. There have been no prior history of aggression between these two residents. Will continue to monitor behavior." There was no documentation to indicate the resident had the 30 minute visual checks as implemented after the incident. The daily Staffing Schedule for the 3:00 p.m. through 11:00 p.m. shift, the shift in which the incident occurred, documented two certified nurse aides were working in the secured unit at the time of the incident. It also documented there was one charge nurse that was covering halls 100, 200, and 500. An incident report dated 04/20/12, documented, "Incident date 04/20/12, time of incident 2 a.m., exact location (not documented)...what happened: called to room by CNA who reports resident on floor having a verbal & physical confrontation /c another resident...steps taken to prevent recurrence: bed alarm..." An incident report for resident #10 documented, "Perhaps a bed alarm to alert staff when shes (arrow up) roaming..." The residents on the incident report were resident #3 and #10. A report sent to the Oklahoma State Department of Health for the incident documented, "Res (#3) entered (Res #10) room during the night and began having a physical, verbal confrontation with him. CN was called to the room where both residents were found in the floor continuing to have altercation. Residents were separated. Res (#3) was redirected out of (Res #10) room...(Res #10) was found to have a scratch on his cheek and neck area, and a bite mark on his LFA. First aid applies to scratches...Both residents deny injury to head....Resident (#3) has recently returned from an acute hospital stay and while there they DC'd most of her psych medications. Received order to send to HOPE unit for med eval and treat behaviors." The daily Staffing Schedule for the 11:00 p.m. through 7:00 a.m. shift, the shift in which the incident occurred, documented two certified nurse aides were working in the secured unit at the time of the incident. It also documented there was one charge nurse that was covering halls 100, 200, and 500. A nurse's note dated 04/20/12, documented, "Spoke to Dr. (Name deleted) regarding resident behaviors and altercation. N.O. recvd to send to (Name deleted) for eval & treat." A care plan dated 04/30/12, did not address the resident's continual resident to resident altercations which had resulted in injury to themselves and others. A physician's telephone order dated 04/31/12, (sic) documented, "Send to (Name deleted) unit for eval & treat." A nurse's note dated 05/01/12, documented, "Resident returned to facility via facility mobile." A Psychiatric Nursing Brief Encounter, dated 05/03/12, documented, "Pt /c episodes of agitation & restlessness per nursing staff. Physically attacking...other residents, attempting elopement...Resident to be evaluated by facility psychiatrist at next visit scheduled next week." There was no documented verification the facility psychiatrist evaluated the resident the following week. A quarterly assessment dated [DATE], documented no changes in the resident's condition since the initial assessment. There were no changes in the resident care plan to address the continual wandering into other resident's rooms. There was no care plan to address the continual resident to resident altercations which had resulted in injuries to self and others. An incident report dated 06/26/12, documented, "Date of incident: 06/26/12, time of incident: 1615 (4:15 p.m..), location of incident: Residents room 502...what happened: Res got into altercation /c another res (#8)...type of injury: abrasion, swelling, location of injurys (sp): left wrist and left eye...steps taken to prevent recurrence: staff instructed to give resi diversional activities & monitor her from wandering." The daily Staffing Schedule for the 3:00 p.m. through 11:00 p.m. shift, the shift in which the incident occurred, documented only two certified nurse aides were working in the secured unit at the time of the incident. An incident report dated 06/27/12, documented, "Date of incident: 06/27/12, time of incident 2020 (8:20 p.m.); exact location t.v. area...what happened: Res got into altercation /c another res he approached (Res #3) & hit her in the face and arm. This resident hit other back...type of injury: hematoma, abrasion, swelling..." A report sent to the Oklahoma State Department of Health for the incident documented, "Resi (#8) approached res (#3) in the TV area and hit her in the face and arm. Resi (#3) hit Resi (#8) back. Altercation stopped by staff. Both residents were redirected away from each other....Resi (#3) was noted that her hand was swollen. Physician notified and X-ray was ordered..." The daily Staffing Schedule for the 3:00 p.m. through 11:00 p.m. shift, the shift in which the incident occurred, documented only two certified nurse aides were working in the secured unit. A physician's telephone order dated 06/27/12 at 7:00 a.m., "X-Ray of hands and (R) wrist." A final X-Ray report dated 06/27/12, documented, "Exam reason: pain from fight; Exam Type: Portable LT Wrist...findings:...small unfused calcification adjacent to the base of the first metacarpal which could be due to a small bony avulsion of indeterminate age...no other fractures to wrist..." A final X-Ray Report dated 06/27/12, documented, exam reason: pain from fight; Exam Type: Portable hand LT...findings: soft tissue swelling...." A care plan dated 06/27/12, documented, "Problems: (Resident) has dx of dementia w/ behav, schizo, and bipolar. She has been in several altercations with other Res. She is at risk for injuries... Goal: Resident will have no injuries thru next review from altercations with other Residents... Interventions: Approach calmly and unhurriedly. Speak in calm tone. Explain all procedures before performing. Attempt to assist (Res) in refocusing and redirecting when behaviors occur. If striking out, determine if (Res) is in pain or disc, report to nurse. Psych RN consult as needed. If in high stimuli area (activities), observe for increased agitation and remove to calmer area as able." There was a hand written note on the care plan dated 06/27/12, documenting, "Alt /c another Resident. No injuries." The resident had seven resident to resident altercations since being admitted to the facility on [DATE]. Two altercations caused injury to self and two caused injury to other residents. Prior to the 06/27/12, there had been no care plan for the resident to resident altercations since the resident had been admitted on [DATE]. 2. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE], documented the resident was able to understand others and be understood by others, was severely impaired with cognitive skills in daily decision making, had short and long term memory problems, exhibited physical behavioral symptoms toward others, and was independent with all transfers and ambulation. An incident report dated 02/05/12 at 6:30 p.m., documented, "...Incident location room 502; event: unobserved res to res event; location: Resident room; initial actions: Resident education, staff intervention...what happened: Res observed another male res lying his bed in room. Res proceeded to punch other male res in face, inflicting minor injury to other male res. 0 injury noted to res, staff intervention required 1:1 provided...Notes: educated res to not touch another res physically. Ordered psych eval." An incident report for resident #11, the other resident, documented he received a 0.2 cm laceration to the nose, left check and right side of his face. There was no documentation resident #8 was provided 1:1 staff after the incident with resident #11. The daily Staffing Schedule for the 3:00 p.m. through 11:00 p.m. shift, the shift in which the incident occurred, documented two certified nurse aides were working in the secured unit at the time of the incident. One charge nurse was floating between halls 100, 200 and 500. A care plan dated 02/06/12, documented, "Problem: (Res #8) has had several altercations with another resident since last review at risk for injuries from altercations. Goal: Will have no injuries thru next review. Will not have any episodes of striking other residents thru next review. Interventions: Approach (Res #8) calmly and unhurriedly. Speak in calm tone. Explain all procedures before performing. Attempt to assist (Res) in refocusing when behavior occurs. If striking out-ask if in pain. Report to nurse. 1:1 counseling to determine rational for feelings and behavior. redirect inappropriate behavior. Psych consult if ordered." An incident report dated 02/14/12 at 9:30 a.m., for resident #8 and resident #11 documented each resident received an injury during an altercation. Resident #11 sustained a cut below the left eye and resident #8 sustained a black eye. The notes documented resident #8 was educated to not touch another resident and was being referred for a psychological evaluation. Staff was educated to continue and redirect the residents. An incident report dated 02/17/12 at 8:30 p.m., for resident #8 and #12 documented resident #8 found his roommate in his bed, became combative and scratched the roommate on the right side of neck. Under the notes section on the incident reports the following intervention to prevent recurrence of event was documented, "Resident (#8) encouraged not to touch another resident physically. Staff educated to monitor residents to make sure they are not getting in other residents bed." On the incident report for resident #12 the steps or interventions were documented as, "Educated staff to monitor and cont redirect resident to his room/bed." The daily Staffing Schedule for the 3:00 p.m. through 11:00 p.m. shift, the shift in which the incident occurred, documented two certified nurse aides were working in the secured unit at the time of the incident. One certified medication aide and one charge nurse were floating between halls 100, 200 and 500. An incident report dated 02/22/12, documented, "Incident date 02//22/12, incident time 2230 (10:30 p.m.) incident location hallway, event: Res to res event; injury: no injury, initial actions: staff education and resident education...describe what happened staff member witnessed (Res #3) and another resident (#8) becoming physical /c punching to the arms and abdomen, staff redirected (Res) stated 0 pain or discomfort will cont. to monitor..." The daily Staffing Schedule for the 3:00 p.m. through 11:00 p.m. shift, the shift in which the incident occurred, documented two certified nurse aides were working in the secured unit at the time of the incident. One certified medication aide and one charge nurse were floating between halls 100, 200 and 500. An incident report dated 02/23/12, documented, "Incident date 02/23/12, Incident time: 1800 (6:00 p.m.); incident location: lobby; residents involved (#8 and #13); event: Res to res event; injury: bruise, swollen jaw (#8) initial actions: staff education...what happened: Both residents standing in lobby (#13) then started punching (#8) in the face and trunk. (Res #8) also punched (#13) in the trunk. This nurse redirected residents by walking (#8) to his room. Notes: (Res #13) will be sent out for psychological evaluation. Neuro checks were initiated on (Res #8)." A report sent to the Oklahoma State Department of Health for the incident documented, "(Res #8) and (Res #13) was observed in a physical alteration. Upon nursing assessment there was a bruising to (Res #8) and swelling to his jaw area. (Res #13) has swelling to his right hand...Residents were separated initially. An ice pack was applied to (#8) jaw area and an order for [REDACTED]. A telephone order dated 02/23/12, documented, "X ray to cheek" There was no documentation in the clinical record the facility obtained the x-ray as ordered on [DATE]. The resident had four resident to resident altercations after the care plan dated 02/06/12, which resulted in injury to themselves or others. The care plan was not updated after the resident to resident altercations to prevent further occurrences. An annual assessment dated [DATE], documented the resident was able to understand others and be understood by others, was severely impaired with cognitive skills in daily decision making, did not exhibit physical or verbal behaviors towards others and did not wander. The assessment documented the resident was independent with transfers and ambulating. The care area assessment summary dated 04/29/12, did not document the resident's behavior symptoms of resident to resident altercations would be care planned. A care plan dated 04/30/12, documented, "Problem: (Res #8) has had several altercations with another resident since last review at risk for injuries from altercations. Goal: Will have no injuries thru next review. Will not have any episodes of striking other Residents thru next review. Interventions: Approach (Res #8) calmly and unhurriedly. Speak in calm tone. Explain all procedures before performing. Attempt to assist (Resident) in refocusing when behavior occurs. If striking out-ask if in pain. Report to nurse. 1:1 counseling to determine rational for feelings and behavior. redirect inappropriate behavior. Psych consult if ordered. Have (Res) telephone his wife to calm down as needed." There was no documentation the facility was providing one on one counseling as documented on the resident's care plan. An incident report dated 05/01/12, documented, "Date of incident: 05/01/12, time of incident: 5:45 p.m., location of incident: common area; ...what happened: Another resident scratched (Res #8) on the (R) cheek according to (Res #8). Not witnessed by staff." There was no documentation the facility investigated the occurrence with the resident being scratched on the cheek. The daily Staffing Schedule for the 3:00 p.m. through 11:00 p.m. shift, the shift in which the incident occurred, documented one certified nurse aide and one certified medication aide was working on the secured unit. An incident report dated 06/19/12, documented, "Person involved (Res #8); Date of incident: 06/20/12, location of incident: Rm 501; ...what happened: Res (#8) struck another res (#6) in (R) arm on secured unit." No interventions were addressed to prevent recurrence. A report sent to the Oklahoma State Department of Health for the incident documented, "Staff instructed to re-direct Resi (#6) away from Resi (#8). An incident report dated 06/26/12, documented, "Date of incident: 06/26/12, time of incident: 1615 (4:15 p.m..), location of incident: Residents room 502...what happened: Res got into altercation /c another res (#3)...type of injury: none apparent...steps taken to prevent recurrence: staff instructed to redirect resi from other resi while in common areas." Resident #3 sustained swelling to the left hand and an abrasion to the left eye. The daily Staffing Schedule for the 3:00 p.m. through 11:00 p.m. shift, the shift in which the incident occurred, documented only two certified nurse aides were working in the secured unit at the time of the incident. There were three resident to resident altercations resulting in injury to themselves or others. The care plan was not updated to reflect changes in interventions to prevent the recurrence of further incidents. An incident report dated 06/27/12, documented, "Date of incident: 06/27/12, time of incident 2020 (8:20 p.m.); exact location t.v. area...what happened: Res got into altercation /c another res. this resident struck other resi in face & arm. The other resi hit this one back...type of injury none...steps to prevent recurrence: Resi placed 1:1 /c staff." There was no documentation the resident received 1:1 staffing after the incident that occurred on 06/27/12, between him and resident #3. A report sent to the Oklahoma State Department of Health for the incident documented, "Res (#8) approached Resi (#3) in the TV area and hit her in the face and arm. Resi (#3) hit Resi (#8) back. Altercation stopped by staff. Both residents were redirected away from each other....Resi (#3) was noted that her hand was swollen. Physician notified and X-ray was ordered..." Resident #3 sustained a hematoma, abrasion, and swelling. The site of the injury's were the left eye, left side of neck, right hand and forearm. A care plan entry dated 06/27/12, under interventions, documented, "Alt /c another Res-0 injuries." During the initial tour of the facility on 06/28/12 at 9:05 p.m., the number of direct care staff on the secured unit was observed. There were two certified nurse aides assigned to the hall and one charge nurse and certified medication aide who floated between halls 100, 200 and 500. Resident #8 was observed in his room unattended. No staff were present with him providing one on one supervision. At 11:10 p.m., the secured unit had two certified nurse aides assigned to the hall. Resident #3 was observed ambulating the hall and resident #8 remained in his room without one on one supervision. An interview was conducted on 07/02/12 at 11:15 a.m., with CNA #6. She was asked to describe resident #3. She stated, "She likes to wander in and out of other resident rooms and likes to get into things." She also stated the resident was combative toward others. She was asked if this caused any problems with other residents. She stated, "Yes." She then identified residents #8 and #10 as residents who have problems with her. She was asked to describe how those residents react to her. She stated, "(Res #8) gets physical with other residents." She was asked what the facility did to intervene and attempt to prevent recurrence of additional resident to resident altercations with resident #3 and resident #8. She stated, "We try to explain to the residents to not go into other rooms or hit other residents, but they don't understand." An interview was conducted on 07/02/12 at 11:30 a.m., with resident #8. The resident was in his room and no staff was present during the interview. He was asked how he felt about other residents coming in his room. He stated, "I don't like residents coming into my room." He was asked what was done when they entered his room. He stated, "I'll get them out myself." An interview was conducted on 07/02/12 at 1:45 p.m., with the DON regarding the resident to resident altercations between resident #3 and #8. She was asked where interventions were listed to prevent further recurrence of altercations. She stated, "The incident report has the interventions listed on them." She was asked why they listed them. She stated, "To put things in place to prevent it from happening again." She was asked about care plans developed with the interventions from the incident reports. She stated, "They should become part of the care plan." She was asked how they tried to prevent the recurrence of resident to resident altercations on the secured unit. She stated, "Try to catch them and redirect away." She then added, "Sometimes it works." She was asked about the cognitive ability of resident #3 to understand education of not wandering or hitting other residents. She stated, "She is not really cognitive at all." When asked about resident #8 she stated, "He isn't cognitively intact." She was asked if the residents' care plans had been developed with appropriate interventions to aid in the prevention of resident to resident altercations on the secured unit. She stated, "(Res #3 and #8) are not able to understand long term." She was asked how effective the intervention of "education' was for the two residents. She stated, "It's not very effective. They don't understand." She was asked about the lack of a care plan for resident #3 to address the resident to resident altercations and injuries she sustained and/or inflicted on other residents. She stated, "We wrote one after the last incident on 06/27/12." A request was made for documentation to verify resident #8 received 1:1 monitoring after the 02/05/12 and 06/27/12 incidents, one on one counseling and a psychological evaluation as indicated was to be done on the care plan. A request was also made for the x-ray results from 02/23/12. No documentation and/or x-ray results were provided. An interview was conducted on 07/03/12 at 9:50 a.m., with the DON. She was asked about the number of staff on the secured unit during the resident to resident altercations of resident #3 and resident #8. She stated, "I know there are only two (aides). I am aware of that. I know it's a problem." She then stated, "At times there is only one aide on the secured unit." She was asked how two aides would redirect residents, provide one on one when needed and provide care. She stated, "We need to increase the staff back there." B. Falls: Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. A nurse's note documented the following activity: "05/04/12, documented, " Resident was hit in the mouth by another resident after screaming in his ear. Family & physician notified. Mild swelling to oral cavity." "05/22/12 at 1130 am res up on secure unit. occ yelling out, when trying to do ADL's & asst, /c meals prep." "05/23/12 at 0800 am res. at dining table res cont. to have occ. yelling/growling." A care plan last updated 05/23/12, documented, Problems "(Res) has a dx of [DIAGNOSES REDACTED]/depression/ETOH dementia/HTN, he also has impaired judgment, concentration and attention-memory deficit with expressive aphagia. At risk for further decline. Cont /c POC. Goals Will be able to function within current level and have no further decline in cog status thru next review. Interventions explain all procedures using simple commands, give (Res) ample time to comprehend. offer fluids, observe for decline in cog status and notify MD." Additional nurses' notes documented the following activity: "06/03/12 at 8 pm, res sitting in chair at table and was observed sliding out over onto floor, did not hit head ROM WNL, no lacerations or bruising." "06/07/12 1130 am, res on secure unit, res placed in w/c due to becoming unsteady and leaning forward /c walker." "06/13/12 at 4:10 pm res found sitting on floor in his room, DON and physician notified." A facility incident report on the same date documented, 'steps taken to prevent recurrence' "staff inserviced on doing more frequent checks on resi. Res instructed to use CL for assistance." A 30 day medicare assessment dated [DATE], documented the resident was readmitted to the facility from a psychiatric hospital, was severely impaired in cognition and exhibited behaviors of screaming or disruptive sounds at least 4 to 6 days a week. The assessment further documented the resident required limited assistance with transfers, dressing, eating, personal hygiene and was steady when ambulating except when changing directions and the resident required a walker/wheelchair for mobility. Additional nurses' notes documented the following activity: "06/16/12 at 900 pm, called to room by staff resident in the floor in the D/R assessed /c {illegible entry}. "06/26/12 at 3

On 06/29/12, an immediate jeopardy was determined to exist due to the facility's failure to have an effective administration who implemented the abuse policy and procedure for investigating allegations of abuse; protected residents from abuse; and acted upon the findings of an abuse investigation. At 2:10 p.m., the Oklahoma State Department of Health confirmed the existence of the immediate jeopardy situation. At 2:29 p.m., the administrator and director of nurses were informed an immediate jeopardy situation existed. On 06/29/12 at 5:20 p.m., an acceptable plan of removal was provided by the administrator. The plan of removal was as followed: "Staff education on abuse policy provided to all staff with focus on protecting residents from harm, investigating allegations of abuse, determining allegations of abuse, reporting allegations of abuse to appropriate agencies and following abuse policy. Completed 06/30/2012 @ 0900 All residents will be screened for inappropriate sexual behaviors, which included any history of behaviors and any precursors that may indicate potential for development of behaviors. Completed 6/30/12 @ 0900 screens completed by LPN's and RN's. Any resident identified with inappropriate sexual behaviors or patterns will be care planned. Completed 6/30/12 @ 0900 by LPN's and RN. Behavior and medication management is provided monthly and PRN by psychologist. Psych certified RN will see identified residents weekly for additional management of behaviors. A quality assurance sub-committee has been established to monitor compliance with facility abuse policy which includes but is not limited to protection of residents, investigations of any allegations, reporting to appropriate agencies including law enforcement, following policy. Sub-committee will meet weekly and review all incidents, allegations of misconduct and any rumors. Sub-committee will provide further training at least quarterly. Ensure abuse policy training with new employees completed with orientation. Completed 6/29/12 @ 3:45. A pre-screening evaluation will be completed prior to all admissions and will include review of : H&P, DOC reports, sex offender registry, medication review, and current caregivers and pre-admission evaluation. Started 2/29/12 and ongoing. Protection of the resident when abuse is alleged or actual will prevent harm to the resident as well as all residents. Protective actions will include but not limited to: Immediate suspension of accused employee with termination pending investigation, removal of resident accused of causing harm with 1 on 1 monitoring during investigation, limitation of care plan to prevent further harm and protect all residents involvement of law enforcement if criminal act." On 07/02/12 at 2:20 p.m., the immediate jeopardy for administration continued to be in effect due to failure to have identified and implemented procedures identifying residents who were at risk for resident to resident altercations in the secured unit. The facility also failed to have an effective administration who identified and implemented facility interventions to prevent recurrence of injuries caused by resident to resident altercations between cognitively impaired residents residing in the secured unit. On 07/02/12 at 4:38 p.m., an acceptable plan of removal was provided by the administrator for supervision to prevent resident to resident altercations on the secured unit. On 07/05/12 at 6:30 p.m., after reviewing all in-services, care plan updates and interviews with staff, the ADM was informed the immediacy had been lifted at 11:00 p.m. on 07/03/12, after all in-services had been completed. The deficient practice remained at a scope of actual harm at a pattern, until the facility is able to ensure a system is in place for administration to prevent the deficient practice from reoccurring. Based on observation, record review and interviews, it was determined the facility failed to have an effective administration who ensured: a. their abuse policy and procedure was followed for acting upon the findings of an investigation, protected residents from abuse, protected residents from other resident abuse and reported resident to resident abuse to OSDH and local law enforcement agencies. b. interventions were in place to aide in the prevention of injuries and resident to resident altercations between cognitively impaired residents. c. there was sufficient staff on the secured unit to provide care and services to the residents. d. the quality assurance program identified and implemented corrective measures on quality of care issues. Findings: A facility form titled, "Administrator Policy Statement" documented, "A licensed administrator is responsible for the day-to-day functions of the facility. The administrator is responsible for, but not limited to:...Ensuring that each resident's right to fair and equitable treatment...Implementing established resident care policies..." 1. The administrator failed to ensure the abuse policy and procedure was implemented for protecting residents, criminal acts were reported to the local law enforcement, allegations of abuse were reported to the Oklahoma State Department of Health and a thorough and complete investigation was conducted. This resulted in an immediate jeopardy and actual harm. This had the potential to affect 114 of 114 residents. Refer to F-224, F-225, and F-226. 2. The administrator failed to ensure there was sufficient staff for supervision on the secured unit to protect residents from injuries resulting from resident to resident altercations. This resulted in an immediate jeopardy and actual harm. This had the potential to affect 28 residents who resided in the secured unit. Refer to F -323. 3. The administrator failed to ensure there was sufficient staff to meet the needs of the residents who resided in the secured unit. This resulted in an actual harm. Refer to F-353. 4. The administrator failed to ensure the quality assurance program identified and implemented corrective measures on quality of care issues. This resulted in an actual harm and had the potential to affect 114 of 114 residents. Refer to F-520.

Based on observation, record review and interview, it was determined the facility failed to: a. develop and implement preventive measures to reduce the number of resident to resident physical altercations with other cognitively impaired residents who resided in the secured unit for two (#3 and #8) of three sampled residents who resided in the secured unit. This resulted in an actual harm, and had the potential to affect the 28 residents who resided on the secured unit. b. develop a care plan with preventive measures to aid in the prevention of assault for one (#6) of one sampled residents with a known history of being sexually inappropriate. This resulted in actual harm. The DON identified seven residents residing in the facility with a known history of sexually inappropriate behavior. c. develop a care plan to address the placement in the secured unit for one (#2) of three sampled residents who resided in the secured unit. This had the potential to affect the 28 residents that resided in the secured unit. Findings: A facility policy titled, "Care Plan Guidelines" documented, "At the review date, if approaches are not yielding the expected results, the approaches must be changed to reflect ongoing effort to meet the goals." A facility policy titled, " Implementation of Care Plan Policy" documented, "...Updates to the care plan will be made at any change in resident status between the scheduled meeting dates..." 1. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An incident report dated 02/18/12, documented, "Incident date 02/18/12, incident time 0330 (3:30 a.m.) incident location 503 B, event: Res to Res event; injury: 0 marks but c/o back pain, initial actions: resident education...describe what happened and assessment and intervention: Res in male res room & took coat & clothes. Male res. woke up & yelled at res to get out but refused. Male res hitting her on the back (arrow up). CNA (name deleted) in room and able to remove (Resident #3) out of room... Notes: Staff educated to monitor residents closely and redirect to their own rooms." An incident report dated 02/22/12 documented, "Incident date 02//22/12, incident time 2230 (10:30 p.m.) incident location hallway, event: Res to Res event; injury: no injury, initial actions: staff education and resident education...describe what happened staff member witnessed (Res #3) and another resident becoming physical /c punching to the arms and abdomen, staff redirected (Res) stated 0 pain or discomfort will cont. to monitor..." An initial assessment dated [DATE], documented the resident had short and long term memory problems, was severely impaired in cognitive skills for daily decision making and delusional. The assessment documented the resident was independent with transfers, ambulation and eating. The assessment also documented the resident had physical and verbal behavioral symptoms directed toward others which put other residents at risk for physical injury, intruded on the privacy of others and disrupted care. The care area assessment summary dated 02/29/12, documented the resident's behavioral symptoms would be care planned. The care area assessment worksheet dated 02/29/12, documented, "Analysis of findings: chart review/admit notes (Resident) has a dx of [MEDICAL CONDITION]-[MEDICAL CONDITION]- she is awake most of shift going in and out of other residents rooms...will care plan for less than 3 episodes of behaviors per week through next review... (Resident) has DX of dementia w/ behaviors, [MEDICAL CONDITIONS]. She is hard to redirect. She is orientated to self. She is delusion in speech. At risk for poor communication. Will care plan...She does not sit still for long..." There was no documentation on the assessment the resident wandered. A care plan dated 03/02/12, documented, "Problems: (Resident) is a new admit to facility. She has DX of schizo, dementia, Alzh, [MEDICAL CONDITION], HTN, DM, depression, and [MEDICAL CONDITION]. She is awake most of the night, going in and out of other res rooms. She is at risk for further decline. Goals: (Resident will function within her current level and have no further decline in cog status... Interventions: Use cues and reminders as needed for day to day activities. Reorient res to room as needed. Administer medications as ordered. Psych RN svs for assessment and observation. Therapeutic teaching as needed. Explain all procedures using simple commands, pleasant tone and repeat as necessary... Problem...she is hard to redirect. She is orientated to self. She is delusional in speech. At risk for poor communication and not getting needs met. Goal: staff to anticipate thru next review. Interventions: Use short phrases, speak clearly, repeat if necessary. monitor resident for changes in LOC, gait, balance. Redirect, reorient as needed. Ask short questions and allow ample time for (Resident ) to express any needs she may have..." The care plan did not address the resident's behaviors of physical and verbal altercations with other residents as indicated on the initial assessment. The care plan did not address the resident's altercations with other residents since being admitted . An incident report dated 04/08/12, documented, "Incident date 04/08/12, incident time 0620 (6:20 a.m.), describe what happened: envolved (sic) in a res to res confrontation, walked into his room struck him in the face leaving a small laceration above Lt eye...steps taken to prevent recurrence: Res encouraged to stay out of fell ow residents rooms. She verbalized understanding (wanders...)" A report sent to the Oklahoma State Department of Health for the incident documented, "Res (Res #3) was redirected by staff with success. Res (Res #3) was placed on Q 30 minute visual checks. Res was educated about behaviors and entering residents rooms. Verbalized understanding...Staff inserviced on keeping up with residents where abouts on the hall." An incident report dated 04/09/12 documented, "Incident date 04/09/12, time of incident 2040 (8:40 p.m.), exact location of incident: dining room...resident was attacked by another resident /c laceration to her (L) side face..." There were no documented steps on the incident report to prevent recurrence of the event. A report sent to the Oklahoma State Department of Health for the incident documented, "Resi (#8) counseled about appropriate behavior, verbalized understanding, resident (#8) placed on Q 30 minute visual checks. Staff informed to keep residents apart. There have been no prior history of aggression between these two residents. Will continue to monitor behavior." An incident report dated 04/20/12, documented, "Incident date 04/20/12, time of incident 2 a.m., exact location (not documented)...what happened: called to room by CNA who reports resident on floor having a verbal & physical confrontation /c another resident...steps taken to prevent recurrence: bed alarm..." An incident report for Resident #10 documented, "Perhaps a bed alarm to alert staff when shes (Res #3) (arrow up) roaming..." A report sent to the Oklahoma State Department of Health for the incident documented, "Res (Res #3) entered (Res # 10) room during the night and began having a physical, verbal confrontation with him. CN was called to the room where both residents were found in the floor continuing to have altercation. Residents were separated. Res (#3) was redirected out of (Res #10) room...(Res #10) was found to have a scratch on his check and neck area, and a bite mark on his LFA. First aide applies to scratches...Both residents deny injury to head....Resident (#3) has recently returned from an acute hospital stay and while there they DC'd most of her psych medications. Received order to send to HOPE unit for med eval and treat behaviors." A nurse's note dated 04/20/12, documented, "Spoke to Dr. (Name deleted) regarding resident behaviors and altercation. N.O recvd to send to (Name deleted) for eval & treat." A care plan dated 04/30/12 did not address the resident's continual resident to resident altercations which resulted in injury to self and others. A physician's telephone order dated 04/31/12 (sic) documented, "Send to (Name deleted) unit for eval & treat." A nurse's note dated 05/01/12, documented, "Resident returned to facility via facility mobile." A "Psychiatric Nursing Brief Encounter" dated 05/03/12, documented, "Pt /c episodes of agitation & restlessness per nursing staff. Physically attacking...other residents, attempting elopement...resident to be evaluated by facility psychiatrist at next visit scheduled next week." There was no documentation the facility psychiatrist evaluated the resident the following week. A quarterly assessment dated [DATE], documented no changes in the resident's condition since the initial assessment. There were no changes in the resident's care plan to address the continual wandering into resident's rooms and resident to resident altercations which had resulted in injuries to the resident and others. An incident report dated 06/26/12, documented, "Date of incident: 06/26/12, time of incident: 1615 (4:15 p.m..), location of incident: residents room [ROOM NUMBER]...what happened: Res got into altercation /c another res...type of injury: abrasion, swelling, location of injurys (sp) : left wrist and left eye...steps taken to prevent recurrence: staff instructed to give Resi diversional activities & monitor her from wandering." The other resident identified in the incident was resident #8. An incident report dated 06/27/12, documented, "Date of incident: 06/27/12, time of incident 2020 (8:20 p.m.); exact location t.v. area...what happened: Res got into altercation /c another res he approached (Resident #3) & hit her in the face and arm. This resident hit other back...type of injury: hematoma, abrasion, swelling..." A report sent to the Oklahoma State Department of Health for the incident documented, "Res (Res #8) approached Resi (Res #3) in the TV area and hit her in the face and arm. Resi (#3) hit Resi (#8) back. Altercation stopped by staff. Both residents were redirected away from each other....Resi (#3) was noted that her hand was swollen. Physician notified and X-ray was ordered..." A care plan dated 06/27/12, documented, "Problems: (Resident) has dx of dementia w/ behav, schizo, and [MEDICAL CONDITION]. She has been in several altercations with other res. She is at risk for injuries... Goal: (Resident) will have no injuries thru next review from altercations with other residents... Interventions: Approach calmly and unhurriedly. Speak in calm tone. Explain all procedures before performing. Attempt to assist (Resident) in refocusing and redirecting when behaviors occur. If striking out, determine if (Resident) is in pain or disc, report to nurse. Psych RN consult as needed. If in high stimuli area (activities), observe for increased agitation and remove to calmer area as able." There was a hand written note on the care plan dated 06/27/12, documenting, "Alt /c another resident. No injuries." Prior to 06/27/12, there had been no care plan for the resident to resident altercations since the resident had been admitted on [DATE]. The resident had seven resident to resident altercations with four of them resulting in injury to self and one to another resident. 2. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE], documented the resident was able to understand others and be understood by others, was severely impaired with cognitive skills in daily decision making, had short and long term memory problems, exhibited physical behavioral symptoms toward others, and was independent with all transfers and ambulation. An incident report dated 02/05/12 at 6:30 p.m., documented, "...Incident location room [ROOM NUMBER]; event: unobserved res to res event; location: resident room; initial actions: resident education, staff intervention...what happened: Res observed another male res lying his bed in room. Res proceeded to punch other male res in face, inflicting minor injury to other male res. 0 injury noted to res, staff intervention required 1:1 provided...Notes: educated res to not touch another res physically. Ordered psych eval." An incident report for resident #11, the other resident, documented he received a 0.2 cm laceration to the nose, left check and right side of his face. There was no documentation resident #8 was provided 1:1 staff after the incident with resident #11. A care plan dated 02/06/12, documented, "Problem: (Res #8) has had several altercations with another resident since last review at risk for injuries from altercations. Goal: Will have no injuries thru next review. Will not have any episodes of striking other residents thru next review. Interventions: Approach (Resident #8) calmly and unhurriedly. Speak in calm tone. Explain all procedures before preforming. Attempt to assist (Resident) in refocusing when behavior occurs. If striking out-ask if in pain. Report to nurse. 1:1 counseling to determine rational for feelings and behavior. redirect inappropriate behavior. Psych consult if ordered." An incident report dated 02/14/12 at 9:30 a.m., for resident #8 and resident #11 documented each resident received an injury during an altercation. Resident #11 sustained a cut below the left eye and resident #8 sustained a black eye. The notes documented resident #8 was educated to not touch another resident and was being referred for a psychological evaluation. Staff was educated to continue and redirect the residents. An incident report dated 02/17/12 at 8:30 p.m., for resident #8 and #12 documented resident #8 found his roommate in his bed, became combative and scratched the roommate on the right side of neck. Under the note section on the incident report the following intervention to prevent recurrence of event was documented, "Resident (#8) encouraged not to touch another resident physically. Staff educated to monitor residents to make sure they are not getting in other residents bed." On the incident report for resident #12, the steps were documented as, "Educated staff to monitor and cont redirect resident to his room/bed." An incident report dated 02/22/12, documented, "Incident date 02/22/12, incident time 2230 (10:30 p.m.) incident location hallway, event: Res to Res event; injury: no injury, initial actions: staff education and resident education...describe what happened staff member witnessed (Res #3) and another resident becoming physical /c punching to the arms and abdomen, staff redirected (Res) stated 0 pain or discomfort will cont. to monitor..." The residents identified in the incident report was resident #3 and resident #8. An incident report dated 02/23/12, documented, "Incident date 02/23/12, Incident time: 1800 (6:00 p.m.); incident location: lobby; residents involved (Res #8 and Res #13); event: res to res event; injury: bruise, swollen jaw (to res #8) initial actions: staff education...what happened: Both residents standing in lobby (Res #13) then started punching (Resident #8) in the face and trunk. (Res #8) also punched (#13) in the trunk. This nurse redirected residents by walking (#8) to his room. Notes: (Res #13) will be sent out for psychological evaluation. Neuro checks were initiated on (Res #8)." A report sent to the Oklahoma State Department of Health for the incident documented, "(Res #8) and (Res #13) was observed in a physical alteration. Upon nursing assessment there was a bruising to (Res #8) and swelling to his jaw area. (Res #13) has swelling to his right hand...Residents were separated initially. An ice pack was applied to (Res #8) jaw area and an order for [REDACTED]. The resident had four resident to resident altercations after the care plan dated 02/06/12, which resulted in injury to self or others. The care plan was not updated with any new interventions after the resident to resident altercations to prevent further occurrences. An annual assessment dated [DATE], documented the resident was able to understand others and be understood by others, was severely impaired with cognitive skills in daily decision making, did not exhibit physical or verbal behaviors towards others and did not wander. The assessment documented the resident was independent with transfers and ambulation. The care area assessment summary dated 04/29/12, did not document the resident's behavioral symptoms of resident to resident altercations would be care planned. A care plan dated 04/30/12, documented, "Problem: (Res #8) has had several altercations with another resident since last review at risk for injuries from altercations. Goal: Will have no injuries thru next review. Will not have any episodes of striking other residents thru next review. Interventions: Approach (Res #8) calmly and unhurriedly. Speak in calm tone. Explain all procedures before performing. Attempt to assist (Res) in refocusing when behavior occurs. If striking out-ask if in pain. Report to nurse. 1:1 counseling to determine rational for feelings and behavior. redirect inappropriate behavior. Psych consult if ordered. Have (Res) telephone his wife to calm down as needed." The care plan written on 04/30/12, had no changes in interventions from the previous care plan. The care plan had not been updated and developed with interventions to aid in the prevention of resident to resident altercations with injuries. An incident report dated 05/01/12, documented, "Date of incident: 05/01/12, time of incident: 5:45 p.m., location of incident: common area; ...what happened: Another resident scratched (Res #8) on the (R) cheek according to (Res #8). Not witnessed by staff." An incident report dated 06/19/12, documented, "Person involved (Res #8); Date of incident: 06/20/12, location of incident: Rm 501; ...what happened: Res struck another res in (R) arm on secured unit." There were no interventions on the facility incident report to prevent recurrence. A second incident report for the same incident documented Resident #6 was the resident struck by resident #8. A report sent to the Oklahoma State Department of Health for the incident documented, "Staff instructed to re-direct Resi (#6) away from Resi (#8)." An incident report dated 06/26/12, documented, "Date of incident: 06/26/12, time of incident: 1615 (4:15 p.m..), location of incident: residents room [ROOM NUMBER]...what happened: Res got into altercation /c another res...type of injury: none apparent...steps taken to prevent recurrence: staff instructed to redirect Resi from other resi while in common areas." The other resident identified in the incident was resident #3, who sustained swelling to the left hand and an abrasion to the left eye. There were three resident to resident altercations since the resident's care plan was written on 04/30/12. The care plan was not updated and or developed to reflect changes in interventions to prevent the recurrence of further incidents which had resulted in injury to himself and others. An incident report dated 06/27/12, documented, "Date of incident: 06/27/12, time of incident 2020 (8:20 p.m.); exact location t.v. area...what happened: Res got into altercation /c another res. this resident struck other resi in face & arm. The other Resi hit this one back...type of injury none...steps to prevent recurrence: Resi placed 1:1 /c staff." A report sent to the Oklahoma State Department of Health for the incident documented, "Res (Res #8) approached Resi (#3) in the TV area and hit her in the face and arm. Resi (#3) hit Resi (#8) back. Altercation stopped by staff. Both residents were redirected away from each other....Resi (#3) was noted that her hand was swollen. Physician notified and X-ray was ordered..." The other resident identified in the incident was resident #3, who sustained a hematoma, abrasion and swelling. The injury sites were left eye, left side of neck, right hand and forearm. A care plan entry dated 06/27/12, under interventions, documented, "Alt /c another res-0 injuries." During the initial tour of the facility on 06/28/12 at 9:05 p.m., the number of direct care staff on the secured unit was observed. There were two certified nurse aides assigned to the hall, one charge nurse for hall 100, 200, and 500. Also there was one certified medication aide who worked halls 100, 200, and 500. Resident #8 was observed in his room unattended. No staff were present with him. At 11:10 p.m., the secured unit had two certified nurse aides assigned to the hall. Resident #3 was observed ambulating the hall and secured unit. Resident #8 remained in his room without one on one supervision. An interview was conducted on 07/02/12 at 11;15 a.m., with CNA #6. She was asked to describe resident #3. She stated, "She likes to wander in and out of other resident rooms and likes to get into things." She also stated the resident was combative toward others. She was asked if this caused any problems with other residents. She stated, "Yes." She then identified resident #8 and #10 as ones that have problems with the resident. She was asked to describe how those residents react to her. She stated, "Resident #8 gets physical with other residents." She was asked what the facility did to intervene and attempt to prevent recurrence of additional resident to resident altercations with resident #3 and resident #8. She stated, "We try to explain to the residents to not go into other rooms or hit other residents, but they don't understand." An interview was conducted on 07/02/12 at 11:30 a.m., with resident #8. The resident was in his room and no staff was present during the interview. He was asked how he felt about other residents coming in his room. He stated, "I don't like residents coming into my room." He was asked what was done when they entered his room. He stated, "I'll get them out myself." An interview was conducted on 07/02/12 at 1:45 p.m., with the DON regarding the resident to resident altercations of resident #3 and resident #8. She was asked where interventions were listed to prevent further recurrence of altercations. She stated, "The incident report has the interventions listed on them." She was asked why they listed them. She stated, "To put things in place to prevent it from happening again." She was asked if the residents care plan should be developed with the interventions from the incident reports. She stated, "They should become part of the care plan." She was shown the care plan for the residents' and asked to locate the interventions for resident to resident altercations. She looked through them and said, "They are not here." She was asked about the lack of care plan for resident #3 addressing the resident to resident altercations and injuries the resident had sustained or caused other residents. She stated, "We wrote one after the last incident on 06/27/12." 3. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. A nurse's note dated 05/04/12, documented, "Resident left for (local psych facility), in stable condition w three days worth of clothes, transported by van and staff." Additional notes dated 05/18/12, documented,"res returns...assessment completed... family and physician notified of re-admission." "05/20/12, Res cont to adjust to room (change). 05/22/12, Res up in secure unit occ. yelling out..." A care plan last updated 05/23/12, documented, Problems "(Resident) has a dx of [MEDICAL CONDITION]/depression/ETOH dementia/HTN, he also has impaired judgment, concentration and attention-memory deficit with [MEDICAL CONDITION]. At risk for further decline. Cont /c POC. Goals Will be able to function within current level and have no further decline in cog status thru next review. Interventions explain all procedures using simple commands, give (Resident) ample time to comprehend. offer fluids, observe for decline in cog status and notify MD." The resident's care plan did not address the resident being moved to the secured unit. On 07/02/12 at 10:55 a.m., an interview was conducted with the DON. She was asked when the decision was made to transfer the resident to the secured unit. She stated, "We made the decision to place him there when we sent him out for evaluation." The surveyor asked the DON for the rationale for the transfer. She stated, "We just thought he would do much better in a smaller more controlled environment and he has." The DON was then asked if the secured unit information was care planned, she stated, "No it wasn't." 4. Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. Nurses' notes from a previous facility dated, 12/06/11, 12/07/11, 12/08/11, 12/18/11, 12/21/11 and 01/09/12, documented, "res cont on one on one monitoring this shift by staff member...no in appropriate behavior noted this shift." Facility 'Behavior Monitoring' forms' dated, 01/12, 02/01 and 03/01, documented, "behavioral symptom... sexual inappropriate" A nurse's note dated 03/03/12, documented, "10:00 A female res. reported that this res.(#6) entered her bedroom & fondled her breast. The female resident told him to stop & she came to report incident to staff... DON, Dr and Son notified. Son reported that this resident has had this type of incident occur in the past." A quarterly assessment dated [DATE], documented the resident was severely impaired in cognition, able to make his needs known, was able to understand and be understood. The assessment further documented the resident was independent with all ADL's except required assistance with bathing. An "Incident/Accident Report" dated 06/19/12, documented, "Person involved: Resident #6/ Resident #1, date of incident/accident: 06/15/12, time of incident 1730 (5:30 p.m.)...location of incident: Rm 410...describe what exactly happened: Res (Resident #6) seen exiting Rm 410. Res (Resident #1) had diaper on but pulled to side. (Resident #1) was quiet, not upset acting. (Resident #6) pants were up & zipped..." The resident's initial care plan and one dated 04/18/12, did not address the resident's behavior of being sexually inappropriate. On 07/02/12 at 10:55 a.m., an interview was conducted with the DON. She was asked about the failure of developing a care plan to address the resident's behavior. The DON stated, "I'm not sure."

Based on observation, record review and interview, it was determined the facility failed to ensure there was sufficient staff on the secured unit to prevent resident to resident altercations for two (#3 and #8) of three sampled residents who resided in the secured unit. This deficient practice resulted in an actual harm. This had the potential to affect the 28 residents who resided in the secured unit on Hall 500. Findings: A facility policy documented, "The facility shall provide 24-hour nursing service, seven days a week to meet the needs of the residents admitted to the facility." 1. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An incident report dated 02/18/12, documented, "Incident date 02/18/12, incident time 0330 (3:30 a.m.) incident location 503 B, event: Res to Res event; injury: 0 marks but c/o back pain, initial actions: resident education...describe what happened and assessment and intervention: Res in male res room & took coat & clothes. Male res. woke up & yelled at res to get out but refused. Male res hitting her on the back (arrow up). CNA (Name deleted) in room and able to remove (Res #3) out of room... Notes: Staff educated to monitor residents closely and redirect to their own rooms." The daily Staffing Schedule for the 11:00 p.m. through 7:00 a.m. shift, the shift on which the incident occurred, documented only two certified nurse aides were working in the secured unit. One charge nurse was covering halls 100, 200 and 500. An incident report dated 02/22/12, documented, "Incident date 02/22/12, incident time 2230 (10:30 p.m.) incident location hallway, event: Res to Res event; injury: no injury, initial actions: staff education and resident education...describe what happened staff member witnessed (Res #3) and another resident (#8) becoming physical /c punching to the arms and abdomen, staff redirected (Resident #3) stated 0 pain or discomfort will cont. to monitor..." The daily Staffing Schedule for the 3:00 p.m. through 11:00 p.m. shift, the shift in which the incident occurred, documented only two certified nurse aides working in the secured unit. A certified medication aide and charge nurse were floating between halls 100, 200 and 500. An initial assessment dated [DATE], documented the resident had short and long term memory problems, was severely impaired in cognitive skills for daily decision making, and delusional. The resident was documented as being independent with transfers and ambulation. The assessment also documented she had physical and verbal behavioral symptoms directed toward others. The care area assessment worksheet dated 02/29/12, documented, "Analysis of findings: chart review/admit notes (Res) has a dx of [MEDICAL CONDITION]-[MEDICAL CONDITION]-she is awake most of shift going in and out of other residents rooms...will care plan for less than 3 episodes of behaviors per week through next review...DX of dementia w/ behaviors, [MEDICAL CONDITIONS]. She is hard to redirect. She is orientated to self. She is delusion in speech. At risk for poor communication. Will care plan...She does not sit still for long..." A care plan dated 03/02/12, documented, "Problems: (Resident) is a new admit to facility. She has DX of schizo, dementia, Alzh, [MEDICAL CONDITION], HTN, DM, depression, and [MEDICAL CONDITION]. She is awake most of the night, going in and out of other res rooms. She is at risk for further decline. Interventions: Use short phrases, speak clearly, repeat if necessary. monitor resident for changes in LOC, gait, balance. Redirect, reorient as needed. Ask short questions and allow ample time for (Resident ) to express any needs she may have..." An incident report dated 04/08/12, documented, "Incident date 04/08/12, incident time 0620 (6:20 a.m..), describe what happened: involved (sic) in a res to res confrontation, walked into his room struck him in the face leaving a small laceration above Lt eye...steps taken to prevent recurrence: Res encouraged to stay out of fell ow residents rooms. She verbalized understanding (wanders...)" A report sent to the Oklahoma State Department of Health for the incident documented, "Res (#3) was redirected by staff with success. Res (#3) was placed on Q 30 minute visual checks. Resi was educated about behaviors and entering residents rooms. Verbalized understanding...Will continue to monitor... Staff inserviced on keeping up with residents where abouts on the hall." The record did not contain any documentation to indicate the 30 minute visual checks were completed. The daily Staffing Schedule for the 11:00 p.m. through 7:00 a.m. shift, the shift in which the incident occurred, documented only two certified nurse aides were working in the secured unit. A charge nurse was floating between halls 100, 200 and 500. An incident report dated 04/09/12, documented, "Incident date 04/09/12, time of incident 2040 (8:40 p.m.), exact location of incident: dining room...resident was attacked by another resident (#8) /c laceration to her (L) side face..." There were no documented steps on the incident report to prevent recurrence of the event. The daily Staffing Schedule for the 3:00 p.m. through 11:00 p.m. shift, the shift in which the incident occurred, documented only two certified nurse aides were working in the secured unit. A charge nurse was floating between halls 100, 200 and 500. An incident report dated 04/20/12, documented, "Incident date 04/20/12, time of incident 2 a.m., exact location (not documented)...what happened: called to room by CNA who reports resident on floor having a verbal & physical confrontation /c another resident...steps taken to prevent recurrence: bed alarm..." An incident report for resident #10 documented, "Perhaps a bed alarm to alert staff when she's (#3) (arrow up) roaming..." The daily Staffing Schedule for the 11:00 p.m. through 7:00 a.m. shift, the shift which the incident occurred, documented only two certified nurse aides were working in the secured unit. A charge nurse was floating between halls 100, 200 and 500. An incident report dated 06/26/12, documented, "Date of incident: 06/26/12, time of incident: 1615 (4:15 p.m..), location of incident: residents room [ROOM NUMBER]...what happened: Res got into altercation /c another res (#8)...type of injury: abrasion, swelling, location of injures: left wrist and left eye...steps taken to prevent recurrence: staff instructed to give Resi diversional activities & monitor her from wandering." The daily Staffing Schedule for the 3:00 p.m. through 11:00 p.m. shift, the shift in which the incident occurred, documented only two certified nurse aides were working in the secured unit. An incident report dated 06/27/12, documented, "Date of incident: 06/27/12, time of incident 2020 (8:20 p.m.); exact location TV area...what happened: Res got into altercation /c another res (#8) he approached (Resident #3) & hit her in the face and arm. This resident hit other back...type of injury: hematoma, abrasion, swelling..." The daily Staffing Schedule for the 3:00 p.m. through 11:00 p.m. shift, the shift in which the incident occurred, documented only two certified nurse aides were working in the secured unit. A physician's telephone order dated 06/27/12, at 7:00 a.m., for resident #3 documented, "X-Ray of hands and (R) wrist." A "Final X-Ray Report dated 06/27/12, documented, "Exam reason: pain from fight; Exam Type: Portable LT Wrist...findings:...small unfused calcification adjacent to the base of the first metacarpal which could be due to a small bony avulsion of indeterminate age...no other fractures to wrist..." A "Final X-Ray Report dated 06/27/12, documented, Exam reason: pain from fight; Exam Type: Portable hand LT...findings: soft tissue swelling...." 2. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE], documented the resident was able to understand others and be understood by others, was severely impaired with cognitive skills in daily decision making, had short and long term memory problems, exhibited physical behavior symptoms toward others, and was independent with all transfers and ambulation. An incident report dated 02/05/12 at 6:30 p.m., documented, "...Incident location room [ROOM NUMBER]; event: unobserved res to res event; location: resident room; initial actions: resident education, staff intervention...what happened: Res observed another male res lying his bed in room. Res proceeded to punch other male res (#11) in face, inflicting minor injury to other male res. 0 injury noted to res, staff intervention required: 1:1 provided...Notes: educated res to not touch another res physically. Ordered psych eval." There was no documented evidence resident #8 was provided 1:1 staff after the incident with resident #11. An incident report for resident #11 documented he received a 0.2 cm laceration to the nose, left check and right side of his face. The daily Staffing Schedule for the 3:00 p.m. through 11:00 p.m. shift, the shift in which the incident occurred, documented only two certified nurse aides were working in the secured unit at the time of the incident. A charge nurse was floating between halls 100, 200 and 500. A care plan dated 02/06/12, documented, "Problem: (Res #8) has had several altercations with another resident since last review at risk for injuries from altercations. Goal: Will have no injuries thru next review. Will not have any episodes of striking other residents thru next review. Interventions: Approach (Resident #8) calmly and unhurriedly. Speak in calm tone. Explain all procedures before performing. Attempt to assist (Resident) in refocusing when behavior occurs. If striking out- ask if in pain. Report to nurse. 1:1 counseling to determine rational for feelings and behavior. redirect inappropriate behavior. Psych consult if ordered." An incident report dated 02/14/12, at 9:30 a.m., for resident #8 and resident #11 documented each resident received an injury during an altercation. Resident #11 sustained a cut below the left eye and resident #8 sustained a black eye. The notes on the incident report documented resident #8 was educated to not touch another resident and was being referred for a psychological evaluation. The staff was educated to continue and redirect the residents. An incident report dated 02/17/12 at 8:30 p.m., for resident #8 and #12 documented resident #8 found his roommate in his bed, became combative and scratched the roommate on the right side of the neck. In the section to prevent recurrence of the event, documented, "Resident (#8) encouraged not to touch another resident physically. Staff educated to monitor residents to make sure they are not getting in other residents bed." The incident report for resident #12 documented the interventions as, "Educated staff to monitor and cont redirect resident to his room/bed." The daily Staffing Schedule for the 3:00 p.m. through 11:00 p.m. shift, the shift in which the incident occurred, documented only two certified nurse aides were working in the secured unit at the time of the incident. A certified medication aide and charge nurse were floating between halls 100, 200 and 500. An incident report dated 02/22/12, documented, "Incident date 02/22/12, incident time 2230 (10:30 p.m.) incident location hallway, event: Res to Res event; injury: no injury, initial actions: staff education and resident education...describe what happened staff member witnessed (#3) and another resident becoming physical /c punching to the arms and abdomen, staff redirected (#8) stated 0 pain or discomfort will cont. to monitor..." The daily Staffing Schedule for the 3:00 p.m. through 11:00 p.m. shift, the shift in which the incident occurred, documented only two certified nurse aides were working in the secured unit. A certified medication aide and a charge nurse were floating between halls 100, 200 and 500. An incident report dated 02/23/12, documented, "Incident date 02/23/12, Incident time: 1800 (6:00 p.m.); incident location: lobby; residents involved (#8 and #13); event: res to res event; injury: bruise, swollen jaw (to resident #8) initial actions: staff education...what happened: Both residents standing in lobby (#13) then started punching (#8) in the face and trunk. (Res #8) also punched (#13) in the trunk. This nurse redirected residents by walking (#8) to his room. Notes: (Res #13) will be sent out for psychological evaluation. Neuro checks were initiated on (Res #8)." A report sent to the Oklahoma State Department of Health of the incident documented, "(Res #8) and (Res #13) was observed in a physical altercation. Upon nursing assessment there was a bruising to (Res #8) and swelling to his jaw area. (Res #13) has swelling to his right hand...Residents were separated initially. An ice pack was applied to (Res #8) jaw area and an order for [REDACTED]. An annual assessment dated [DATE], documented the resident did not exhibit physical or verbal behaviors towards others and did not wander. A care plan dated 04/30/12, documented, "Problem: (Res #8) has had several altercations with another resident since last review at risk for injuries from altercations. Goal: Will have no injuries thru next review. Will not have any episodes of striking other residents thru next review. Interventions: Approach (Res #8) calmly and unhurriedly. Speak in calm tone. Explain all procedures before performing. Attempt to assist (Res) in refocusing when behavior occurs. If striking out- ask if in pain. Report to nurse. 1:1 counseling to determine rational for feelings and behavior. redirect inappropriate behavior. Psych consult if ordered. Have (Res) telephone his wife to calm down as needed." An incident report dated 05/01/12, documented, "Date of incident: 05/01/12, time of incident: 5:45 p.m., location of incident: common area; ...what happened: Another resident scratched (#8) on the (R) cheek according to (#8). Not witnessed by staff." The daily Staffing Schedule for the 3:00 p.m. through 11:00 p.m. shift, the shift in which the incident occurred, documented only one certified nurse aide and one certified medication aide were working on the secured unit. An incident report dated 06/19/12, documented, "Person involved (Resident #8); Date of incident: 06/20/12, location of incident: Rm 501; ...what happened: Res struck another Res (#8) in (R) arm on secured unit." An incident report dated 06/26/12, documented, "Date of incident: 06/26/12, time of incident: 1615 (4:15 p.m.,) location of incident: residents room [ROOM NUMBER]...what happened: Res got into altercation /c another res (#3)...type of injury: none apparent...steps taken to prevent recurrence: staff instructed to redirect resi from other resi while in common areas." The daily Staffing Schedule for the 3:00 p.m. through 11:00 p.m. shift, the shift in which the incident occurred, documented only two certified nurse aides were working in the secured unit. An incident report dated 06/27/12, documented, "Date of incident: 06/27/12, time of incident 2020 (8:20 p.m.); exact location TV area...what happened: Res(#8) got into altercation /c another res. this resident struck other resi in face & arm. The other resi hit this one back...type of injury none...steps to prevent recurrence: Resi placed 1:1 /c staff." There was no documented verification resident #8 received 1:1 staffing. A report sent to the Oklahoma State Department of Health for the incident documented, "Res (#8) approached Resi (#3) in the TV area and hit her in the face and arm. Resi (#3) hit Resi (#8) back. Altercation stopped by staff. Both residents were redirected away from each other....Resi (#3) was noted that her hand was swollen. Physician notified and X-ray was ordered..." Resident #3 sustained a hematoma, abrasion, and swelling. The sight of the injuries were the left eye, left side of the neck, right hand and forearm. An interview was conducted on 07/02/12 at 11:15 a.m., with CNA #6. She was asked to describe resident #3. She stated, "She likes to wander in and out of other resident rooms and likes to get into things." She also stated the resident was combative toward others. During the initial tour of the facility on 06/28/12 at 9:05 p.m., the number of direct care staff on the secured unit was observed. There were two certified nurse aides assigned to the hall and one charge nurse and a certified medication aide floating between halls 100, 200 and 500. Resident #8 was observed in his room unattended with no staff present. At 11:10 p.m., the secured unit had two certified nurse aides assigned to the hall. Resident #3 was observed ambulating in the hall of the secured unit. Resident #8 remained in his room without one on one supervision. An interview was conducted on 07/03/12 at 9:50 a.m., with the DON. She was asked about the number of staff on the secured unit during the resident to resident altercations of resident #3 and resident #8. She stated, "I know there are only two (aides). I am aware of that. I know it's a problem." She then stated, "At times there is only one aide on the secured unit." She was asked how two aides would redirect residents, provide one on one when needed and provide care. She stated, "We need to increase the staff back there."

Based on observation, record review, and interviews, it was determined the facility failed to have an effective quality assurance program in place to identify problems and implement plans of action to correct deficient practice. The facility failed to identify and implement a plan of action to correct system failures related to: a. protecting an incapacitated female resident from a male resident with known inappropriate sexual behaviors, thoroughly investigate allegations of resident to resident sexual abuse, report findings in accordance to the local law enforcement and the Oklahoma State Department of Health, and implement their abuse policy to protect an incapacitated female resident from a male resident with known inappropriate sexual behaviors; b. supervision and implementation of measures to prevent resident to resident altercations for two (#3 and #8) of three sampled residents residing on the secured unit. This had the potential to affect 114 of 114 residents residing in the facility. Findings: A facility policy titled, "Quality Assurance-Internal Audit Policy" documented, "A committee of the whole shall be appointed to act as the Quality assurance Team. It shall review and audit all areas of the facility: ...Nursing...security...social services..." A facility abuse policy documented, "All occurrences of abuse, neglect, mistreatment, injuries of an unknown source and theft or misappropriation of resident property will be analyzed by the quality assessment and assurance committee to determine if a system changes need to be made... The quality assessment and assurance committee will review all reports during their regularly scheduled meetings." 1. The facility failed to identify and implement interventions for a resident who had a known history of being sexually inappropriate which resulted in an incapacitated female being assaulted, failed to report this incident to the Oklahoma State Department of Health and local law enforcement agency, and failed to implement their abuse policy and procedure for protecting and reporting. This resulted in an immediate jeopardy situation and and actual harm. Refer to F-224, F-225, and F-226. 2. The facility failed to identify a problem on the secured unit with resident to resident altercations and a low number of direct care staff working on the unit. This resulted in an actual harm. Refer to F-323 and F-353. An interview was conducted on 07/03/12 at 10:05 a.m., with the administrator regarding the facility quality assurance program. She was asked how often the facility quality assurance committee meet. She stated, "Quarterly." She was asked what the committee reviewed She stated, "Incident reports, medication errors, infection control, and any quality issues." She was asked about the incident reports being reviewed for the resident to resident altercations on the secured unit. She stated, "We look at them but don't trend them." She was asked about the residents with behaviors such as inappropriate sexual behavior. She stated, "We never really talked about that." She was asked how effective her quality assurance program was for identifying the problems above. She stated, "The quality assurance was not very effective."

Based on observation, record review and interview, it was determined the facility failed to ensure the they had an effective quality assurance program to implement changes to correct quality of care and quality of life deficiencies as evidenced by deficient practices being recited. This had the potential to affect all 111 residents currently residing in the facility. Findings: The facility failed to notify a physician and family of severe weight loss. Refer to F-157. The facility failed to assess, have medical justification with a physician's orders [REDACTED]. Refer to F-221. The facility failed to develop and implement care plans to address a severe weight loss and restraints. Refer to F-279. The facility failed to provide adequate positioning to residents in a geri-chair while being assisted with meals, ensure water temperatures were safe on halls 100 and 200 and ensure resident's rooms did not have locks on the doors. Refer to F-323. The facility failed to ensure resident's clinical records were accurate. Refer to F-514. An interview was conducted on 08/23/12 at 10:11 a.m., with the administrator. She was asked how effective the QA process was with dealing with her plan of correction for the deficiencies that had been recited. She stated, "It's not very effective."

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist in regard to the facility's failure to implement their abuse policy to ensure an incident of neglect was prevented, identified and thoroughly investigated for a resident who was found non-responsive, with garbled speech, gurgled respirations and whose skin was cold to the touch. The resident had a temperature of 84.6 degrees Fahrenheit. On [DATE] at 3:30 p.m., the Oklahoma State Department of Health was notified. The immediate jeopardy situation was verified. At 3:36 p.m., the administrator and the director of nurses were notified of the IJ situation, which constituted substandard quality of care. At 4:26 p.m., an initial plan of removal for the IJ was presented to the survey team. At 4:35 p.m., the initial plan of removal was not accepted. At 4:59 p.m., a second plan of removal was submitted to the survey team. At 5:12 p.m., the second plan of removal was not accepted. At 5:36 p.m., a third plan of removal was submitted to the survey team. At 5:41 p.m., the third plan of removal was not accepted. At 6:38 p.m., the following plan of removal was presented to the survey team: "All incidents will be identified and thoroughly investigated and reported per state regulation. All staff will be in-serviced starting [DATE] at 6:00 p.m. Staff was started notification of in-service at 5:30 p.m. [DATE]. Staff will be in-serviced on what is required as a reportable to the DON (director of nurses) and/or designee. All licensed staff will be in-serviced on the importance of documentation and interventions in nursing notes. All staff will implement first response interventions (i.e. blankets, pillows, ice packs, etc...) Staff will not be allowed to work until they have been in-serviced. Each employee will be in-serviced over, Investigating Allegations of Neglect and Abuse. Conduct the investigation in accordance with established policy. Utilize the Abuse Prohibition Investigations Protocol to complete the task. Those who can't make it due to out of town or vacation will be in-serviced via telephone. Upon returning to work they will be again in-serviced and signed the in-service sheet. The telephone in-services will be documented by those who are giving the in-service and dated. Those employees who cannot be reached by 3 p.m. on [DATE] for inservice will be removed from schedule until they make the required inservice. The DON will come in at 10:30 pm on [DATE], 6:30 am [DATE] and 2:30 pm [DATE] to inservice staff. All staff will be in-serviced by [DATE]. DON or designee will monitor for compliance via incident report and DON will submit detailed summary of all reportable investigations to Administrator. Administrator or designee will follow up on investigation. All reports will be reviewed during morning administrative meetings that meet Monday thru Friday except for holidays. QA (quality assurance) committee will monitor the effectiveness of the plan by discussing and evaluating the interventions taken by staff. The first QA committee will begin [DATE]. The QA committee will meet monthly or as needed. During weather below 50 degrees and above 85 degrees all residents will be escorted outside during appropriate smoking or activity times. This weather would include rain, sleet, snow and ice. The keypad combination will be changed as needed. At time of incident the Administrator of DON was not notified that resident may or may not have been outside. 6:45 p.m." On [DATE] at 10:35 a.m., the administrator and DON were informed that the inservice provided to staff did not cover a plan to prevent another occurrence. The DON stated that she would re-inservice the staff on checking on residents in inclement weather, knowing where residents are and a plan to keep track of residents. On [DATE] at 4:20 p.m., the IJ was removed when all staff had been in-serviced on the following: "IN SERVICE DATE: [DATE] Staff will provide visual every 1 hour checks on resident when temperature falls below 40 and temperatures above 80. Key pad codes will be changed as needed. For memory care unit when residents taking their supervised smoke breaks, and supervised outdoor activities when the temperatures are below 40 and/or above 80 staff will provide a head count before going out and when reentry into building. Report any/all incidents to the DON (director of nurses)/Administrator as soon as possible. DON and Administrators phone numbers will be posted at both nurses stations and will be available to all staff." The deficient practice remained at a pattern level of actual harm. Based on record review and interview, it was determined the facility failed to implement their abuse policies to ensure an incident of neglect was prevented, identified, thoroughly investigated and reported to the proper state agencies for one (#1) of one residents who were found non-responsive, with garbled speech, gurgled respirations and whose skin was cold to the touch. The resident had a temperature of 84.6 degrees Fahrenheit. The resident was transferred to the hospital and expired less than 48 hours later with [DIAGNOSES REDACTED]. The facility's failure to implement their abuse policies had the likelihood to affect all resident's who resided in the facility. Findings: The facility's Abuse Prevention policies and procedures documented: "Investigating Allegations of Neglect Policy Statement All reported incidents of neglect are promptly and thoroughly investigated. Policy Interpretation and Implementation 1. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a resident's physical or mental condition. Neglect also means the failure to protect the resident from abuse, neglect, or exploitation. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death. 2. When conducting an investigation of neglect, implement the following protocol: a. Determine what goods or services were not provided to the resident; b. Determine if physical harm, mental anguish, mental illness or deterioration in the resident's physical or mental condition resulted from the failure of the facility to provide goods or services; and c. Determine if the intent of the negligence was willfu. 3. Conduct the investigation in accordance with established policy... Reporting Abuse to State Agencies and Other Entities/Individuals Policy Statement All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities or individuals as may be required by law. Policy Interpretation and Implementation 1. Should an alleged/suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse...be reported, the facility administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: a. The State licensing/certification agency responsible for surveying/icensing the facility; b. The local/State ombudsman; c. The resident's representative (sponsor) of record; d. Adult protective services; e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 2. Notices to the above agencies/individuals shall be made with 12 hours after the occurrence of the incident or when the facility learns of the abuse... 3. The administrator, or his/her designee, will provide the appropriate agencies/individuals listed above with a written report of the findings of the investigation within ____ days of the occurrence of the incident... Preventing Resident Abuse... Policy Interpretation and Implementation... 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following:... j. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect... Recognizing Signs and Symptoms of Abuse/Neglect Policy Statement Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or other designee immediately. Policy Interpretation and Implementation 1. The following are some examples of signs of or actual abuse/neglect and signs and symptoms of abuse/neglect that should be promptly reported. However, this listing is not all-inclusive. Other signs and symptoms or actual abuse/neglect may be apparent. When in doubt, report it. a. Signs of actual physical abuse:... - Excessive exposure to heat or cold... b. Signs of actual physical neglect:... - Inadequate provision of care - Left alone, but needs supervison... Investigation Unexplained Injuries Policy Statement An investigation of all unexplained injuries (including bruises, abraisions and injuries of an unknown source) will be conducted by the administrator or his/her designee to ensure that the safety of our residents has not been jeopardized. Policy Interpretation and Implementation 1. Should a resident be observed with unexplained injuries (including bruises, abrasions, and injuries of unknown source), the supervisor on duty must complete an accident/incident form and record such information in the resident's clinical record. 2. A listing of all personnel, including consultants, contract employees, visitors, family members, etc., who have had contact with the resident during the past 48 hours will be compiled and provided to the person conducting the investigation... 3. The investigation will follow the protocols set forth in our facility's established abuse investigation guidelines... Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures Policy Statement The administrator assumes the responsibility for the overall coordination and implementation of our facilty's abuse prevention program policies and procedures. Policy Interpretation and Implementation 1. The administrator has the overall responsibility for the coordination and implementation of our facility's abuse prevention program policies and procedures. 2. The administrator has the authority to delegate coordination and implementation of various components of these policies and procedures to other individuals within the facility..." Resident #1 had [DIAGNOSES REDACTED]. The assessment, dated [DATE], documented the resident was severely impaired and never/rarely made decisions. The resident was easily distracted, had periods of altered perception and restlessness, and her mental function varied over the course of the day. The resident wandered about the unit and required limited to extensive assistance with activities of daily living. The care plan, dated [DATE], documented the resident: ~ had a self-care deficit, required supervision on and off the unit. Required limited assistance with dressing, personal hygiene, and bathing; she required extensive assist with toileting; ~ wandered around the locked unit and was easily agitated; ~ had an altered thought process related to dementia; and ~ had a potential for alteration in communication related to dementia. The elopement risk scale, dated [DATE], documented the resident was ambulatory and wandered aimlessly within the facility or off facility grounds, and had been medically diagnosed with [REDACTED]. A nurse's note entry documented, "[DATE] 23:15 (11:15 p.m.) Res (resident) in TV area of hall 500 sitting on couch. Res non responsive, Garbled speech, gurgled resp (respiration). Res skin cool to touch. Vitals: BP (blood pressure) ,[DATE] P (pulse) 58 faint. R (respirations) 16 T (temperature) 84.6. 0 (no) facial grimacing noted. Physician (name deleted) called. Waiting on return call. 23:16 (11:16 p.m.) TC (telephone call) to ambulance, DON (director of nurses), resident's son. Left message cont. (continued- on back of page) for res son. 23:30 (11:30 p.m.) Res sent to (name deleted) Hosp (hospital) via ambulance. Mar (medication administration record), cover sheet, & transfer form sent. 23:45 (11:45 p.m.) TC from Dr. (name deleted). Advised Dr about res status and res sent to (name deleted) Hosp. Dr. (name deleted) stated, "OK, thank you." A physician's telephone order, dated [DATE], documented, "Send to (name deleted) hospital for eval (evaluation) & treatment (arrow down) LOC (level of consciousness), (arrow down) V/S (vital signs)" The emergency medical service (EMS) report, dated [DATE] at 2323 (11:23 p.m.), documented, "slumped over on couch in day area of NH (nursing home), staff @ side, Resp - irreg (irregular), shallow, audible congestion, pms (pulse, motor, sensation)- 0 (no) radial, cold to touch, 0 obvious recent trauma. ...Patient found as above after NH staff called (secondary to) unresponsive, hypothermic & hypotensive pt (patient). Pt on couch unable to follow commands, resp- shallow & "gurgling+ unsure of pt's activities this evening, normally confused c (with) "severe dementia" but ambulatory & compliant c commands, occasionally combative. 0 reported recent illness or med (medication) change." The hospital emergency room progress note documented: "admitted : [DATE] TIME 0715 (7:15 a.m.) SUMMARY I was called to CCU (critical care unit) on a doctor stat (at once) call. The patient is a [AGE] year-old female admitted earlier this morning with altered mental status, hypothermia, and [MEDICAL CONDITION]. The nursing staff reports that after arrival to the floor she had a decrease in her oxygen level and blood pressure. She was there for transfer to the CCU for more intensive monitoring... On my arrival to the unit the patient is being ventilated... The decision was made to go ahead and place the patient on mechanical ventilation due to her respiratory insufficiency." The hospital history and physical documented: "admitted [DATE]... PHYSICAL EXAMINATION GENERAL APPEARANCE: The patient is intubated... The patient responds to sternum rub, but not verbal. VITAL SIGNS: Vital signs at this time show temperature of 95.5, pulse 81, respiratory rate 18, blood pressure ,[DATE]. HEENT (head, eyes, ears, nose, and throat): The patient's pupils are dilated and do not react... ASSESSMENT AND PLAN 1. Acute hypothermia. Unfortunately, I cannot assess how long the patient was outside, but given the very low temperature, the prognosis is very critical. For the time being, I will continue current treatment including warm intravenous fluids and warm blankets... 7. Overall, the patient is critically ill and the prognosis is poor..." A consultation report, dated [DATE], documented: "REASON FOR CONSULTATION Respiratory distress CONSULTATION REPORT ...This patient was found to be unresponsive at the nursing home. She apparently had ventured outside. Her temperature was 88 and blood pressure was noted to be 40. She was brought to the ER (emergency room ) for evaluation. She was initially brought to the floor for treatment of [REDACTED]. She was transferred to the intensive care unit and was intubated and placed on the ventilator. The patient is unable to provide any history at this time... ASSESSMENT AND PLAN 1. Acute [MEDICAL CONDITION] with mixed respiratory and metabolic acidosis. 2. Shock, it appears to be secondary to a combination of hypothermia and septic shock. ...and we will continue to volume resuscitate the patient. We will discontinue mechanical ventilation as needed. Her overall prognosis appears to be poor. ...The patient has been resuscitated on 3 different occasions... Her overall prognosis is extremely poor..." The hospital discharge summary documented: "...Admit [DATE] 03:23 (3:23 A.M.) Discharg: [DATE] 21:45 (9:45 p.m.) HISTORY OF PRESENT ILLNESS The patient is a [AGE] year-old white female who was admitted to ICU (intensive care unit) after being found unconscious outside the nursing home the night before. At the time of admission, the patient's rectal temperature was 88.3 Fahrenheit, decreased. No further history obtained. The patient was intubated at the time of admission. HOSPITAL COURSE Despite intensive care, including pulmonologist, Dr. (name deleted), in consultation, the patient appeared to suffer from multiple conditions, [MEDICAL CONDITIONS], acute [MEDICAL CONDITION], hypothermia, metabolic acidosis, and hypothermia. The patient expired on [DATE], at 2145 (9:45 p.m.). The patient was discharged to the funeral home after that. CAUSES OF DEATH 1. Hypothermia. 2.[MEDICAL CONDITION]. 3. Acute [MEDICAL CONDITION]. 4. [MEDICAL CONDITION]." A nurse's note entry documented, "[DATE] 1435 (12:35 p.m.) M.E. (medical examiners) office called, resident expired." The most recent documentation in the nurse's progress notes, prior to the [DATE], entry was dated [DATE] at 1:45 p.m. There was no documentation to determine what had precipitated the resident's worsened condition and/or of interventions implemented to determine what events had occurred to predispose the resident to that non-responsive/hypothermic state. The facility neglected to immediately implement emergency nursing interventions and/or first response/comfort measures when the resident was documented as non-responsive and with a temperature of 84.6 degrees Fahrenheit. While awaiting the ambulance and a call from the physician, the facility neglected to implement emergency response measures for the resident, neglected to continue assessments, and neglected to continue to monitor the resident's vital signs. The facility neglected to initiate immediately an investigation to determine what events had occurred that predisposed the resident to that non-responsive/hypothermic state. On [DATE], an attempt was made to contact all employees by telephone and/or in person. The following interviews were conducted within the facility: At 11:05 a.m., certified medication aide (CMA) #4 stated close to shift change a female resident was on the floor (in the unit). He stated he and another CNA had placed the resident on the couch. He stated "they" had attempted to place the blame on the ,[DATE] shift, but apparently the resident had gotten outside on the ,[DATE] shift. He stated LPN (licensed practical nurse) #1was the charge nurse. He stated when the resident was found he did not know how long she had been outside. At 11:20 a.m., CNA #6 stated the resident was on the couch asleep when she left and had not been outside. She stated the resident had been fine and had her clothes and shoes on when they left. She stated "they" said the resident went outside on the ,[DATE] shift. When asked if the resident smoked. She stated she did not think the resident smoked, and if not, she went out and sat with the others. She stated the charge nurse on the ,[DATE] shift was LPN #1. At 1:39 p.m., CMA #2 stated "they" had tried to blame the ,[DATE] shift, but she didn't know as she had worked the front. When asked who was on duty, she stated LPN #1 and CNA #7 were on duty and she could not remember who else had worked. She stated she had heard the resident did not want to go to bed and was on the couch with her clothes on. When asked who had told her about the incident, she stated she did not remember. At 1:53 p.m., CMA #3 stated she had heard resident #1 was found outside. When asked if she knew on what shift the incident had happened. She stated she did not know; even to this date. At 2:00 p.m., CNA #4 stated she had heard a person went outside in January, became hypothermic, and went to the hospital. At 2:03 p.m., CMA #4 stated he had passed medication on that hall and toward the end of the (,[DATE]) shift, he had helped to lift the resident from the floor. He stated the incident had been reported to LPN #1. He stated the resident was on the couch when he left. He stated he did not know how long she had been there and he never saw her go outside. He stated normally only the smokers went out to the patio and he did not know how she had gotten out. He stated he did not think the resident had the ability to punch the code in the keypad. He stated the next day the resident had been sent out. He stated he did not know who had found her. He stated CNAs #6 and #7 had worked the unit. At 2:15 p.m., CNA #6 stated the resident was asleep on the couch when she left. She stated CNA #7 had called CMA #4 for assistance to lift the resident from the floor. She stated she did not know if the resident had fallen or not because she would lay on the floor at times. She stated she had words with CNAs #8 and #9, who had worked the ,[DATE] shift that night, on the next day because the ,[DATE] shift had said the resident was cold at 11:00 p.m. When asked if the resident smoked. She stated not to her knowledge, but the resident would go outside with everyone and return when everyone came back inside. When asked who had found the resident. She stated she didn't know. She stated she did not think the resident was at risk for wandering. At 2:48 p.m., LPN #2 stated stated LPN #3 was angry because a resident had a low grade temperature on the ,[DATE] shift. She stated LPN #3 felt she had not been told the truth and was upset the day shift had left the resident and had told no one. She stated she did not know who the resident was and had not heard what happened. At 4:58 p.m., LPN #4 stated she knew of the resident. She stated they had come on duty that night and had just taken over the floor. She stated LPN #1 came to borrow a thermometer. She stated she went to the unit with LPN #1 and LPN #1 monitored the resident's temperature. She stated she had told LPN #1 since the resident was "not acting right" and her temperature was low; she might need to send her out. She stated LPN #1 called Dr. (name deleted). She stated it had happened at the beginning of the shift. She stated the resident was on the sofa in the day area and she had asked LPN #1 if that was normal for the resident. LPN #1 stated, "It was totally not her." She stated she had told LPN #1 they probably needed to send her out. She stated she had helped prepare the papers to send the resident to the hospital went back to her area. On [DATE], multiple interviews were conducted with employees. The following interviews were conducted by telephone and/or within the facility: At 10:30 a.m., when asked if she had reported the incident to anyone. CNA #6 stated she was not on the unit when the resident was on the floor and had heard it after the fact. At 3:13 p.m., the DON stated she had been made aware the resident had a low temperature and had been sent to the hospital. She stated LPN #1 had found the resident on the sofa, the resident felt cool, and the LPN had taken her temperature and it had been low. At 3:31 p.m., the administrator stated he had not been aware the resident had been outside any length of time without supervision. He stated he was told she was in the day room and was sent out to the hospital and passed from exposure or hypothermia or something of that nature. When asked if he had investigated the incident. He stated, "No, that's what I was told. I didn't know anything. She was found on the sofa. I didn't know that she was outside." - At 6:15 p.m., LPN #5 stated she was not there, but was told the resident was real cold when she was found and was laid on the couch in the TV area. She stated she was told the resident was found at change of shift at 11 p.m. She stated everybody knew about it and to keep it hush hush. - At 6:24 p.m., CNA #10 stated she was there the evening it happened, but had left early. She stated when she came back they said they found her outside. On [DATE] at 12:10 p.m., LPN #1 was asked about the night resident #1 was sent to the hospital. She stated she worked the ,[DATE] shift. She stated she was doing her walk through with the ,[DATE] nurse and the resident was up on the sofa. She stated that was usual for the resident, that she didn't usually go to bed until late. She stated they had walked by the resident on the sofa and she said "Hi" to the resident, but she didn't answer. She said she didn't pay much attention, because the TV was on and she thought the resident was watching TV. When she finished her walk through, she sat down beside the resident and spoke to her. She stated there was no response. She touched the resident and she was cold. She stated she got a blood pressure cuff and thermometer to take the resident's vital signs. She stated her blood pressure was hard to tak, her pulse was slow and hard to feel and her temperature was real low. She stated she went to the front and got the other thermometer, that you wipe across the forehead, and went back to take the resident's temperature. She realized there wasn't anything wrong with the thermometer. She stated she then called EMS, the physician, the family and the DON. She stated when EMS got here and went to put her on the gurney, the resident became combative. She started yelling and cursing. She stated that was the resident's first verbal response since she had come on. The LPN was asked if anyone had said why the resident was so cold. She stated, "No, no one said anything." The LPN was asked if the resident could open the outside door unassisted. She stated, "No, normally that was something she was not capable of doing." The LPN was asked if there was anyone else (residents) on the unit that could get out the door without assistance. She stated she believed there were others that could get out. On [DATE] at 9:00 a.m., EMS staff #1 was asked where the resident was when she arrived at the facility. She stated the resident was sitting on the couch in the locked unit. She was asked if the resident was sitting on the couch or if someone was holding her on the couch. She stated the resident was slumped over onto the arm of the sofa. She was asked if the resident started yelling and cursing when they put her on the stretcher. She stated the resident did not yell or curse until they were in route to the hospital.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist in regard to the facility's failure to assess, monitor and/or supervise a resident to ensure they did not develop severe hypothermia of 84.6 degrees Fahrenheit. On [DATE] at 3:30 p.m., the Oklahoma State Department of Health was notified. The immediate jeopardy situation was verified. At 3:36 p.m., the administrator and the director of nurses were notified of the IJ situation, which constituted substandard quality of care. At 4:26 p.m., an initial plan of removal for the IJ was presented to the survey team. At 4:35 p.m., the initial plan of removal was not accepted. At 4:59 p.m., a second plan of removal was submitted to the survey team. At 5:12 p.m., the second plan of removal was not accepted. At 5:36 p.m., a third plan of removal was submitted to the survey team. At 5:41 p.m., the third plan of removal was not accepted. At 6:38 p.m., the following plan of removal was presented to the survey team: "All incidents will be identified and thoroughly investigated and reported per state regulation. All staff will be in-serviced starting [DATE] at 6:00 p.m. Staff was started notification of in-service at 5:30 p.m. [DATE]. Staff will be in-serviced on what is required as a reportable to the DON (director of nurses) and/or designee. All licensed staff will be in-serviced on the importance of documentation and interventions in nursing notes. All staff will implement first response interventions (i.e. blankets, pillows, ice packs, etc...) Staff will not be allowed to work until they have been in-serviced. Each employee will be in-serviced over, Investigating Allegations of Neglect and Abuse. Conduct the investigation in accordance with established policy. Utilize the Abuse Prohibition Investigations Protocol to complete the task. Those who can't make it due to out of town or vacation will be in-serviced via telephone. Upon returning to work they will be again in-serviced and signed the in-service sheet. The telephone in-services will be documented by those who are giving the in-service and dated. Those employees who cannot be reached by 3 p.m. on [DATE] for inservice will be removed from schedule until they make the required inservice. The DON will come in at 10:30 pm on [DATE], 6:30 am [DATE] and 2:30 pm [DATE] to inservice staff. All staff will be in-serviced by [DATE]. DON or designee will monitor for compliance via incident report and DON will submit detailed summary of all reportable investigations to Administrator. Administrator or designee will follow up on investigation. All reports will be reviewed during morning administrative meetings that meet Monday thru Friday except for holidays. QA (quality assurance) committee will monitor the effectiveness of the plan by discussing and evaluating the interventions taken by staff. The first QA committee will begin [DATE]. The QA committee will meet monthly or as needed. During weather below 50 degrees and above 85 degrees all residents will be escorted outside during appropriate smoking or activity times. This weather would include rain, sleet, snow and ice. The keypad combination will be changed as needed. At time of incident the Administrator of DON was not notified that resident may or may not have been outside. 6:45 p.m." On [DATE] at 10:35 a.m., the administrator and DON were informed that the inservice provided to staff did not cover a plan to prevent another occurrence. The DON stated that she would re-inservice the staff on checking on residents in inclement weather, knowing where residents are and a plan to keep track of residents. On [DATE] at 4:20 p.m., the IJ was removed when all staff had been in-serviced on the following: "IN SERVICE DATE: [DATE] Staff will provide visual every 1 hour checks on resident when temperature falls below 40 and temperatures above 80. Key pad codes will be changed as needed. For memory care unit when residents taking their supervised smoke breaks, and supervised outdoor activities when the temperatures are below 40 and/or above 80 staff will provide a head count before going out and when reentry into building. Report any/all incidents to the DON (director of nurses)/Administrator as soon as possible. DON and Administrators phone numbers will be posted at both nurses stations and will be available to all staff." The deficient practice remained at an pattern level of actual harm. Based on record review and interview, it was determined the facility neglected to assess, monitor and/or supervise one (#1) of one sampled residents to ensure they did not develop severe hypothermia of 84.6 degrees Fahrenheit. The resident was found on [DATE] to be unresponsive with garbled speech, gurgled respirations and skin cold to the touch. In addition, the facility failed to immediately provide emergency nursing interventions and/or first response/comfort measures which included attempting to warm the resident and restore body temperature. The resident was transported to the emergency room , admitted to the critical care unit and placed on mechanical ventilation. The resident expired on [DATE], less than 48 hours later, with [DIAGNOSES REDACTED]. Findings: Resident #1 was admitted on [DATE]. The resident had [DIAGNOSES REDACTED]. The elopement risk scale, dated [DATE], documented the resident was ambulatory and wandered aimlessly within the facility or off facility grounds, and had been medically diagnosed with [REDACTED]. The form documented a score of 11 or above indicated a high risk to wander. A Special Care Unit Admission Criteria Review, dated [DATE], documented the resident had Alzheimer's or a related dementia [DIAGNOSES REDACTED]." The admission assessment, dated [DATE], documented the resident had severely impaired cognitive skills and never/rarely made decisions. The resident was easily distracted, had periods of altered perception and restlessness, and her mental function varied over the course of the day. The resident wandered about the unit and required limited to extensive assistance with activities of daily living. The care plan, dated [DATE], documented the resident: ~ had a self-care deficit; required supervision on and off the unit; required limited assistance with dressing, personal hygiene, and bathing; and required extensive assist with toileting; ~ wandered around the locked unit and was easily agitated; ~ had an altered thought process related to dementia; and ~ had a potential for alteration in communication related to dementia. A National Weather Service Form F-6, of local climatological data, documented the low temperature for Oklahoma City on [DATE], was 7 degrees Fahrenheit and the high temperature was 22 degrees Fahrenheit. Medication Administration Records for [DATE], documented the resident received routine medications at 8:00 p.m. A nurse's note, dated [DATE] at 11:15 p.m., documented, "Res (resident) in TV area of hall 500 sitting on couch. Res non responsive, Garbled speech, gurgled resp (respiration). Res skin cool to touch. Vitals: BP (blood pressure) ,[DATE] P (pulse) 58 faint. R (respirations) 16 T (temperature) 84.6. 0 (no) facial grimacing noted. Physician (name deleted) called. Waiting on return call. 23:16 (11:16 p.m.) TC (telephone call) to ambulance, DON (director of nurses), resident's son. Left message cont. (continued- on back of page) for res son. 23:30 (11:30 p.m.) Res sent to (name deleted) Hosp (hospital) via ambulance. Mar (medication administration record), cover sheet, & transfer form sent." The emergency medical service (EMS) report, dated [DATE], documented the ambulance arrived at the facility at 11:31 p.m. The note documented, "slumped over on couch in day area of NH (nursing home), staff @ side, Resp - irreg (irregular), shallow, audible congestion, pms (pulse, motor, sensation)- 0 (no) radial, cold to touch, 0 obvious recent trauma. ...Patient found as above after NH staff called (secondary to) unresponsive, hypothermic & hypotensive pt (patient). Pt on couch unable to follow commands, resp- shallow & "gurgling+ unsure of pt's activities this evening, normally confused c (with) "severe dementia" but ambulatory & compliant c commands, occasionally combative. 0 reported recent illness or med (medication) change." A nurse's note, dated [DATE] at 11:45 p.m., documented, "TC from Dr. (name deleted). Advised Dr about res status and res sent to (name deleted) Hosp. Dr. (name deleted) stated, "OK, thank you." A physician's telephone order, dated [DATE], documented, "Send to (name deleted) hospital for eval (evaluation) & treatment (arrow down) LOC (level of consciousness), (arrow down) V/S (vital signs)" The EMS report documented the ambulance left the nursing home at 11:56 p.m. and arrived at the hospital at 12:15 a.m. An Initial Assessment Form from the emergency room at the hospital documented the resident presented on [DATE] at 12:20 a.m. Her temperature was 88.3 degrees rectally. The resident was admitted to the hospital and transferred out of the emergency room at 4:42 a.m. A hospital ER (emergency room ) note documented: "admitted : [DATE] TIME 0715 (7:15 a.m.) SUMMARY I was called to CCU (critical care unit) on a doctor stat (at once) call. The patient is a [AGE] year-old female admitted earlier this morning with altered mental status, hypothermia, and [MEDICAL CONDITION]. The nursing staff reports that after arrival to the floor she had a decrease in her oxygen level and blood pressure. She was there for transfer to the CCU for more intensive monitoring...On my arrival to the unit the patient is being ventilated... The decision was made to go ahead and place the patient on mechanical ventilation due to her respiratory insufficiency." The hospital history and physical documented: "admitted [DATE]... History of present illness The patient is a [AGE] year-old white female who was found unconscious outside the nursing home last night for an unknown duration. At that time, the patient's rectal temperature was 88.3 degrees. The patient was then admitted to the hospital, but later transferred to coronary care unit and intubated due to an acute [MEDICAL CONDITION] and [MEDICAL CONDITION] PHYSICAL EXAMINATION GENERAL APPEARANCE: The patient is intubated... The patient responds to sternum rub, but not verbal. VITAL SIGNS: Vital signs at this time show temperature of 95.5, pulse 81, respiratory rate 18, blood pressure ,[DATE]. HEENT (head, eyes, ears, nose, and throat): The patient's pupils are dilated and do not react... ASSESSMENT AND PLAN 1. Acute hypothermia. Unfortunately, I cannot assess how long the patient was outside, but given the very low temperature, the prognosis is very critical. For the time being, I will continue current treatment including warm intravenous fluids and warm blankets... 7. Overall, the patient is critically ill and the prognosis is poor..." A consultation report, dated [DATE], documented: "REASON FOR CONSULTATION Respiratory distress CONSULTATION REPORT ...This patient was found to be unresponsive at the nursing home. She apparently had ventured outside. Her temperature was 88 and blood pressure was noted to be 40. She was brought to the ER for evaluation. She was initially brought to the floor for treatment of [REDACTED]. She was transferred to the intensive care unit and was intubated and placed on the ventilator. The patient is unable to provide any history at this time... ASSESSMENT AND PLAN 1. Acute [MEDICAL CONDITION] with mixed respiratory and metabolic acidosis. 2. Shock, it appears to be secondary to a combination of hypothermia and septic shock. ...and we will continue to volume resuscitate the patient. We will discontinue mechanical ventilation as needed. Her overall prognosis appears to be poor. ...The patient has been resuscitated on 3 different occasions... Her overall prognosis is extremely poor..." The hospital discharge summary documented: "...Admit [DATE] 03:23 (3:23 A.M.) Discharg: [DATE] 21:45 (9:45 p.m.)... HISTORY OF PRESENT ILLNESS The patient is a [AGE] year-old white female who was admitted to ICU (intensive care unit) after being found unconscious outside the nursing home the night before. At the time of admission, the patient's rectal temperature was 88.3 Fahrenheit, decreased. No further history obtained. The patient was intubated at the time of admission. HOSPITAL COURSE Despite intensive care, including pulmonologist, Dr. (name deleted), in consultation, the patient appeared to suffer from multiple conditions, [MEDICAL CONDITIONS], acute [MEDICAL CONDITION], hypothermia, metabolic acidosis, and hypothermia. The patient expired on [DATE], at 2145 (9:45 p.m.). The patient was discharged to the funeral home after that. CAUSES OF DEATH 1. Hypothermia. 2.[MEDICAL CONDITION]. 3. Acute [MEDICAL CONDITION]. 4. [MEDICAL CONDITION]." A nurse's note, dated [DATE] at 2:35 p.m., documented, "M.E. (medical examiners) office called, resident expired." The most recent documentation in the nurses' notes, prior to [DATE], was on [DATE] at 1:45 p.m. There was no documentation to determine what had precipitated the resident's worsened condition and/or of interventions implemented to determine what events had occurred to predispose the resident to that non-responsive/hypothermic state. The facility neglected to immediately implement emergency nursing interventions and/or first response/comfort measures when the resident was documented as non-responsive and with a temperature of 84.6 degrees Fahrenheit. While awaiting the ambulance and a call from the physician, the facility neglected to implement emergency response measures for the resident, neglected to continue assessments, and neglected to continue to monitor the resident's vital signs. The facility neglected to initiate immediately an investigation to determine what events had occurred that predisposed the resident to that non-responsive/hypothermic state. On [DATE], an attempt was made to contact all employees by telephone and/or in person. The following interviews were conducted within the facility: - At 11:05 a.m., certified medication aide (CMA) #4 was asked if he knew of anyone who might have gotten harmed or was out in the cold when the weather was bad. He stated there was a female resident, who close to shift change, was on the floor (in the unit). He stated he and another CNA had placed the resident on the couch. He stated "they" had attempted to place the blame on the ,[DATE] shift, but apparently the resident had gotten outside on the ,[DATE] shift. He stated LPN (licensed practical nurse) #1 was the charge nurse. He stated when the resident was found he did not know how long she had been outside. - At 11:20 a.m., CNA #6 stated the resident was on the couch asleep when she left and had not been outside. She stated the resident had been fine and had her clothes and shoes on when they left. She stated "they" said the resident went outside on the ,[DATE] shift. When asked if the resident smoked. She stated she did not think the resident smoked, and if not, she went out and sat with the others. She stated the charge nurse on the ,[DATE] shift was LPN #1. - At 1:39 p.m., CMA #2 stated "they" had tried to blame the ,[DATE] shift, but she didn't know as she had worked the front. When asked who was on duty, she stated LPN #1 and CNA #7 were on duty and she could not remember who else had worked. She stated she had heard the resident did not want to go to bed and was on the couch with her clothes on. When asked who had told her about the incident, she stated she did not remember. - At 1:53 p.m., CMA #3 stated she had heard resident #1 was found outside. When asked if she knew on what shift the incident had happened. She stated she did not know; even to this date. - At 2:00 p.m., CNA #4 stated she had heard a person went outside in January, became hypothermic, and went to the hospital. - At 2:03 p.m., CMA #4 stated he had passed medication on that hall and toward the end of the (,[DATE]) shift, he had helped to lift the resident from the floor. He stated the incident had been reported to LPN #1. He stated the resident was on the couch when he left. He stated he did not know how long she had been there and he never saw her go outside. He stated normally only the smokers went out to the patio and he did not know how she had gotten out. He stated he did not think the resident had the ability to punch the code in the keypad. He stated the next day the resident had been sent out. He stated he did not know who had found her. He stated CNAs #6 and #7 had worked the unit. - At 2:15 p.m., CNA #6 stated the resident was asleep on the couch when she left. She stated CNA #7 had called CMA #4 for assistance to lift the resident from the floor. She stated she did not know if the resident had fallen or not because she would lay on the floor at times. She stated she had words with CNAs #8 and #9, who had worked the ,[DATE] shift that night, on the next day because the ,[DATE] shift had said the resident was cold at 11:00 p.m. When asked if the resident smoked. She stated not to her knowledge, but the resident would go outside with everyone and return when everyone came back inside. When asked who had found the resident. She stated she didn't know. She stated she did not think the resident was at risk for wandering. - At 2:48 p.m., LPN #2 stated LPN #3 was angry because a resident had a low grade temperature on the ,[DATE] shift. She stated LPN #3 felt she had not been told the truth and was upset the day shift had left the resident and had told no one. She stated she did not know who the resident was and had not heard what happened. - At 4:58 p.m., LPN #4 stated she knew of the resident. She stated they had come on duty that night and had just taken over the floor. She stated LPN #1 came to borrow a thermometer. She stated she went to the unit with LPN #1 and LPN #1 took the resident's temperature. She stated she had told LPN #1 since the resident was "not acting right" and her temperature was low; she might need to send her out. She stated LPN #1 called Dr. (name deleted). She stated it had happened at the beginning of the shift. She stated the resident was on the sofa in the day area and she had asked LPN #1 if that was normal for the resident. LPN #1 stated, "It was totally not her." She stated she had told LPN #1 they probably needed to send her out. She stated she had helped prepare the papers to send the resident to the hospital and went back to her area. On [DATE], multiple interviews were conducted with employees. The following interviews were conducted by telephone and/or within the facility: - At 10:30 a.m., CNA #6 was asked if she had reported the incident to anyone. She stated she was not on the unit when the resident was on the floor and had heard it after the fact. - At 3:13 p.m., the DON stated she had been made aware the resident had a low temperature and had been sent to the hospital. She stated LPN #1 had found the resident on the sofa, the resident felt cool, and the LPN had taken her temperature and it had been low. - At 3:31 p.m., the administrator stated he had not been aware the resident had been outside any length of time without supervision. He stated he was told she was in the day room and was sent out to the hospital and passed from exposure or hypothermia or something of that nature. When asked if he had investigated the incident. He stated, "No, that's what I was told. I didn't know anything. She was found on the sofa. I didn't know that she was outside." - At 6:15 p.m., LPN #5 stated she was not there, but was told the resident was real cold when she was found and was laid on the couch in the TV area. She stated she was told the resident was found at change of shift at 11 p.m. She stated everybody knew about it and to keep it hush hush. - At 6:24 p.m., CNA #10 stated she was there the evening it happened, but had left early. She stated when she came back they said they found her outside. On [DATE] at 12:10 p.m., LPN #1 was asked about the night resident #1 was sent to the hospital. She stated she worked the ,[DATE] shift. She stated she was doing her walk through with the ,[DATE] nurse and the resident was up on the sofa. She stated that was usual for the resident, that she didn't usually go to bed until late. She stated they had walked by the resident on the sofa and she said "Hi" to the resident, but she didn't answer. She said she didn't pay much attention, because the TV was on and she thought the resident was watching TV. When she finished her walk through, she sat down beside the resident and spoke to her. She stated there was no response. She touched the resident and she was cold. She stated she got a blood pressure cuff and thermometer to take the resident's vital signs. She stated her blood pressure was hard to tak, her pulse was slow and hard to feel and her temperature was real low. She stated she went to the front and got the other thermometer, that you wipe across the forehead, and went back to take the resident's temperature. She realized there wasn't anything wrong with the thermometer. She stated she then called EMS, the physician, the family and the DON. She stated when EMS got here and went to put her on the gurney, the resident became combative. She started yelling and cursing. She stated that was the resident's first verbal response since she had come on. The LPN was asked if anyone had said why the resident was so cold. She stated, "No, no one said anything." The LPN was asked if the resident could open the outside door unassisted. She stated, "No, normally that was something she was not capable of doing." The LPN was asked if there was anyone else (residents) on the unit that could get out the door without assistance. She stated she believed there were others that could get out. On [DATE] at 9:00 a.m., EMS staff #1 was asked where the resident was when she arrived at the facility. She stated the resident was sitting on the couch in the locked unit. She was asked if the resident was sitting on the couch or if someone was holding her on the couch. She stated the resident was slumped over onto the arm of the sofa. She was asked if the resident started yelling and cursing when they put her on the stretcher. She stated the resident did not yell or curse until they were in route to the hospital. The CNA, who cared for the resident on the ,[DATE] shift on [DATE], no longer worked at the facility. She was unable to be contacted for an interview.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist in regard to the facility's failure to thoroughly identify, investigate and protect a resident from neglect for a resident who was found non-responsive, with garbled speech, gurgled respirations, and whose skin was cold to touch. The resident had a temperature of 84.6 degrees Fahrenheit. On [DATE] at 3:30 p.m., the Oklahoma State Department of Health was notified. The immediate jeopardy situation was verified. At 3:36 p.m., the administrator and the director of nurses were notified of the IJ situation, which constituted substandard quality of care. At 4:26 p.m., an initial plan of removal for the IJ was presented to the survey team. At 4:35 p.m., the initial plan of removal was not accepted. At 4:59 p.m., a second plan of removal was submitted to the survey team. At 5:12 p.m., the second plan of removal was not accepted. At 5:36 p.m., a third plan of removal was submitted to the survey team. At 5:41 p.m., the third plan of removal was not accepted. At 6:38 p.m., the following plan of removal was presented to the survey team: "All incidents will be identified and thoroughly investigated and reported per state regulation. All staff will be in-serviced starting [DATE] at 6:00 p.m. Staff was started notification of in-service at 5:30 p.m. [DATE]. Staff will be in-serviced on what is required as a reportable to the DON (director of nurses) and/or designee. All licensed staff will be in-serviced on the importance of documentation and interventions in nursing notes. All staff will implement first response interventions (i.e. blankets, pillows, ice packs, etc...) Staff will not be allowed to work until they have been in-serviced. Each employee will be in-serviced over, Investigating Allegations of Neglect and Abuse. Conduct the investigation in accordance with established policy. Utilize the Abuse Prohibition Investigations Protocol to complete the task. Those who can't make it due to out of town or vacation will be in-serviced via telephone. Upon returning to work they will be again in-serviced and signed the in-service sheet. The telephone in-services will be documented by those who are giving the in-service and dated. Those employees who cannot be reached by 3 p.m. on [DATE] for inservice will be removed from schedule until they make the required inservice. The DON will come in at 10:30 pm on [DATE], 6:30 am [DATE] and 2:30 pm [DATE] to inservice staff. All staff will be in-serviced by [DATE]. DON or designee will monitor for compliance via incident report and DON will submit detailed summary of all reportable investigations to Administrator. Administrator or designee will follow up on investigation. All reports will be reviewed during morning administrative meetings that meet Monday thru Friday except for holidays. QA (quality assurance) committee will monitor the effectiveness of the plan by discussing and evaluating the interventions taken by staff. The first QA committee will begin [DATE]. The QA committee will meet monthly or as needed. During weather below 50 degrees and above 85 degrees all residents will be escorted outside during appropriate smoking or activity times. This weather would include rain, sleet, snow and ice. The keypad combination will be changed as needed. At time of incident the Administrator of DON was not notified that resident may or may not have been outside. 6:45 p.m." On [DATE] at 10:35 a.m., the administrator and DON were informed that the inservice provided to staff did not cover a plan to prevent another occurrence. The DON stated that she would re-inservice the staff on checking on residents in inclement weather, knowing where residents are and a plan to keep track of residents. On [DATE] at 4:20 p.m., the IJ was removed when all staff had been in-serviced on the following: "IN SERVICE DATE: [DATE] Staff will provide visual every 1 hour checks on resident when temperature falls below 40 and temperatures above 80. Key pad codes will be changed as needed. For memory care unit when residents taking their supervised smoke breaks, and supervised outdoor activities when the temperatures are below 40 and/or above 80 staff will provide a head count before going out and when reentry into building. Report any/all incidents to the DON (director of nurses)/Administrator as soon as possible. DON and Administrators phone numbers will be posted at both nurses stations and will be available to all staff." The deficient practice remained at an pattern level of actual harm. Based on record review and interview, it was determined the facility failed to identify, thoroughly investigate, report to the proper state agencies, and protect a resident from neglect for 1 (#1) of 1 sampled resident who was found non-responsive, with garbled speech, gurgled respirations, and whose skin was cold to touch. The resident had a temperature of 84.6 degrees Fahrenheit. The resident died on [DATE], with [DIAGNOSES REDACTED]. Resident #1 was admitted on [DATE]. The resident had [DIAGNOSES REDACTED]. The elopement risk scale, dated [DATE], documented the resident was ambulatory and wandered aimlessly within the facility or off facility grounds, and had been medically diagnosed with [REDACTED]. The form documented a score of 11 or above indicated a high risk to wander. A Special Care Unit Admission Criteria Review, dated [DATE], documented the resident had Alzheimer's or a related dementia [DIAGNOSES REDACTED]." The admission assessment, dated [DATE], documented the resident had severely impaired cognitive skills and never/rarely made decisions. The resident was easily distracted, had periods of altered perception and restlessness, and her mental function varied over the course of the day. The resident wandered about the unit and required limited to extensive assistance with activities of daily living. The care plan, dated [DATE], documented the resident: ~ had a self-care deficit; required supervision on and off the unit; required limited assistance with dressing, personal hygiene, and bathing; and required extensive assist with toileting; ~ wandered around the locked unit and was easily agitated; ~ had an altered thought process related to dementia; and ~ had a potential for alteration in communication related to dementia. A National Weather Service Form F-6, of local climatological data, documented the low temperature for Oklahoma City on [DATE], was 7 degrees Fahrenheit and the high temperature was 22 degrees Fahrenheit. A nurse's note, dated [DATE] at 11:15 p.m., documented, "Res (resident) in TV area of hall 500 sitting on couch. Res non responsive, Garbled speech, gurgled resp (respiration). Res skin cool to touch. Vitals: BP (blood pressure) ,[DATE] P (pulse) 58 faint. R (respirations) 16 T (temperature) 84.6. 0 (no) facial grimacing noted. Physician (name deleted) called. Waiting on return call. 23:16 (11:16 p.m.) TC (telephone call) to ambulance, DON (director of nurses), resident's son. Left message cont. (continued- on back of page) for res son. 23:30 (11:30 p.m.) Res sent to (name deleted) Hosp (hospital) via ambulance. Mar (medication administration record), cover sheet, & transfer form sent." The emergency medical service (EMS) report, dated [DATE], documented the ambulance arrived at the facility at 11:31 p.m. The note documented, "slumped over on couch in day area of NH (nursing home), staff @ side, Resp - irreg (irregular), shallow, audible congestion, pms (pulse, motor, sensation)- 0 (no) radial, cold to touch, 0 obvious recent trauma. ...Patient found as above after NH staff called (secondary to) unresponsive, hypothermic & hypotensive pt (patient). Pt on couch unable to follow commands, resp- shallow & "gurgling+ unsure of pt's activities this evening, normally confused c (with) "severe dementia" but ambulatory & compliant c commands, occasionally combative. 0 reported recent illness or med (medication) change." A nurse's note, dated [DATE] at 11:45 p.m., documented, "TC from Dr. (name deleted). Advised Dr about res status and res sent to (name deleted) Hosp. Dr. (name deleted) stated, "OK, thank you." A physician's telephone order, dated [DATE], documented, "Send to (name deleted) hospital for eval (evaluation) & treatment (arrow down) LOC (level of consciousness), (arrow down) V/S (vital signs)" The EMS report documented the ambulance left the nursing home at 11:56 p.m. and arrived at the hospital at 12:15 a.m. An Initial Assessment Form from the emergency room at the hospital documented the resident presented on [DATE] at 12:20 a.m. Her temperature was 88.3 degrees rectally. The resident was admitted to the hospital and transferred out of the emergency room at 4:42 a.m. A hospital ER (emergency room ) note documented: "admitted : [DATE] TIME 0715 (7:15 a.m.) SUMMARY I was called to CCU (critical care unit) on a doctor stat (at once) call. The patient is a [AGE] year-old female admitted earlier this morning with altered mental status, hypothermia, and [MEDICAL CONDITION]. The nursing staff reports that after arrival to the floor she had a decrease in her oxygen level and blood pressure. She was there for transfer to the CCU for more intensive monitoring...On my arrival to the unit the patient is being ventilated... The decision was made to go ahead and place the patient on mechanical ventilation due to her respiratory insufficiency." The hospital history and physical documented: "admitted [DATE]... History of present illness The patient is a [AGE] year-old white female who was found unconscious outside the nursing home last night for an unknown duration. At that time, the patient's rectal temperature was 88.3 degrees. The patient was then admitted to the hospital, but later transferred to coronary care unit and intubated due to an acute [MEDICAL CONDITION] and [MEDICAL CONDITION] PHYSICAL EXAMINATION GENERAL APPEARANCE: The patient is intubated... The patient responds to sternum rub, but not verbal. VITAL SIGNS: Vital signs at this time show temperature of 95.5, pulse 81, respiratory rate 18, blood pressure ,[DATE]. HEENT (head, eyes, ears, nose, and throat): The patient's pupils are dilated and do not react... ASSESSMENT AND PLAN 1. Acute hypothermia. Unfortunately, I cannot assess how long the patient was outside, but given the very low temperature, the prognosis is very critical. For the time being, I will continue current treatment including warm intravenous fluids and warm blankets... 7. Overall, the patient is critically ill and the prognosis is poor..." A consultation report, dated [DATE], documented: "REASON FOR CONSULTATION Respiratory distress CONSULTATION REPORT ...This patient was found to be unresponsive at the nursing home. She apparently had ventured outside. Her temperature was 88 and blood pressure was noted to be 40. She was brought to the ER for evaluation. She was initially brought to the floor for treatment of [REDACTED]. She was transferred to the intensive care unit and was intubated and placed on the ventilator. The patient is unable to provide any history at this time... ASSESSMENT AND PLAN 1. Acute [MEDICAL CONDITION] with mixed respiratory and metabolic acidosis. 2. Shock, it appears to be secondary to a combination of hypothermia and septic shock. ...and we will continue to volume resuscitate the patient. We will discontinue mechanical ventilation as needed. Her overall prognosis appears to be poor. ...The patient has been resuscitated on 3 different occasions... Her overall prognosis is extremely poor..." The hospital discharge summary documented: "...Admit [DATE] 03:23 (3:23 A.M.) Discharg: [DATE] 21:45 (9:45 p.m.)... HISTORY OF PRESENT ILLNESS The patient is a [AGE] year-old white female who was admitted to ICU (intensive care unit) after being found unconscious outside the nursing home the night before. At the time of admission, the patient's rectal temperature was 88.3 Fahrenheit, decreased. No further history obtained. The patient was intubated at the time of admission. HOSPITAL COURSE Despite intensive care, including pulmonologist, Dr. (name deleted), in consultation, the patient appeared to suffer from multiple conditions, [MEDICAL CONDITIONS], acute [MEDICAL CONDITION], hypothermia, metabolic acidosis, and hypothermia. The patient expired on [DATE], at 2145 (9:45 p.m.). The patient was discharged to the funeral home after that. CAUSES OF DEATH 1. Hypothermia. 2.[MEDICAL CONDITION]. 3. Acute [MEDICAL CONDITION]. 4. [MEDICAL CONDITION]." A nurse's note, dated [DATE] at 2:35 p.m., documented, "M.E. (medical examiners) office called, resident expired." The most recent documentation in the nurses' notes, prior to [DATE], was on [DATE] at 1:45 p.m. There was no documentation to determine what had precipitated the resident's worsened condition and/or of interventions implemented to determine what events had occurred to predispose the resident to that non-responsive/hypothermic state. The facility neglected to immediately implement emergency nursing interventions and/or first response/comfort measures when the resident was documented as non-responsive and with a temperature of 84.6 degrees Fahrenheit. While awaiting the ambulance and a call from the physician, the facility neglected to implement emergency response measures for the resident, neglected to continue assessments, and neglected to continue to monitor the resident's vital signs. The facility neglected to initiate immediately an investigation to determine what events had occurred that predisposed the resident to that non-responsive/hypothermic state. On [DATE], an attempt was made to contact all employees by telephone and/or in person. The following interviews were conducted within the facility: - At 11:05 a.m., certified medication aide (CMA) #4 was asked if he knew of anyone who might have gotten harmed or was out in the cold when the weather was bad. He stated there was a female resident, who close to shift change, was on the floor (in the unit). He stated he and another CNA had placed the resident on the couch. He stated "they" had attempted to place the blame on the ,[DATE] shift, but apparently the resident had gotten outside on the ,[DATE] shift. He stated LPN (licensed practical nurse) #1 was the charge nurse. He stated when the resident was found he did not know how long she had been outside. - At 11:20 a.m., CNA #6 stated the resident was on the couch asleep when she left and had not been outside. She stated the resident had been fine and had her clothes and shoes on when they left. She stated "they" said the resident went outside on the ,[DATE] shift. When asked if the resident smoked. She stated she did not think the resident smoked, and if not, she went out and sat with the others. She stated the charge nurse on the ,[DATE] shift was LPN #1. - At 1:39 p.m., CMA #2 stated "they" had tried to blame the ,[DATE] shift, but she didn't know as she had worked the front. When asked who was on duty, she stated LPN #1 and CNA #7 were on duty and she could not remember who else had worked. She stated she had heard the resident did not want to go to bed and was on the couch with her clothes on. When asked who had told her about the incident, she stated she did not remember. - At 1:53 p.m., CMA #3 stated she had heard resident #1 was found outside. When asked if she knew on what shift the incident had happened. She stated she did not know; even to this date. - At 2:00 p.m., CNA #4 stated she had heard a person went outside in January, became hypothermic, and went to the hospital. - At 2:03 p.m., CMA #4 stated he had passed medication on that hall and toward the end of the (,[DATE]) shift, he had helped to lift the resident from the floor. He stated the incident had been reported to LPN #1. He stated the resident was on the couch when he left. He stated he did not know how long she had been there and he never saw her go outside. He stated normally only the smokers went out to the patio and he did not know how she had gotten out. He stated he did not think the resident had the ability to punch the code in the keypad. He stated the next day the resident had been sent out. He stated he did not know who had found her. He stated CNAs #6 and #7 had worked the unit. - At 2:15 p.m., CNA #6 stated the resident was asleep on the couch when she left. She stated CNA #7 had called CMA #4 for assistance to lift the resident from the floor. She stated she did not know if the resident had fallen or not because she would lay on the floor at times. She stated she had words with CNAs #8 and #9, who had worked the ,[DATE] shift that night, on the next day because the ,[DATE] shift had said the resident was cold at 11:00 p.m. When asked if the resident smoked. She stated not to her knowledge, but the resident would go outside with everyone and return when everyone came back inside. When asked who had found the resident. She stated she didn't know. She stated she did not think the resident was at risk for wandering. - At 2:48 p.m., LPN #2 stated LPN #3 was angry because a resident had a low grade temperature on the ,[DATE] shift. She stated LPN #3 felt she had not been told the truth and was upset the day shift had left the resident and had told no one. She stated she did not know who the resident was and had not heard what happened. - At 4:58 p.m., LPN #4 stated she knew of the resident. She stated they had come on duty that night and had just taken over the floor. She stated LPN #1 came to borrow a thermometer. She stated she went to the unit with LPN #1 and LPN #1 took the resident's temperature. She stated she had told LPN #1 since the resident was "not acting right" and her temperature was low; she might need to send her out. She stated LPN #1 called Dr. (name deleted). She stated it had happened at the beginning of the shift. She stated the resident was on the sofa in the day area and she had asked LPN #1 if that was normal for the resident. LPN #1 stated, "It was totally not her." She stated she had told LPN #1 they probably needed to send her out. She stated she had helped prepare the papers to send the resident to the hospital and went back to her area. On [DATE], multiple interviews were conducted with employees. The following interviews were conducted by telephone and/or within the facility: - At 10:30 a.m., CNA #6 was asked if she had reported the incident to anyone. She stated she was not on the unit when the resident was on the floor and had heard it after the fact. - At 3:13 p.m., the DON stated she had been made aware the resident had a low temperature and had been sent to the hospital. She stated LPN #1 had found the resident on the sofa, the resident felt cool, and the LPN had taken her temperature and it had been low. - At 3:31 p.m., the administrator stated he had not been aware the resident had been outside any length of time without supervision. He stated he was told she was in the day room and was sent out to the hospital and passed from exposure or hypothermia or something of that nature. When asked if he had investigated the incident. He stated, "No, that's what I was told. I didn't know anything. She was found on the sofa. I didn't know that she was outside." - At 6:15 p.m., LPN #5 stated she was not there, but was told the resident was real cold when she was found and was laid on the couch in the TV area. She stated she was told the resident was found at change of shift at 11 p.m. She stated everybody knew about it and to keep it hush hush. - At 6:24 p.m., CNA #10 stated she was there the evening it happened, but had left early. She stated when she came back they said they found her outside. On [DATE] at 12:10 p.m., LPN #1 was asked about the night resident #1 was sent to the hospital. She stated she worked the ,[DATE] shift. She stated she was doing her walk through with the ,[DATE] nurse and the resident was up on the sofa. She stated that was usual for the resident, that she didn't usually go to bed until late. She stated they had walked by the resident on the sofa and she said "Hi" to the resident, but she didn't answer. She said she didn't pay much attention, because the TV was on and she thought the resident was watching TV. When she finished her walk through, she sat down beside the resident and spoke to her. She stated there was no response. She touched the resident and she was cold. She stated she got a blood pressure cuff and thermometer to take the resident's vital signs. She stated her blood pressure was hard to tak, her pulse was slow and hard to feel and her temperature was real low. She stated she went to the front and got the other thermometer, that you wipe across the forehead, and went back to take the resident's temperature. She realized there wasn't anything wrong with the thermometer. She stated she then called EMS, the physician, the family and the DON. She stated when EMS got here and went to put her on the gurney, the resident became combative. She started yelling and cursing. She stated that was the resident's first verbal response since she had come on. The LPN was asked if anyone had said why the resident was so cold. She stated, "No, no one said anything." The LPN was asked if the resident could open the outside door unassisted. She stated, "No, normally that was something she was not capable of doing." The LPN was asked if there was anyone else (residents) on the unit that could get out the door without assistance. She stated she believed there were others that could get out. On [DATE] at 9:00 a.m., EMS staff #1 was asked where the resident was when she arrived at the facility. She stated the resident was sitting on the couch in the locked unit. She was asked if the resident was sitting on the couch or if someone was holding her on the couch. She stated the resident was slumped over onto the arm of the sofa. She was asked if the resident started yelling and cursing when they put her on the stretcher. She stated the resident did not yell or curse until they were in route to the hospital.