Every finding on record at Pocola Health and Rehab

Based on observation, record review, and interview, the facility failed to monitor and prevent sexual abuse for 1 (#1) 1 sampled resident reviewed for abuse.The director of nursing identified 62 residents resided in the facility. Findings:Findings: An undated, Elder Abuse Policy and Procedure, read in part, It is the policy of .to thoroughly investigate all allegations concerning resident abuse .to prevent further abuse .pending an investigation. This facility reserves the right to take whatever actions it, in its sole discretion, deems appropriate to investigate and to prevent possible abuse .Abuse: Any intentional act of one or more of the following .sexual physical, mental/emotional .involuntary seclusion which may be imposed on a resident of this facility by any .or other residents .Abuse is a non-accidental .or sexual abuse, whenever there is impermissible or unjustifiable harmful or offensive contact with the resident .Contact with a resident may constitute abuse even if there is no evidence of physical injury, as long as there has been significant psychological harm. Significant psychological harm has occurred if .the contact intimidates the resident .or the contact subjects the resident to .loss of privacy or personal dignity, and the contact causes noticeable level of .emotional distress .examples .twisting, squeezing, or pinching part of resident's body .sexual molestation .Neglect is when a caregiver fails to provide treatment or services which are necessary to maintain or improve resident's health or safety and this failure results in lack of expected improvements or noticeable deterioration of physical, mental, or emotional condition and jeopardy to health, safety, or welfare .Examples .failure to adequately supervise resident's whereabouts .Battery is touching someone without permission .roughly, or forcing someone to do something they don't want to do.An undated, Abuse Prohibition Training Program, read in part, The abuse prohibition program promotes resident safety and prevents abuse in the long-term care environment. It is designed to give .confidence in the facility's ability to minimize the risk of abuse within the facility. Abuse can be resident to resident .remember .most residents are placed in long term care facilities to provide them with a safe environment. Abuse is serious business.Res #1's EHR, under face sheet, showed them as their own responsible party.Res #1's EHR, under medical diagnosis tab, showed a medical diagnosis, dated 04/15/25, of unspecified dementia, unspecified severity with other behavioral disturbance. Res #2's, EHR, under medical diagnosis tab, showed a medical diagnosis, dated 05/19/25, of hypertension and kidney failure.Res #1's care plan, dated 09/02/25, showed the resident had impaired cognitive function/dementia or impaired thought processes r/t dementia, short term memory loss with behavioral disturbances.Res #1's quarterly MDS, dated [DATE], showed the resident admitted to the facility 03/08/23 and had a BIMS of 03 which indicated a cognitive status of severe impairment.A nursing note, dated 10/05/25, read in part, [Resident #1] was found in another Resident's room [Resident #3], with a [gender withheld] [Resident #2]. Both were on the bed [they] were sitting on the bed, and the [gender withheld] [Resident #2] was lying back on the bed with the zipper of [their] pants open. Separated residents and sent them to their respective rooms. Notified DON.An OSDH form 283, dated 11/10/25, read in part, Allegation of abuse/mistreatment .housekeeper came to this nurse and reported another resident had touched this resident on the breast. Nurse asked both residents, in which the other resident stated [they] did not and that this resident did it to [themselves.] Nurse asked a resident sitting directly next to the incident, in which the resident states, 'I did not see anything, leave me out of it.' This nurse immediately went to DON and cameras were watched to verify incident.A Behavior Note, dated 10/03/25 by LPN #5, read in part, Activities staff came to nurses' desk and stated that [Resident #2] and [Resident #5] were making out in the activities room. [Resident #2] and other [Resident #5] were sitting beside each other and [Resident #2] stated [they] wanted the other [Resident #5] separated. Spoke with staff and [Resident #5] stated [Resident #2] was a 'willing participant.' Residents were separated and will continue to monitor.A Behavior Note, dated 10/04/25 at 11:46 a.m., by LPN #2, read in part, One of our cognitively impaired residents kicked [Resident #2] and [they] turned around and [their] fist up like [they were] going to hit [them.] Staff redirected both residents away from each other. [Resident #2] was reminded that the resident who kicked [them] does not know what [they were] doing due to [their] cognitive status and that if [they] kicked [them] again, [they needed] to step away from [them] and get a staff member.A Behavior Note, dated 10/04/25 at 9:01 p.m., by LPN #4, read in part, CMA notified nurse that [they] could not find [Resident #2] to give evening medications. Looked for [Resident #2] and found [them] in [Resident #3] room lying in bed B with [their] pants unzipped with [Resident #1] sitting on the bed beside [them]. Nurse sent residents back to their respective rooms. Called DON to notify regarding behaviors.A Behavior Note, dated 10/05/25 at 1:04 p.m., by RN #1, read in part, [Resident #2] found sitting up front of building on couch with a cognitively impaired [gender withheld] with [their] arm the top of [their] shoulders. This nurse requested [Resident #2] walk with me, which [they] did. Spoke with [Resident #2] and told [them] could not be cuddling up with this [gender withheld.] He said, 'I know. I know. I'm sorry.' Resident ambulated to dining room. Will continue to monitor.A Behavior Note, dated 10/05/25 at 1:15 p.m., by RN #1, read in part, [Resident #2] ambulated through dining room and around back to day room where [they] called previous [gender withheld)] resident back over to sit with [them] again. [Resident #2] noted to be holding [their] hand when this nurse approached. Requested [Resident #2] to please move away from said [gender withheld.] [Resident #2] stated, 'I'll just fuckin go to my room!' and was heard mumbling curse words down [their] hall.A Behavior Note, dated 10/05/25 at 3:00 p.m., by LPN #6, read in part, Aid came to nurse station, stating what if [family member #4] walked in and seen [them] holding hands with [Resident #4], at this nurse then walked over and asked [Resident #2] to quit holding hands with [Resident #4], that [they] was married and this was not appropriate, [Resident #2] grinned and said, 'ok', this nurse also reminded [Resident #2] that [RN #1] had already advised [them] that [they] was not to have physical contact with any of the [gender withheld] residents. [Resident #2] stated, 'no [they] did not', I said yes [they] did and these actions would not be tolerated, at this point [RN #1] came and reaffirmed [RN #1] did in fact advise [Resident #2] this was inappropriate. [RN #1] and myself stood by and asked [Resident #2] to either move seats or go to [their] room, [they] continued to sit next to [Resident #4], I stated, [Resident #2] please either go to your room or move to another seat away from [Resident #4]. [Resident #2] looked at me and said, 'only because you said please,' [they] then got up and went to [their] room.A Behavior Note, dated 10/05/25 at 3:18 p.m., read in part, DON notified of [Resident #2] recent reoccurring behaviors. Stated [they the DON] would contact family. Resident placed on 1:1 with staff at this time.A Communication with family, NOK, POA, dated 10/05/25 at 3:52 p.m. by RN #1, read in part, DON spoke with residents POA concerning [Resident #2] behaviors towards other residents, POA agrees to sending referrals out to .and .Referrals faxed out .[Resident #2] to remain 1 on 1 with staff until further notice for resident safety.A Behavior Note, dated 10/06/25 at 8:21 a.m., by LPN #2, read in part, Staff told [Resident #2] that [they] had to sit in one of the chairs in the day room and could not sit on the couch with anyone else. Res (#2) replied to the staff member, 'Shut the fuck up.' and proceeded to go to [their] room.A Behavior Note, dated 10/06/25 at 11:16 a.m., by the DON, read in part, Spoke with [name deleted] social worker that was the social worker who we worked with to get [them] into the facility. [They] had started with unwanted attention (in a romantic nature and/or sexual nature) to our vulnerable elderly [gender withheld] in the facility with dementia. [They had] been told numerous times that [they] cannot do that and explained why but has cursed staff and disregarded the instruction. Me and the Administrator spoke with [Resident #2] this am and explained to [them] that [they] cannot go into a [gender withheld] room nor can [they] make advances to the [[gender withheld] in this facility especially those who have dementia. I explained that we have spoke with the social worker and sent referrals out to other facilities who might take [them] into their facility and [they] said that was fine 'send me out of here'. This behavior was noticed on Saturday and [they] had been one on one since then until we can find a place for [them] to go. We will continue to monitor this situation very closely and [they] will continue with the one on one.A Behavior Note, dated 10/06/25 at 11:51 a.m., by LPN #2, read in part, [Resident #2] went into the activities room and went up to talk to one of the [gender withheld] residents. Staff told [Resident #2] that [they] needed to move to another seat. [Resident #2] went to another table across the room facing the same resident and proceeded to start making faces and hand gestures, sticking out [their] tongue in a sexually suggestive manner. [Resident #2] then started making the same gestures to another cognitively impaired resident and [they] were moved away from [them]. [Resident #2] remains 1 on 1 direct supervision with staff member. After 10/09/25 at 11:47 p.m. until 10/22/25 p.m. there was no one on one documentation for Resident #2 for 13 days or 16 days after the DON documented, [Resident #2] has been one on one since then until we can find a place for [them] to go.A Behavior Note, dated 10/12/25 at 1:31 a.m., read in part, twice this shift [Resident #2] has gotten up and roaming around, stops at the nurse's station saying, 'this place is a piece of shit' then walks off [they] has gone down wrong hallway and when asked [they] says [they] is looking for [their] room, once directed to hall 4 [they] goes straight to [their] room and lays down.A Behavior Note, dated 10/12/25 at 7:23 p.m., read in part, [Resident #2] found to be sitting next to [gender withheld] resident with dementia holding hands. [Resident #2] was asked to scoot away. [Resident #2] got up rounded the desk cursing, said 'what the fuck is this shit?'A Behavior Note, dated 10/15/25, read in part, [Resident #2] noted to be sitting next to a [gender withheld] resident with dementia on couch in dayroom. This nurse approached residents to ensure [Resident #2] was not being inappropriate. Encouraged [Resident #2] to sit in one of the many empty chairs, [Resident #2] became angry stating, 'I don't know about this shit.'A Psychiatric Progress Note, dated 10/15/25, read in part, Staff have no new reports or requests regarding pt at this time.Resident #2's, care plan, dated 10/26/25, read in part, behavior problem, [they] attempted to be sexually/romantically inappropriate with other residents .[they] will have no evidence of behavior problems through the review date .caregivers to provided opportunity for positive interaction, attention .explain/reinforce why behavior is inappropriate and/or unacceptable to the resident .intervene as necessary to protect the rights and safety of others .remove from situation and take to alternate location as needed .monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes .Praise any indication of resident's progress/improvement in behavior.A Communication with resident dated 10/22/25 at 4:21 p.m., read in part, It was brought to the attention of the administrator and the director of nursing about [Resident #2] going into [gender withheld] resident's rooms after being told [they] cannot go into a [gender withheld] resident's room especially if they have dementia. [Resident #2] became very defensive and aggressive slamming the glass door to the DON's office. Called [family member #2 POA guardian] to tell [them] that [Resident #2] will have to be discharged d/t disregard for [gender withheld] residents and going into their room after being told many times not to do that. [Resident #2] has been a one on one before for this type of behavior with [gender withheld] residents but continues to disregard instruction and gets very defensive and aggressive. I (DON) called [their] [family member #2] and told [them] [Resident #2] cannot stay here anymore giving [them] a verbal 30-day notice and will give them (Resident #2 and POA/guardian) a written 30-day notice. I [DON] have sent out referrals before when [Resident #2] was inappropriate, but no one would take [Resident #2], but we cannot subject our vulnerable [gender withheld] residents to this type of inappropriate behavior. [Resident #2] is one on one until this inappropriate behavior can be resolved.A Behavior Note, date 10/23/25 at 6:30 p.m., read in part, [Resident #2] attempted to follow a [gender withheld] resident to [their] room. When attempting to redirect [Resident #2] [they] proceeded to say, 'call the cops. I have dealt with them before. The number is 1-800-eat-shit. I don't know how you all deal with this bullshit place.' Informed [Resident #2] that [they] had [their] own room, and [they] could not go into the [gender withheld] resident's room. [Resident #2] eventually went to [their] own room.After 10/24/25 at 6:09 a.m. there were no one on one documentation for Resident #2. A nursing note, dated 11/10/25 at 2:54 p.m., showed the housekeeper reported an allegation of abuse; 17 days from the last one on one documentation; 19 days after the DON documented, [Resident #2] is one on one until this inappropriate behavior can be resolved.Res #2's, discharge return not anticipated MDS, dated [DATE], showed the resident admitted to the facility 05/19/25 and had a BIMS of 09 which CMS showed a total score of 09 reflected a cognitive status of moderate impairment.On 11/24/25 at 3:44 p.m., CNA #2 stated activity people were used for one on one's for resident monitoring.On 11/24/25 at 12:46 p.m., LPN #5 identified [gender withheld] Resident #5. They stated [Resident #2] did not resist.On 11/25/25 at 8:41 a.m., housekeeper #1 stated they were cleaning the shower room on hall 4, [Resident #2] was sitting next to [Resident #1.] [Resident #2] would flirt with them to get them to hold their hand or rub their leg. Housekeeper #1 stated they witnessed [Resident #2] was touching their upper body [breast.] When they told them they had to report it, they laughed and stated, I don't care. [Nurse #1] was on duty at the nurse's station.On 11/25/25 at 8:52 a.m., LPN #1 described Resident #2 as very flirtatious. They stated, [They'll] try to get away with what [they] can. They went straight to the DON. They stated [Resident #2] would be flirtatious with certain individuals because they would give them attention. Every time Resident #2 would have an incident they would be put on a one on one. Activity would rotate. Then after they left, we, the nurses, would keep an eye on him. LPN #1 stated the DON determined when to start the one on one and when to stop the one on one. LPN #1 stated Resident #2 interacted mostly with dementia residents.On 11/25/25 at 9:36 a.m., the DON stated they determined a resident was a one on one any time there was inappropriate behavior.On 11/25/25 at 11:07 a.m., LPN #4 stated a CNA had started rounds and had seen [Resident #2] in [Resident #3's room] with [Resident #1]. LPN #4 observed [Resident #1] was sitting at the foot board. [Resident #2] was leaning back sitting on bed, feet on floor, [their] bottom to head laid back on bed; noticed pants unzipped. No appendages out. [their] pants were unzipped. [Resident #1] was sitting on the end of the bed. Nobody was touching themselves or each other.On 11/25/25 at 11:24 a.m., the DON stated nobody accepted [Resident #2] with the first round of referrals. [Resident #2] got much better.On11/25/25 at 11:57 a.m., LPN #2 stated they could not remember who the two [gender withheld] residents were. LPN #2 stated Resident #2 did make sexually suggestive faces and hand gestures.On 11/25/25 at 12:24 p.m., activity assistant #1 stated Resident #2 used sexual gestures with tongue and hands, but really remembered them for being angry, loud, and agitated.On 11/25/25 at 3:09 p.m., the DON stated they determined consent by the resident's mental status, their (DON) experience, and if they (Resident's) were of sound mind.

Based on record review and interview, the facility failed to provide a copy of the facility bed hold policy to residents discharged to the hospital for 2 (#9 and #61) of 2 sampled residents whose clinical records were reviewed for hospital discharge. The DON identified three residents who were discharged to the hospital in the last 90 days. Findings: 1. A significant change assessment, dated 04/16/25, showed Res #61 had diagnoses which included renal failure and hypertension. The assessment showed Res #61 had a BIMS score (a test of cognitive function) of 2, which was indicative of severe cognitive impairment. A health status note, dated 06/01/25 at 10:50 a.m., showed Res #61 was being sent to the emergency room for evaluation and the power of attorney was notified and an ambulance was called. On 07/24/25 at 2:28 p.m., LPN #1 stated they did not give a copy of the bed hold policy to residents when they were sent to the hospital. On 07/24/25 at 2:30 p.m., the DON stated they gave residents a copy of the bed hold policy upon admission, but not at the time of transfer to the hospital. 2. A nurse's progress note, dated 05/15/25, showed Res #9 was sent to the emergency room and later admitted to the hospital for acute cystitis on 05/15/25. There was no documentation in the clinical record the resident received a copy of the facility bed hold policy when they transferred to the hospital. A nurse's progress note, dated 05/17/25, showed Res #9 was readmitted to the facility from the hospital on [DATE]. The quarterly assessment, dated 06/22/25, showed Res #9 was moderately impaired in cognition (BIMS of 10). On 07/24/25 at 2:30 p.m., LPN #1 stated they did not provide residents with copies of the facility bed hold policy when residents were sent to the hospital. On 07/28/25 at 4:10 p.m., the DON stated the facility went over the bed hold policy on admission and normally did not hand out the bed hold policy again after the initial admission. The DON stated the resident was probably told about the bed hold policy 10 years ago and their bed was held ever since.

Based on observation and interview, the facility failed to ensure an enteral tube feeding bag was properly labeled for 1 (#7) of 1 sampled resident reviewed for tube feeding management. The DON identified one resident who received enteral tube feeding via continuous pump. Findings:On 07/22/25 at 12:51 p.m., Res #7 was observed with tube feeding running at 50ml/hr. No label was observed on the tube feeding bag. On 07/29/25 at 8:04 a.m., Res #7 was observed with tube feeding running at 50ml/hr. No label was observed on the tube feeding bag.On 07/29/25 at 2:03 p.m., certified medication aide #1 stated they could not tell by looking at the tube feeding bag which resident it was intended for or what time it was hung. They stated it should have a label on the bag. On 07/29/25 at 2:06 p.m., LPN #1 stated they could not identify which resident the tube feeding was for because the bag was not labeled. LPN #1 stated they did not know why it was not labeled. On 07/29/25 at 2:30 p.m., the DON stated they could not tell what time or date the bag of tube feeding was hung. They stated they could not tell which resident it was intended for because there was not a label on the bag. The DON stated it should have a label on it and they did not know why it was not labeled.

Based on record review and interview, the facility failed to ensure PRN psychotropic medication orders were limited to 14 days and then re-evaluated for 1 (#57) of 5 sampled residents reviewed for unnecessary medications.The DON identified 50 residents received psychotropic medications. Findings:An undated Pharmacy Service Policy, read in part, PRN orders for psychotropic drugs are limited to 14 days, unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. Should the attending physician or prescribing practitioner believe that it is appropriate for the PRN order to be extended beyond 14 days, he or she will document his/her rationale in the residents' medical record and indicate the duration for the PRN order.A physician's order, dated 02/22/25, showed Res #57 was to receive 0.5 milligrams of Ativan (an antidepressant medication) by mouth every 12 hours as needed for anxiety. The order did not have an end date.A Pharmaceutical Consultant Report, dated 03/28/25, read in part, This resident has been identified as receiving an 'AS NEEDED' psychoactive medication which could be considered a chemical restraint. The order may be extended beyond 14 days if prescribing physician believes it is appropriate. Physician should document the rationale for the extended time period in the medical record and indicate a specific duration .Physician Response to Review (Please check appropriate line & write needed comments): Report Reviewed-No Changes as I prefer the order remain as a 'PRN', unless directed to change in the future. My rationale for continuance is as follows (Must be handwritten rationale): No duration or handwritten rationale was provided by the physician. A quarterly assessment, dated 06/05/25, showed Res #57 had diagnoses which included anxiety disorder and depression. The assessment showed Res #57 had a BIMS (a test for cognition) of 15 which was indicative of intact cognition and Res #57 received an antianxiety medication.On 07/24/25 at 2:28 p.m., LPN #1 stated PRN antianxiety medications should only be ordered for two weeks at a time.On 07/24/25 at 2:28 p.m., the DON stated PRN psychotropic medications should only be ordered for two weeks unless a rationale and a duration were provided by the physician.

On 03/24/25, an Immediate Jeopardy (IJ) was determined to exist related to the facilities failure to ensure CMAs were trained and competent to ensure residents were administered medications as ordered. On 03/15/25 at 10:10 a.m., a nurse note showed CMA #1 reported to RN #1 they may have administered the wrong medications to Resident #2. The note showed the DON was notified and camera footage was reviewed, confirming Resident #2 was administered the wrong medications. The note showed the physician was notified and orders were received to send the resident to the emergency room . On 03/24/25 at 8:13 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On 03/24/25 at 8:27 p.m., the DON was notified of the IJ situation and provided the IJ template. On 03/26/25 at 12:58 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The POR showed the actions to remove the immediacy of the alleged deficient practice were as follows: The plan of removal read in part, POR for Immediate Jeopardy Template #2. The following is a POR (Plan of Removal) for Pocola Health and Rehab on an Immediate Jeopardy given to this facility at 8:36 pm on 03-24-25 on [resident name withheld] for a medication error on 03-15-25 by a CMA. 1) Policy updated on Medication Administration for all staff members (which include CMAs and Nurses) who give medications. Which will include new hire competency skills check, training which will be determined by experience of a minimum of 2 weeks and more if determined necessary. Yearly competency skills check and evaluation will be done. Job descriptions were also update [sic] on staff who give medications which include CMAs and Nurses. All CMAs are also required to do an 8 hour update class yearly on medication administration. 2) The EHR and the EMAR will be flagged for all staff members who give medications for residents who look alike or similar in appearance and also residents who share the same last name. 3) In services will be held for CMAs and Nurses on medications errors, new policies for medication errors, competency skills checks and evaluation. In services already completed were done on 03-17-25 for CMAs and 03-21-25 for Nurses. 4) Competency skills check offs starting today 03-25-25 for all 3 CMAs on duty by a designee of the DON on medication pass for 5 residents reach [sic] and this will continue until all CMAs and Nurses are checked off for their shift and cannot returned [sic] to work until completed. 5) QAPI [Quality Assurance and Performance Improvement] Committee Meeting held this morning at 9:00 am on 03-25-25 for recent IJ for medication error on 03-15-25. A Plan of Removal discussed and will be submitted for approval. 6) To ensure that this does not happen again to the 2 residents that look alike 2 CMAs or Nurse will monitor the medication administration for those 2 residents involved in the most recent medication error on 03-15-25. All of the above mentioned POR have already been completed and if not are in the process of being completed, and will continued [sic] to be Policy [sic] of this facility to ensure that this facility DOES NOT EVER have another medication error. We understand that all residents are at risk for this alleged deficiency which all steps will be done to ensure that this does not happen to another resident in this facility. POR will be competed [sic] by 03-26-25 at midnight. On 03/27/25, after interviews with facility staff, a review of in-service training, and staff competencies, the IJ was lifted effective 03/27/25 at 12:10 p.m. The deficient practice remained at an isolated level with the potential for more than minimal harm. Based on record review and interview, the facility failed to ensure CMAs were trained and competent to ensure residents were administered their medications as ordered for 1 (#2) of 4 sampled residents reviewed for medication administration. The DON reported 55 residents resided in the facility. Findings: A facility policy, titled Medication Administration, dated 10/10/16, read in part, It is the policy of Pocola Health and Rehab (PHR) to give the correct medication to the correct resident following the eight rights. The right resident, the right medication, the right dose, the right route, the right time, the right documentation, the right reason, and the right response. Resident #2 had diagnoses which included aphasia, vascular dementia, and cerebrovascular disease. A care plan focus, revised on 09/21/24, showed Resident #2 was at risk for hypotension (low blood pressure). A quarterly assessment, dated 02/06/25, showed Resident #2 had a BIMS score (a test for cognitive function) of 3, which was indicative of severe impairment for daily decision making. A nurse note, dated 03/15/25 at 10:10 a.m., showed CMA #1 reported to RN #1 they may have administered the wrong medications to Resident #2. The note showed the DON was notified and camera footage was reviewed, confirming Resident #2 was administered another residents medication. The note showed the physician was notified and orders were received to send Resident #2 to the emergency room . An incident note, dated 03/15/25, showed Resident #2's blood pressure was 146/21 when paramedics arrived to transport the resident to the hospital. A nurse note, dated 03/15/25 at 5:33 p.m., showed Resident #2 was admitted to the intensive care unit for adverse reaction to medication, hypotension (low blood pressure), and hyponatremia (low sodium level). An Oklahoma State Department of Health form 283, dated 03/15/25, showed Resident #2 had been administered another residents medication including: furosemide 20mg (a diuretic), lisinopril 40mg (a blood pressure medication), citalopram 40mg (an antidepressant), diazepam 2mg (an antianxiety medication), oxycodone/acetaminophen 10/325mg (a pain medication), and carbidopa/levodopa 25/100mg (an antiparkinsonian medication). An After Visit Summary, dated 03/24/25 at 9:05 a.m., showed Resident #2 was admitted to the hospital because they were administered medications which were not prescribed to them that caused very low blood pressure. The summary also showed Resident #2 was administered medications to keep their blood pressure up while the other medications wore off. A review of CMA #1's employee file showed they were hired on 03/22/23 and had no skills evaluation/check off since 05/19/23. A review of CMA #2's employee file showed they were hired on 12/06/22 and had no skills evaluation/check off since 12/09/23. A review of CMA #3's employee file showed they were hired on 04/19/21 and had no skills evaluation/check off since 04/17/23. A review of CMA #4's employee file showed they were hired 12/29/22 and did not show any skills evaluations had been completed. A review of CMA #6's employee file showed they were hired on 03/11/22 and had not had a skills evaluation/check off since 04/19/23. On 03/24/25 at 4:05 p.m., the DON reported CMA's completed skills check offs upon hire, but they were unsure if they were done routinely after hire. The DON stated on 01/21/24, the exact same medication error had occurred when CMA #2 administered Resident #2 the wrong medications. The DON stated Resident #2 was hospitalized on that occasion as well and that CMA #2 was educated regarding the 8 rights of medication administration, but no other interventions were put in place. The DON also stated they did not routinely observe medication administration. On 03/24/25 at 5:26 p.m., the DON stated the facility considers the eight hours of annual CMA training to be their annual competencies. On 03/25/25 at 9:45 a.m., CMA #2 stated they had taken the position of CNA/CMA supervisor in February. They stated they had not completed any annual CMA competencies since then, and they were unsure if the facility was doing them prior to that. On 03/25/25 at 10:47 a.m., CMA #3 stated they did not recall completing a skills check off. On 03/25/25 at 10:55 a.m., CMA #4 stated they were unsure if the facility did annual skills check offs or not. On 03/25/25 at 11:50 a.m., the pharmacy consultant for the facility stated they visited the facility once a month and usually observed medication administration while in the facility. They also stated they only visited during normal business hours, so they had never observed night shift staff or weekend staff pass medication. On 03/27/25 at 10:26 a.m., the DON stated annual CMA competencies have not been completed consistently for the last two years. They also stated all medication errors are avoidable.

On 03/24/25, an Immediate Jeopardy (IJ) was determined to exist related to the facilities failure to ensure CMAs were trained and competent to ensure residents were administered medications as ordered. On 03/15/25 at 10:10 a.m., a nurse note showed CMA #1 reported to RN #1 they may have administered the wrong medications to Resident #2. The note showed the DON was notified and camera footage was reviewed, confirming Resident #2 was administered the wrong medications. The note showed the physician was notified and orders were received to send the resident to the emergency room . On 03/24/25 at 8:13 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On 03/24/25 at 8:27 p.m., the DON was notified of the IJ situation and provided the IJ template. On 03/26/25 at 12:58 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. It showed the actions to remove the immediacy of the alleged deficient practice were as follows: The plan of removal read in part, POR for Immediate Jeopardy Template #2. The following is a POR (Plan of Removal) for Pocola Health and Rehab on an Immediate Jeopardy given to this facility at 8:36 pm on 03-24-25 on [resident name withheld] for a medication error on 03-15-25 by a CMA. 1) Policy updated on Medication Administration for all staff members (which include CMAs and Nurses) who give medications. Which will include new hire competency skills check, training which will be determined by experience of a minimum of 2 weeks and more if determined necessary. Yearly competency skills check and evaluation will be done. Job descriptions were also update [sic] on staff who give medications which include CMAs and Nurses. All CMAs are also required to do an 8 hour update class yearly on medication administration. 2) The EHR and the EMAR will be flagged for all staff members who give medications for residents who look alike or similar in appearance and also residents who share the same last name. 3) In services will be held for CMAs and Nurses on medications errors, new policies for medication errors, competency skills checks and evaluation. In services already completed were done on 03-17-25 for CMAs and 03-21-25 for Nurses. 4) Competency skills check offs starting today 03-25-25 for all 3 CMAs on duty by a designee of the DON on medication pass for 5 residents reach [sic] and this will continue until all CMAs and Nurses are checked off for their shift and cannot returned [sic] to work until completed. 5) QAPI [Quality Assurance and Performance Improvement] Committee Meeting held this morning at 9:00 am on 03-25-25 for recent IJ for medication error on 03-15-25. A Plan of Removal discussed and will be submitted for approval. 6) To ensure that this does not happen again to the 2 residents that look alike 2 CMAs or Nurse will monitor the medication administration for those 2 residents involved in the most recent medication error on 03-15-25. All of the above mentioned POR have already been completed and if not are in the process of being completed, and will continued [sic] to be Policy [sic] of this facility to ensure that this facility DOES NOT EVER have another medication error. We understand that all residents are at risk for this alleged deficiency which all steps will be done to ensure that this does not happen to another resident in this facility. POR will be competed [sic] by 03-26-25 at midnight. On 03/27/25 after interviews with facility staff, a review of in-service training, and staff competencies, the IJ was lifted effective 03/27/25 at 12:10 p.m. The deficient practice remained at an isolated level with the potential for more than minimal harm. Based on record review and interview, the facility failed to ensure CMAs were trained and competent to ensure residents were administered their medications as ordered for 1 (#2) of 4 sampled residents reviewed for medication administration. The DON reported 55 residents resided in the facility. Findings: A facility policy, titled Medication Administration, dated 10/10/16, read in part, It is the policy of Pocola Health and Rehab (PHR) to give the correct medication to the correct resident following the eight rights. The right resident, the right medication, the right dose, the right route, the right time, the right documentation, the right reason, and the right response. Resident #2 had diagnoses which included aphasia, vascular dementia, and cerebrovascular disease. A care plan focus, revised on 09/21/24, showed Resident #2 was at risk for hypotension (low blood pressure). A quarterly assessment, dated 02/06/25, showed Resident #2 had a BIMS score (a test for cognitive function) of 3, which was indicative of severe impairment for daily decision making. A nurse note, dated 03/15/25 at 10:10 a.m., showed CMA #1 reported to RN #1 they may have administered the wrong medications to Resident #2. The note showed the DON was notified and camera footage was reviewed, confirming Resident #2 was administered another residents medication. The note showed the physician was notified and orders were received to send Resident #2 to the emergency room . An incident note, dated 03/15/25, showed Resident #2's blood pressure was 146/21 when paramedics arrived to transport the resident to the hospital. A nurse note, dated 03/15/25 at 5:33 p.m., showed Resident #2 was admitted to the intensive care unit for adverse reaction to medication, hypotension (low blood pressure), and hyponatremia (low sodium level). An Oklahoma State Department of Health form 283, dated 03/15/25, showed Resident #2 had been admiistered another residents medication including: furosemide 20mg (a diuretic), lisinopril 40mg (a blood pressure medication), citalopram 40mg (an antidepressant), diazepam 2mg (an antianxiety medication), oxycodone/acetaminophen 10/325mg (a pain medication), and carbidopa/levodopa 25/100mg (an antiparkinsonian medication). An After Visit Summary, dated 03/24/25 at 9:05 a.m., showed Resident #2 was admitted to the hospital because they were administered medications which were not prescribed to them that caused very low blood pressure. The summary also showed Resident #2 was administered medications to keep their blood pressure up while the other medications wore off. A review of CMA #1's employee file showed they were hired on 03/22/23 and had no skills evaluation/check off since 05/19/23. A review of CMA #2's employee file showed they were hired on 12/06/22 and had no skills evaluation/check off since 12/09/23. A review of CMA #3's employee file showed they were hired on 04/19/21 and had no skills evaluation/check off since 04/17/23. A review of CMA #4's employee file showed they were hired 12/29/22 and did not show any skills evaluations had been completed. A review of CMA #6's employee file showed they were hired on 03/11/22 and had not had a skills evaluation/check off since 04/19/23. On 03/24/25 at 4:05 p.m., the DON reported CMA's completed skills check offs upon hire, but they were unsure if they were done routinely after hire. The DON stated on 01/21/24 the exact same medication error had occurred when CMA #2 administered Resident #2 the wrong medications. The DON stated Resident #2 was hospitalized on that occasion as well and CMA #2 was educated regarding the 8 rights of medication administration, but no other interventions were put in place. The DON also stated they did not routinely observe medication administration. On 03/24/25 at 5:26 p.m., the DON stated the facility considers the eight hours of annual CMA training to be their annual competencies. On 03/25/25 at 9:45 a.m., CMA #2 stated they had taken the position of CNA/CMA supervisor in February. They stated they had not completed any annual CMA competencies since then, and they were unsure if the facility was doing them prior to that. On 03/25/25 at 10:47 a.m., CMA #3 stated they did not recall completing a skills check off. On 03/25/25 at 10:55 a.m., CMA #4 stated they were unsure if the facility did annual skills check offs or not. On 03/25/25 at 11:50 a.m., the pharmacy consultant for the facility stated they visited the facility once a month and usually observed medication administration while in the facility. They also stated that they only visited during normal business hours, so they had never observed night shift staff or weekend staff pass medication. On 03/27/25 at 10:26 a.m., the DON stated annual CMA competencies have not been completed consistently for the last two years. They also stated all medication errors are avoidable.

Based on record review and interview, the facility failed to ensure an allegation of abuse was reported within the two hours to OSDH for two (#1 and #2) of three sampled residents reviewed for abuse. The DON identified 56 residents resided in the facility. Findings: An abuse policy titled POCOLA HEALTH AND REHAB, addendum 08/29/18, read in parts .The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultant, volunteers, .Staff is responsible for identifying, correcting, and intervening in situations in which abuse, neglect, and misappropriation of property are more likely to occur .The Administrator and the Director of Nursing are responsible for the initial reporting, investigation of the alleged violations and reporting the results to the proper authorities .All alleged violations and/or abuse reported to the charge nurse will be assessed and then reported to the appropriate agencies with a 2 hour timeline. The nurse will also notify the Administrator and Director of Nursing immediately . 1. Resident #1 had diagnoses which included diabetes mellitus, morbid obesity, major depressive disorder, anxiety disorder, and schizophrenia. A facility incident report, dated 07/11/24 at 3:15 p.m., documented two nurses were told by resident #1 the aide with black hair called me a motherfucking C-U-N-T. The report documented the two nurses questioned the aides working on the resident hall. Two aides stated they did not here the identified incident regarding the accused third aide, but had heard the third aide call the resident a fat fuck earlier in the day and they informed their supervisor of the verbal abuse. The report documented the nurse immediately reported the incident to the ADON and the DON was made aware and was investigating the incident. A state incident report, dated 07/11/24, documented an allegation of abuse/mistreatment for resident #1. The report documented the see progress notes. A fax confirmation report, dated 07/11/24 at 7:36 p.m., documented a state incident report regarding the abuse allegation for resident #1 was faxed to OSDH. 2. Resident #2 had diagnoses which included a fracture of the right tibia, anxiety disorder, dementia, and Alzheimer's Disease. A facility incident report, dated 07/11/24 at 9:30 a.m., documented the nurse was called to the resident's room. The report documented the resident told the nurse that girl threw me in the chair and it hurt my back. A progress note, dated 07/11/24 at 7:30 p.m., documented the incident regarding the resident. The note documented the DON was aware of the incident and was investigating at that time. A state incident report, dated 07/11/24, documented an allegation of abuse/mistreatment for resident #2. The report documented the see progress notes. A fax confirmation report, dated 07/11/24 at 7:38 p.m., documented a state incident report regarding the abuse allegation for resident #2 was faxed to OSDH. On 08/13/24 at 2:48 p.m., the DON was interviewed regarding the incidents for resident #1 and resident #2. The DON reviewed the documents regarding the reporting of both incidents. The DON stated neither incident was reported to the OSDH within the two required time frame.

Based on record review and interview, the facility failed to implement their abuse policy by immediately reporting abuse for two (#1 and #2) of three sampled residents reviewed for abuse. The DON identified 56 residents resided in the facility. Findings: An abuse policy titled POCOLA HEALTH AND REHAB, addendum 08/29/18, read in parts .The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultant, volunteers, .Staff is responsible for identifying, correcting, and intervening in situations in which abuse, neglect, and misappropriation of property are more likely to occur .All alleged violations and/or abuse reported to the charge nurse will be assessed and then reported to the appropriate agencies with a 2 hour timeline. The nurse will also notify the Administrator and Director of Nursing immediately . 1. Resident #1 had diagnoses which included diabetes mellitus, morbid obesity, major depressive disorder, anxiety disorder, and schizophrenia. A facility incident report, dated 07/11/24 at 3:15 p.m., documented two nurses were told by resident #1 the aide with black hair called me a motherfucking C-U-N-T. The report documented the two nurses questioned the aides working on the resident hall. Two aides stated they did not here the identified incident regarding the accused third aide, but had heard the third aide call the resident a fat fuck earlier in the day and they informed their supervisor of the verbal abuse. The report documented the nurse immediately reported the incident to the ADON and the DON was made aware and was investigating the incident. A state incident report, dated 07/11/24, documented an allegation of abuse/mistreatment for resident #1. The report documented the see progress notes. A fax confirmation report, dated 07/11/24 at 7:36 p.m., documented a state incident report regarding the abuse allegation for resident #1 was faxed to OSDH. 2. Resident #2 had diagnoses which included a fracture of the right tibia, anxiety disorder, dementia, and Alzheimer's Disease. A facility incident report, dated 07/11/24 at 9:30 a.m., documented the nurse was called to the resident's room. The report documented the resident told the nurse that girl threw me in the chair and it hurt my back. A progress note, dated 07/11/24 at 7:30 p.m., documented the incident regarding the resident. The note documented the DON was aware of the incident and was investigating at that time. A state incident report, dated 07/11/24, documented an allegation of abuse/mistreatment for resident #2. The report documented the see progress notes. A fax confirmation report, dated 07/11/24 at 7:38 p.m., documented a state incident report regarding the abuse allegation for resident #2 was faxed to OSDH. On 08/13/24 at 3:15 p.m., the DON stated they were unaware of the incident regarding the allegation of abuse by resident #2 until in the afternoon. On 08/15/24 at 8:45 a.m., the DON was interviewed regarding the incidents for resident #1 and resident #2. The DON stated the staff did not notify them or the administrator of the allegations of abuse and/or neither incident was reported to the OSDH within the two required time frame per facility policy.

Based on record review and interview, the facility failed to conduct a thorough abuse investigation for two (#1 and #2) of three residents reviewed for abuse. The DON identified 56 residents resided in the facility. Findings: An abuse policy titled POCOLA HEALTH AND REHAB, addendum 08/29/18, read in parts .The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultant, volunteers, .Staff is responsible for identifying, correcting, and intervening in situations in which abuse, neglect, and misappropriation of property are more likely to occur .The Administrator and the Director of Nursing are responsible for the initial reporting, investigation of the alleged violations and reporting the results to the proper authorities. The facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while investigation is in the progress .Staff - to - Resident: Immediately respond to the needs of the injured party. The accused or suspected employee will be immediately suspended pending the investigation .The progress notes, concerning all residents involved should include: assessment of residents involved, who was involved, what happened, what was done, what interventions were used, how did the resident respond to the intervention, what was done to prevent further harm to residents and others. Follow up documentation will continue for 72 hours . 1. Resident #1 had diagnoses which included diabetes mellitus, morbid obesity, major depressive disorder, anxiety disorder, and schizophrenia. A facility incident report, dated 07/11/24 at 3:15 p.m., documented two nurses were told by resident #1 the aide with black hair called me a motherfucking C-U-N-T. The report documented the two nurses questioned the aides working on the resident hall. Two aides stated they did not here the identified incident regarding the accused third aide, but had heard the third aide call the resident a fat fuck earlier in the day and they informed their supervisor of the verbal abuse. The report documented the nurse immediately reported the incident to the ADON and the DON was made aware and was investigating the incident. A state incident report, dated 07/11/24, documented an allegation of abuse/mistreatment for resident #1. The report documented the see progress notes. A document titled final investigation for resident #1 regarding incident on 07/11/24 read in parts .Upon my investigation I questioned all the resident on this hall .I spoke with the other staff on the hall that day and their personal statements have been added with this investigation . The DON provided documentation for the completed investigation. There was no statement from the resident. There was one nurse statement provided. There was no statement for the other nurse identified in the incident report. There was no documentation provided regarding the date, time, name, or number of residents interviewed regarding the incident. A statement provided by the CNA who was providing care for the resident at the time of the alleged incident documented a second CNA who assisted with resident care. A statement from the second CNA identified in the room was not provided. 2. Resident #2 had diagnoses which included a fracture of the right tibia, anxiety disorder, dementia, and Alzheimer's Disease. A facility incident report, dated 07/11/24 at 9:30 a.m., documented the nurse was called to the resident's room. The report documented the resident told the nurse that girl threw me in the chair and it hurt my back. A progress note, dated 07/11/24 at 7:30 p.m., documented the incident regarding the resident. The note documented the DON was aware of the incident and was investigating at that time. A document titled final investigation for resident #2 regarding incident on 07/11/24 read in parts .Upon my investigation I questioned all the resident on this hall .Spoke with the other staff on the hall that day . The DON provided documentation for the completed investigation. There was no documentation provided regarding the date, time, name, or number of residents interviewed regarding the incident. A document, not dated or timed, documented the resident was was yelling saying she had hit her. On 08/15/24 at 8:45 a.m., the DON was interviewed regarding the incidents for resident #1 and resident #2. The DON stated the investigations were completed together because they were made aware of the incidents at the same time and involved the same staff member. The DON stated there were no documented resident interviews and some staff identified did not have documented interviews.

Based on observation, record review, and interview, the facility failed to ensure a resident was free from abuse for one (#1) of three residents sampled for abuse. The DON identified 56 residents residing in the facility. Findings: Res #1 had diagnoses which included Alzheimer's disorder, dementia, depression disorder, and anxiety disorder. A document titles Oklahoma State Department of Health Incident Report Form, dated 04/19/24, signed by the DON read in part, .CNA had made and put on her story on Snap Chat, .in a mocking and abusive way, verbally not physically .From the video . seemed very upset and disturbed by the CNA talking to her . She then posted this video on snap chat for all her viewers to see. This Incident Report Form documented physician, family/representative, DHS/APS, and Nurse Aide Registry was notified of the abusive behavior and video. This report also documented that the CNA involved in the video was terminated on 04/19/24. On 04/29/24, an in-service was conducted with all employees on abuse and reporting abuse. On 05/08/24 at 1:54 p.m., the DON stated they found out about the video shortly after CNA #1 posted it on social media. They also stated they immediately called everyone into their office that knew about the video recording and posting. CNA #2 informed the DON they advised CNA #1 to stop recording and to take the video off social media. The DON stated once they talked to everyone involved then they terminated CNA #1. They also stated, CNA #2 was given a written warning on abuse and reporting abuse. The DON stated they immediately turned the incident in to the state. On 05/08/24 at 2:48 p.m., an observation was made of a video with CNA #1 mocking and verbally abusing res #1 while they were sitting in their wheelchair in their room. Res #1 appeared to be crying and CNA #1 was laughing at them. On 05/08/24 at 2:55 p.m., the DON stated they only kept the video so they could show the video to anyone sent to investigate the complaint. They also stated the video would be deleted off of their phone soon after someone had investigated the complaint.

Based on observation and interview the facility failed to ensure staff followed infection control guidelines to prevent the potential spread of communicable disease while performing wound care, COVID testing and assisting resident to eat. The DON identified 53 resident who resided in the facility. Findings: 1. On 03/06/24 at 8:03 a.m., CNA #2 was observed assisting residents to eat in the dining room. CNA #2 was observed to scratch their face after assisting a resident with his cup, the CNA then they assisted another resident with bites of food. Hand hygiene was not observed during the observation. On 03/06/24 at 8:07 a.m., CNA#2 was observed to touch their clothing and continued to assist the residents with their breakfast. Hand hygiene was not observed during the observation. On 03/06/24 at 8:15 a.m., CNA #3 was observed assisting a resident to eat breakfast the CNA then assisted another resident with their coffee, CNA #3 then went back to assisting the first resident to eat. Hand hygiene was not observed between residents. On 03/06/24 at 8:17 a.m., CNA #2 was observed to stack the dirty dishes at the table and then assisted a resident to put honey in their oatmeal and assisted the resident to eat the oatmeal. Hand hygiene was not observed. On 03/07/24 at 12:34 p.m., the IP stated the staff should be using hand hygiene between resident and if they touch something dirty when assisting residents to eat. 2. On 03/07/24 at 3:04 p.m., Res #3's wound care was observed performed by RN #2. RN #2 washed their hands before care and the applied gloves. The resident had a BM and the nurse cleaned the resident, changed gloves but hand hygiene was not done. The RN then removed the old dressing from the resident, cleaned the wound changed gloves, hand hygiene was not performed. The RN then treated and dressed the area. The RN then applied skin prep to the residents heels in the same gloves. On 03/07/24 at 3:17 p.m., RN #2 stated they should have washed their hands after cleaning the resident up from a bowel movement before starting wound care. Also between dirty and clean. 3. On 03/07/24 at 9:35 a.m., the IP was observed to test a resident for COVID in the activity room with other resident in the room and without proper PPE on. The IP stated if the resident tested positive they could have spread the infection to others in the facility.

Based on observation and interview the facility failed to store food in accordance with professional standards for food service safety for 53 of 53 residents who received meals from the kitchen. The DON identified 53 residents who received meals from the kitchen. Findings: On 03/05/24 at 10:07 a.m., the ice machine in the dining room was observed with the pad lock unlocked. On 03/05/24 at 10:10 a.m., an initial tour of the kitchen was conducted. A large trash can by the hand washing sink did not have a lid, the lid was in the floor behind the trash can. On 03/05/24 at 10:13 a.m., the freezer observed to have bags of French fries and onion rings open to air the bags were not dated when they had been opened. On 03/05/24 at 10:16 a.m., the DM stated the items in the freezer should not be open to air and should be dated when opened. On 03/05/24 at 10:21 a.m., the ice machine was wiped with a clean cloth from the the ice drop a brown/black substance on the cloth. The DM stated they did not know what the substance was on the cloth. The DM stated they wiped the ice machine down but had never cleaned it from the ice drop. They stated maintenance cleaned it when the light came on or a company came in to service the ice machine. The DM stated the ice machine should be locked when a staff member was not getting ice. They stated the staff will unlock it and not lock it back at times. On 03/05/24 at 10:26 a.m., the DM entered the kitchen and did no wash their hands. On 03/05/24 at 10:27 a.m., The DM was asked if the trash can should have a lid covering the trash. The DM stated they were worried about touching the lid and contaminating their hands. The DM stated a surveyor last year told them they only needed it covered the trash when transporting the trash. The DM stated staff entering the kitchen should wash their hands.

Based on observation and interview, the facility failed to post the required staffing information in a manner easily accessible to residents and vistors. This affected 53 of 53 residents. The DON identified 53 residents who resided in the facility. Findings: On 03/06/24 at 10:00 a.m., surveyor was unable to locate posted staffing. RN #1 reported posted staffing was on the bulletin board on 200 Hall outside the dining room entrance. Observed posted staffing information on an 8.5 x 11 piece of copy paper pinned to a bulletin board approximately six feet from the floor. Surveyor was unable to read the posted staffing information unless directly in front of the bulletin board looking up ten inches. Posted staffing information did not document the census or staffing hours for each employee. Posted staffing remained in the same location and without the facility census or staffing hours for each employee for the remainder of the survey. On 03/08/24 at 10:00 a.m., the DON questioned why the residents can't tilt their heads up and read the staffing information. The DON reported that's a new one when informed of the regulations regarding posted staffing requirements and accessibility for residents and visitors.

Based on observation, record review, and interview, the facility failed to ensure residents were fully assessed for the use of side rails for four (#11, 22, 42, and #45) of 35 sampled residents who were reviewed for side rails. The DON identified 35 resident utilized bed rails out of 53 residents residing in the facility. Findings: 38495 1. Res #11 had diagnoses which included CHF, chronic kidney disease, and Alzheimer's Disease. A care plan revised 01/01/23, documented the resident required the assistance of half bed rails. The care plan documented to assess and evaluate the use of half bed rails. An annual assessment, dated 01/11/24. documented the resident was moderately impaired with cognition and required substantial to maximal assistance with most ADLs. The assessment documented the resident required substantial/maximal assistance to roll left to right, sit to lying, lying to sitting, sit to stand, chair to bed,and toilet transfer. The resident EHR did not contain bed rail assessments. On 03/05/24 at 11:26 a.m., the resident was observed sitting in the bed with half rails up on both sides of the bed. On 03/06/24 at 8:30 a.m., the resident was sitting up in bed eating breakfast, the rails were up on both sides of the resident's bed. On 03/07/24 at 2:54 p.m., during an observation of care the resident was in bed bed rails in the up position on both sides of the bed. The rail were not observed to be used by the resident during the observation. On 03/11/24 at 1:15 p.m., the POA was visiting they stated they had been informed of the risk of the bed rails. The POA stated they wanted the bed rails so the resident would not try and get out of the bed. On 03/11/24 at 4:43 p.m., LPN #1 stated they just started doing bed rail assessments last week. The LPN stated they do not have a template to go by for the assessment. The LPN stated the resident used the bed rail to help roll for care to assist the CNAs. The LPN stated they did feel the bed rail was beneficial to the resident and was not a restraint. The LPN stated the resident did not have the strength to get out of bed. 2. Res #22 had diagnoses which included generalized anxiety disorder, major depressive disorder, diabetes mellitus with diabetic neuropathy, CHF, and schizophrenia. A care plan, revised 10/31/21, documented the resident requires the assistance of half bed rails for bed mobility. The care plan documented the resident would be safe while half rails were in use to maximize independence with turning and positioning. The care plan documented to assess and evaluate the use of half bed rails. A quarterly assessment, dated 12/20/23, documented the resident was moderately impaired with cognition and was dependent with most ADLs. The assessment documented the resident was dependent to roll left to right, sit to stand, and lying to sitting. The assessment documented the bed rails were not used a a restraint. There were no bed rail assessment observed in the EHR. On 03/05/24 at 12:09 p.m., the resident stated she used the bed rails for positioning. The resident stated she had never fallen out of the bed and wanted the rails. On 03/11/24 at 4:45 p.m., LPN #1 stated the resident did use the bed rail to assist staff with care and the resident did not get out of bed on their own. Bed rail assessments for the resident had not been completed. 3. Res #42 had diagnoses which included CHF, Alzheimer's Disease, anxiety disorder, and insomnia. A quarterly assessment, dated 02/21/24, documented the resident was severly impaired with cognition and was dependent with most ADLs. The assessment documented the resident required substantial/maximal assistance to roll left to right, sit to lying, lying to sitting, sit to stand, bed to chair, toilet transfer, and tub/shower transfer. The resident's care plan, documented the resident required the use of half bed rails. The care plan documented the resident used half bed rails to maximize independence with turning and repositioning in bed. The care plan documented to assess and evaluate the use of half bed rails. The EHR did not contain assessments for bed rails for the resident. A bed rail waver, dated 12/15/22, was signed by the resident's POA. On 03/05/24 at 12:23 p.m., the resident was observed laying in the bed, on an air mattress, with half rails up on both sides of the bed and a bed alarm in place. On 03/08/24 at 12:25 p.m., CNA #1 stated the resident was one that was more active and fidgets. CNA #1 stated the resident would use the bed rails to turn over in the bed. 4. Res #45 had diagnoses which included unspecified osteoarthritis, chronic obstructive pulmonary disease, primary osteoarthritis of right and left shoulder, and pain in right and left shoulder. On 10/31/21 a waiver was signed by the resident for side rails. A care plan, dated 10/31/21, documented to assess and evaluate the use of half side rails. A physician order, dated 05/30/22, documented the half side rails x 2 to assist resident with turning and re-positioning. A care plan, dated 08/28/23, documented the resident would be safe while half rails are in use. A quarterly assessment, dated 12/29/23, documented the resident was intact with cognition and required maximum assistance with ADLs. The assessment also documented the resident was utilized bed rails for repositioning. A physician's order, date 05/15/23, documented air mattress to bed, no directions specified. On 03/05/24 at 12:12 p.m., an observation was made of half side rails and an air mattress on the resident's bed. On 03/07/24 at 3:25 p.m., a registered nurse stated the assessment and evaluation for side rails should be in the chart under assessments or progress notes. There was no documentation found in the chart on bed rails. On 03/07/24 at 3:48 p.m., the resident stated the bed rails were utilized daily. On 03/09/24, the DON stated the nurses asses the side rails every day but do not document the assessment anywhere in the chart. They also stated there was a bed rail assessment form in the chart and they would start utilizing the form routinely.

Based on interview and record review, the facility failed to follow their abuse prevention policy by not obtaining criminal background checks upon hire for 13 of 74 employees hire between 2016 and 2024. The DON identified 53 residents who resided in the facility. Findings: The Abuse Prevention Policy, undated, read in part, .Candidates for employment will be screened for a potential history of abuse, neglect, or mistreating residents before employment. Employee background checks will be done upon hiring and the facility will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals. The following methods for screening will be utilized: .OK Screen background checks . The Consent and Release Form, undated, read in part, .You must be fingerprinted to work with this employer . The Employee Information Report, dated 03/06/24, documented the following: a. CNA #7 was hired on 04/18/16 b. BOM was hired on 03/23/17 c. Laundry #1 was hired on 10/03/21 d. CNA #11 was hired on 08/22/22 e. CNA #2 was hired on 10/16/22 f. CMA #2 was hired on 10/17/22 g. CNA #8 was hired on 01/06/23 h. CMA #1 was hired on 03/22/23 i. CNA #4 was hired on 05/12/23 j. CMA #3 was hired on 06/02/23 k. CNA #5 was hired on 10/05/23 l. CNA #9 was hired on 11/24/23 m. CNA #6 was hired on 01/08/24 n. CNA #10 was hired on 01/08/24 The [Facility name] Employee Roster, dated 03/07/24, provided by OK Screen did not document CNA #2, CNA #4, CNA #5, CNA #6, CNA #7, CNA #8, CNA #9, CNA #10, CNA #11, Laundry #1, CMA #1, CMA #2, and CMA #3, as current eligible employees. On 03/07/24 at 1:30 p.m., the BOM could not provide criminal background checks for these employees (CNA #2, 4, 5, 6, 7, 8, 9, 10, and #11. Laundry #1 and CMA #1, 2, and #3) Payroll records for 03/07/24 documented CNA #2, CNA #6, CNA #7, CNA #10, CNA #11 and CMA #2 were permitted to work without a criminal background check. Payroll records for 03/08/24 documented CMA #1, CMA #3, CNA #4, CNA #5, CNA #8 and CNA #9 were permitted to work day shift without a criminal background check. On 03/08/24 at 12:48 p.m., the BOM could not provide clearance letters from OK Screen for CNA #7 or Laundry #1. The BOM reported criminal background checks could not be done because CNA #7 and Laundry #1 had not been fingerprinted. On 03/07/24 at 10:30 a.m., the BOM reported if an employee leaves and comes back within three years of their separation date the facility is not required to do a new background check. On 03/07/24 at 1:30 p.m., the DON was unaware there were employees without criminal background checks. On 03/11/24 at 10:00 a.m., the BOM reported Laundry #1 was working in the facility and CNA #7 was scheduled to work at 7:00 p.m. CNA #7 and Laundry #1 had not been fingerprinted yet. On 03/11/24 at 3:13 p.m., the administrator reported they were not aware there were employees without criminal background checks. The administrator reported the BOM was not aware there were so many staff members without background checks. The administrator reported Laundry #1 and CNA #7 have been scheduled for fingerprinting, and the BOM did not know they had not been fingerprinted.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed for weight loss for one (#10) of two sampled residents whose care plans were reviewed. The DON reported 53 residents resided in the facility. Findings: Res #10 had diagnoses which included diabetes mellitus type 2 without complications, abdominal hernia without obstruction, and major depressive disorder. A physician's order dated, 04/15/23, documented snacks three times a day for nutritional supplements. A physician's order dated, 04/16/23, documented health shakes for weight management. A physician's order dated, 06/27/23, documented protein powder three times a day for weight loss of 6.2 pounds in five months. A quarterly assessment, dated 12/29/23, documented the resident was cognitively impaired and required moderate to maximum assistance with all ADLs. A care plan, dated 02/04/24, contained no documentation of weight loss for Res #10. On 03/07/24 at 12:40 p.m., the MDS coordinator stated there was no care plan for weight loss for the resident.

Based on record review and interview the facility failed to ensure the OHCA was notified of a resident with a serious mental illness who stayed in the facility long term for one (#22)of two residents reviewed for PASRR level I screenings. The DON identified 53 residents who resided in the facility. Findings: Res #22 had diagnoses which included generalized anxiety disorder, major depressive disorder, and schizophrenia. A PASRR I, dated 06/26/14, documented the resident had a serious mental illness. The PASRR I documented the hospital called OHCA they stated with a letter from the physician and a short stay for therapy only was a PASRR level II not required. A care plan, revised 08/26/22, documented the resident was always worried someone was talking about her and constantly thinks they are going to die due to diagnosis of schizophrenia. The care plan documented the resident used psychotropic medications related to behavior management. An annual assessment, dated 09/19/23 documented the resident was not considered by the state level two PASRR process to have a serious mental illness or intellectual disability or related condition. On 03/11/24 at 3:06 p.m., the DON stated she called OHCA and they would have to order a PASRR II. She stated another staff member didn't do another PASRR I when the resident stayed in the facility.

Based on observation, record review, and interview, the facility failed to ensure the accuracy of MDS assessments for four (#2, #25, #38 and #42) of 21 residents whose assessments were reviewed. The Long-Term Care Facility Application for Medicare and Medicaid form documented 53 residents resided in the facility. Findings: 1. Res #2 had diagnoses which included idiopathic peripheral autonomic neuropathy, dysphagia, pharyngoesophageal, hyperlipidemia, hypertension, and history of deep vein thrombosis. A physician order, dated 05/30/22, doucmented the facility was to administer apixaban (an antiplatelet medication) 5 mg twice a day for a diagnosis of history of deep vein thrombosis. A care plan, date 12/02/23, documented to administer one tablet twice a day related to deep vein thrombosis and to monitor for adverse reactions of anticoagulants. An quarterly assessment, dated 02/25/24, documented the resident was independent in cognitive skills for daily decision making. The assessment documented the resident was frequently incontinent of bladder and always incontinent bowel and required moderate to maximum assistance with most ADLs. The assessment documented Res #2 utilized a walker and wheelchair for transporting. The assessment also documented the resident had taken an anticoagulant, a diuretic, and an antiplatelet in the past seven days. On 03/07/24 at 11:45 a.m., the MDS coordinator stated the resident was not on an anticoagulant but was on a antiplatelet. she also stated the anticoagulant should not have been marked on the MDS. 45913 2. Res #25 had diagnoses which included blindness to left and right eye and dementia. A care plan, last revised on 04/22/23, documented in part, .communication problem related to hearing deficit (when in noisy environment). An annual resident assessment, dated 02/15/24, documented in error Res #25's hearing is adequate. On 03/06/24 at 9:03 a.m., Res #25's guardian reported the resident is blind and hard of hearing, essentially deaf. The guardian reported they felt it was important for anyone caring for their mother to know hearing and sight is a challenge On 03/11/24 at 3:06 p.m., the DON reported Res #25 has trouble hearing in a noisy environment. 3. Res #38 had diagnoses which included dementia, left femur fracture, traumatic subdural hemmorrhage without loss of consciousness. An incident report, dated 02/24/24, documented Res #25 had a non-injury fall. An incident report, dated 02/29/24, documented Res #25 had a fall resulting in a subdural hematoma. A significant change resident assessment, dated 03/04/24, did not document the falls for Res #38 on 02/24/24 and 02/29/24. On 03/11/24 at 3:06 p.m., the DON reported MDS Coordinator #1 completed the MDS and was not available to ask why the falls were not documented on the significant change resident assessment for Res #25. The DON reported the falls for Res #25 should have been documented. 38495 4. Res #42 had diagnoses which included CHF, Alzheimer's Disease, and hypertension. A physician order, dated 09/26/23, documented to place a Foley catheter due to urinary retention. A quarterly assessment, dated 02/21/24, documented the resident was severly impaired with cognition and was dependent on staff for most ADLs. The assessment documented the resident had a catheter and was always incontinent of urine. On 03/05/24 at 12:24 p.m., the resident was observed to have a catheter it was positioned below the bladder in a privacy cover. On 03/06/24 at 9:26 a.m., a phone interview with the POA. The POA stated the resident had a catheter a while for a UTI. On 03/08/24 at 12:46 p.m., RN #1 stated the resident had urinary retention. RN #1 stated at one time the resident had ESBL and when we removed the catheter the resident was not able to urinate. On 03/08/24 at 1:24 p.m., the DON stated well some times the resident had a catheter and when she did not have one the resident was incontinent.

Based on record review and interview, the facility failed to ensure DNR forms were complete and legal for two (#11 and #40) of 24 residents who were reviewed for advanced directives. The DON identified 29 residents in the facility had DNRs. Findings: Policy DNR ACT, dated 06/01/03, read in part, IT IS THE POLICY OF POCOLA NURSING CENTER TO FOLLOW THE OKLAHOMA DNR ACT OF 1997 . 1. Res #11 had diagnoses which included CHF, chronic kidney disease, and Alzheimer's Disease. An annual assessment, dated 01/11/24. documented the resident was moderately impaired with cognition and required substantial to maximal assistance with most ADLs. A care plan revised 01/01/23, documented the resident had a DNR and the resident would not be resuscitated her their wishes. The EHR documented the resident had a DNR. The DNR form in the resident EHR was signed by the resident's POA and dated 12/30/22. The DNR form did not have two witnesses as required. On 03/07/24 at 2:35 p.m., the DON stated there was not two witnesses on the DNR. 2. Res #49 had diagnoses which included major depressive disorder, anxiety disorder, and osteoarthritis. A care plan, revised on 10/04/23, documented the resident was a DNR per signed request. A quarterly assessment, dated 01/09/24, documented the resident was moderately impaired with cognition and was dependent for most ADLs. A DNR form was observed in the DNR book signed by the residents POA. The form was not dated. On 03/07/24 at 2:15 p.m., the DON stated it was an over site and they would get the POA to sign and date a DNR.

Based on record review, observation, and interview, the facility failed to ensure residents were not catheterized unless required by a clinical condition and assess a resident for continued need for an indwelling urinary catheter for two (#25 and #29) of four resident reviewed for an indwelling urinary catheter. The DON indentified eight residents with an indwelling urinary catheter Findings: 1. Res #29 was admitted to the facility on [DATE] with diagnoses of left artificial hip joint, hypertension, type 2 diabetes mellitus, nephropathy, and was later diagnosed with stage 3 kidney disease, dementia, congestive heart failure, and urinary tract infection. A physician's order, dated 02/06/24, documented Foley catheter 18 F/30 CC, place for isolation: ESBL. A physician's order, dated 02/06/24, documented clean foley catheter every shift with soap and water. A 5-day assessment, dated 02/26/24, documented the resident was cognitively impaired and required total assistance with all ADLs. The assessment also documented the resident was frequently incontinent of urine. A care plan, dated 02/20/24, documented res #29 had a urinary tract infection with ESBL. There was no documentation of a catheter for res #29. On 03/11/24 the DON stated res #29 had ESBL in their urine and should have been isolated but some residents will not stay in their rooms. The doctor will order a catheter for isolation precautions then the staff would educate the resident and family on the risk and benefits of the catheter. The DON also stated the care plan should have been updated for the catheter. The DON stated ESBL was not a proper diagnoses for a catheter they use a catheter to keep from spreading the bacteria. 45913 2. Res #25 had diagnoses which included chronic kidney disease stage 4 and dementia. A progress note, dated 02/27/24 at 10:40 a.m., documented Res #25 had ESBL and Ecoli in their urine and a 16 Fr indwelling urinary catheter was placed and isolation initiated. A physician's order, dated 02/27/24, read in part, 16 Fr foley cath while being treated for ESBL. There were no physician's orders for catheter care or the changing of the indwelling foley catheter. A care plan, last revised on 02/28/24, read in part, risk for UTI related to history of ESBL .foley catheter per infection control . On 03/06/24 at 10:00 a.m., Res #25 was observed to have an indwelling urinary catheter in place. On 03/06/24 at 2:00 p.m., the infection preventionist reported there was no policy or infection control protocol for catheterizing people with urinary tract infections. The infection preventionist reported they were not knowledgeable regarding the requirements for indwelling urinary catheters and reported catheterizing a resident for a urinary tract infection probably doesn't meet criteria. On 03/11/24 at 3:30 p.m., the DON reported they catheterize residents who are difficult to keep in their rooms for contact precaution isolation. The DON did not feel a brief would be a viable, less invasive alternative because of the risk of urine not being contained. The DON reported ESBL was not a proper diagnoses for a use of an indwelling urinary catheter.

On 08/29/18 at 9:30 a.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failures to follow the facility abuse policy and procedure by failing to identify, protect, investigate, and report abuse of resident #1. Oklahoma State Department of Health (OSDH) was notified and verified the IJ situation. On 08/21/18, licensed practical nurse (LPN) #1 was the evening shift charge nurse for the facility. LPN #1 reported on 08/21/18 at 8:21 p.m., she was notified by certified medication aide (CMA) #1 resident #2 was in resident #1's bed with one leg over the resident and was rubbing resident #1's breasts. LPN #1 reported she had notified the director of nursing (DON) immediately. LPN #1 reported the DON instructed her to only monitor resident #1 and resident #2. LPN #1 reported she was instructed by the DON to not write an incident report. LPN #1 reported she had instructed CMA #1 and the certified nurse aides (CNAs) to monitor the residents. LPN #1 reported she gave resident #1 an [MEDICATION NAME] (an anti-anxiety medication) after the resident was observed to have had increased anxiety after the incident. LPN #1 documented in the progress notes resident #2 was found in resident #1's bed, under the blankets, rubbing resident #1's breasts. The note documented when staff attempted to redirect resident #2, the resident stated she could do what she wanted. The note documented staff removed resident #2 and redirected the resident to her own bed in the same room. LPN #1 reported resident #1 and resident #2 were roommates. A family member for resident #1 reported resident #1 and resident #2 remained roommates from 08/21/18 until 08/27/18. The DON acknowledged in an interview resident #1 and resident #2 remained roommates from 08/21/18 until 08/27/18 when resident #1's family requested their loved one be moved from the room. The DON reported she had not considered the incident as abuse but rather behaviors exhibited by resident #2. On 08/29/18 at 8:00 a.m., the administrator (ADM) reported he was informed by the DON of the incident the day after it had happened. The ADM reported he was told by the DON the incident was considered a behavior and had not been considered as abuse by the DON. On 08/29/18 at 9:35 a.m., the ADM and DON were notified of the IJ situation related to failures to implement the facility abuse policy and procedure by failing to identify, protect, investigate, and report abuse of resident #1. On 08/29/18 at 2:55 p.m., the plan of removal for the Immediate Jeopardy related to abuse was accepted by the survey team. The plan of Removal for the Immediate Jeopardy documented: The plan of Removal for the Immediate Jeopardy documented: . Resident #1 was moved to a different room. Resident #2 was placed on 1:1 (one on one) and monitored by DON (Director of Nursing) or designee. (Name-deleted) a geri-psych unit was called for evaluation for placement and treatment. She was accepted by (Name-deleted geri-psych unit) and will be transported as soon as possible but will remain on 1:1 until she leaves the facility. (Name-deleted) was notified of room change and resident #2's family was notified of having her evaluated for geri-psych unit and were agreeable. The investigation process has begun by the Administrator, the Director of Nursing and the Assistant Director of Nursing (ADON) with interviewing staff and residents in regards to the alleged allegation of abuse from one resident to another. Resident #1 will be closely monitored with documentation every shift for 1 week and daily for two weeks until it is reported there is no decline in health or mental status for a total of 3 weeks ending on 09/19/18. All staff will be educated on abuse. Education will begin immediately and be completed by midnight (08/29/18) either face to face or verbally by telephone. Inservice and Training: All staff will be instructed and educated on Abuse and Neglect by midnight on 08/29/18. Instruction will be given by the DON, ADON, and the Administrator. This inservice and/or training will be done either face to face or verbally by telephone. Inservice will be documented with content and staff members attendance. Nursing staff will be inserviced on the importance of Abuse and Neglect the reporting process and the investigation. All staff members will be given a copy of the policy and procedure for Abuse and Neglect, signed a placed in the personnel file. QAPI (Quality Assurance and Performance Improvement) will be updated to add Abuse and Neglect to the root/cause analysis. Reports will be completed and sent to the appropriate agencies with a final investigation of the incident. The plan or correction (plan of removal) will be completed by 08/29/18. On 08/29/18 at 12:00 a.m. (midnight), the IJ was removed when all components of the plan of removal had been completed. The deficiency remained at a pattern level of actual harm. On 09/04/18 at 9:33 a.m., interviews were conducted with staff regarding the education in-services pertaining to abuse and reporting abuse. The staff reported an in-service was provided on 08/29/18. The staff was able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. Based on observation, interview, and record review, it was determine the facility failed to implement their abuse and neglect policy for one (#1) of three residents reviewed for abuse. On 08/21/18 at 8:21 p.m., LPN #1 was notified by CMA #1, resident #2 was in bed with resident #1 with her leg over resident #1 and rubbing resident #1's breasts. Resident #2 remained in the same room as resident #1 from 08/21/18 until 08/27/18. The facility failed to identify, protect, investigate, and report abuse. A progress note, dated 08/21/18 at 10:09 p.m., documented resident #1 received [MEDICATION NAME] (an antianxiety medication) due to increased anxiety. The facility identified no allegations of abuse in the past six months. The facility identified 77 residents who resided in the facility. Findings: The facility policy for abuse documented the facility would identify abuse. The policy documented it was committed to protecting residents from abuse including resident to resident abuse. The policy documented protection during an investigation would be provided. The policy documented resident to resident abuse would be immediately responded to and the needs of the injured party. The policy documented all alleged violations and all substantiated incidents will be reported to the appropriate agencies. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The re-admission assessment, dated 02/14/18, documented the resident was severely cognitively impaired. The admission assessment documented the resident required extensive to total assistance from staff for activities of daily living. The admission assessment documented the resident was not able to walk. A care plan, updated on 07/01/18, documented the resident was dependent on staff for assistance for activities of daily living. The care plan documented the resident was transferred from bed to a wheelchair by a hoyer lift. The care plan documented the resident was dependent on staff for meeting physical, emotional, intellectual, and social needs. The quarterly assessment, dated 07/05/18, documented the resident was severely cognitively impaired. The quarterly assessment documented the resident required extensive to total assistance from staff for activities of daily living. The admission assessment documented the resident was not able to walk. A progress note, dated 08/21/18 at 9:27 p.m., documented LPN #1 was told by CMA #1 and a CNA that resident #1's roommate (resident #2) was in her bed, laying under the blankets, and resident #2 was rubbing resident #1's breasts. The note documented the roommate was redirected back to her own bed. The progress note documented the LPN would continue to monitor. A progress note, dated 08/21/18 at 10:09 p.m., documented resident #1 received [MEDICATION NAME] (an antianxiety medication) due to increased anxiety. The medication administration report (MAR) documented, resident #1 received [MEDICATION NAME] 0.5 milligrams (mg) in addition to [MEDICATION NAME] 25 mg for anxiety on 08/21/18 at 10:09 p.m. A communication with physician note, dated 08/26/18 at 8:24 a.m., documented a request to renew resident #1's [MEDICATION NAME] for another 14 days due to increased anxiety for the past week. 2. Resident #2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. An interim care plan, dated 08/21/18, documented the resident required limited assistance with activities of daily living; was cognitively impaired; was able to communicate easily with staff; and was independent with ambulation, locomotion, dressing, and toilet use. A progress note, dated 08/21/18 at 9:27 p.m., documented the resident was found in bed with her roommate lying under the blanket rubbing her roommate on the breasts. The progress note documented when staff attempted to redirect resident #2 she stated, I can do what I want. The progress note documented resident #2 did not want to move. The progress note documented resident #2 was redirected back to her bed. An comprehensive care plan, dated 08/25/18, documented resident #2 had a potential to be physically aggressive. The care plan documented the resident was prescribed an antipsychotic medications related to behavior management and delusional disorder. An admission assessment, dated 08/29/18, documented the resident was severely cognitively impaired. The admission assessment documented the resident exhibited physical behaviors towards others, put others at significant risk for physical harm, and significantly intruded on the privacy or activity of others. The admission assessment documented the resident required limited assistance with activities of daily living. The admission assessment documented the resident had no limitations in her arms or legs. On 08/29/18 at 4:10 a.m., resident #2 was observed in bed with her eyes closed. The resident had no roommate. On 08/29/18 at 4:30 a.m., CNA #2 reported staff was told when they came on duty about resident #2 in bed with resident #1 and grabbing her breast. The CNA reported the staff were not instructed to stay in the room with resident #1 and resident #2 and were only to check on them when they could. On 08/29/18 at 5:00 a.m., LPN #2 reported she was not at the facility when the abuse occurred but came on duty the following shift. The LPN stated the nurse going off duty told her that resident #2 had climbed in bed with resident #1, was rubbing resident #1 on the breast, and resident #1 was given an [MEDICATION NAME] for increased anxiety. LPN #2 stated it was not reported to her as sexual abuse. The LPN reported she was not sure if the DON or ADM had been notified of the abuse. The LPN stated she had not reported the abuse to the DON or ADM. On 08/29/18 at 5:45 a.m., CNA #1 reported the staff were told when they came on the shift on 08/21/18 night shift, one resident had touched another resident. The CNA reported resident #2 remained in the same room with resident #1. The CNA reported the following night, 08/22/18, after the abuse occurred, resident #2 was observed in resident #1's bed on two separate occasions. The CNA reported both times resident #1 was not in the bed. The CNA stated she was never instructed to stay one on one with either resident #1 or resident #2. The CNA confirmed resident #1 was not able to use her call light and was totally dependent on staff to get out of bed and to her wheelchair. On 08/29/18 at 7:10 a.m., resident #2 was observed in bed with her eyes closed. On 08/29/18 at 7:19 a.m., resident #1 was observed being assisted by staff eating breakfast. On 08/29/18 at 7:40 a.m., resident #1 was observed being assisted by staff in her room. On 08/29/18 at 7:50 a.m., the DON stated she was notified by LPN #1 regarding the abuse when it happened. The DON reported she had not consider the incident as abuse. The DON reported she had considered the incident as a behavior by resident #2. The DON reported resident #1 and resident #2 were left in the same room together until 08/27/18. The DON reported resident #1 was moved upon the family's request on 08/27/18. On 08/29/18 at 8:00 a.m., the ADM reported he was told of the abuse the next day but the DON considered it a behavior. He stated, I just go by what the DON decides. On 08/29/18 at 8:40 a.m., resident #2 was observed in the dining room sitting at a table. The resident's cane was by her side. The resident was asked simple questions and answered appropriately. On 08/29/18 at 2:20 p.m., resident #1's family member stated the family had requested for resident #1 to be removed from the same room as resident #2. The family member stated, I requested for the facility to move (name deleted resident #1) a couple of days before she was moved to another room. A progress note, dated 08/29/18 at 3:30 p.m., documented resident #2 was transferred to a geriatric psychiatric unit for evaluation. On 09/04/18 at 8:30 a.m., the DON reported resident #2 remained at the geriatric psychiatric unit. 09/06/18 at 11:30 a.m., CNA #6 had not responded to efforts to communicate via telephone call. It was reported to the surveyor CNA #6 witnessed the abuse. On 09/06/18 at 11:37 a.m., via telephone conference with LPN #1, the LPN reported she was the evening charge nurse on 08/21/18 when the abuse occurred. The LPN stated CMA #1 told her resident #2 was in the bed with resident #1 and was squeezing (name deleted resident #1's) boobs. LPN stated the DON was notified immediately. The LPN stated the DON told her to watch resident #1 and resident #2. The LPN stated the DON told her not to write an incident report, but to write a behavior note about the incident. The LPN stated she told the CMAs and the CNAs to watch resident #2. The LPN stated she considered the incident a sexual advance and it was not appropriate. On 09/06/18 at 12:25 p.m., the ADM reported the incident was considered by the DON as a behavior for resident #2. The ADM reported he follows the recommendations of the DON. The ADM reported the facility did not investigate or report the abuse to OSDH. The ADM reported nursing was responsible for the investigations. On 09/06/18 at 1:30 p.m., a return telephone call was received from CMA #1. The CMA reported she had observed resident #2 in the bed of resident #1 on 08/21/18. The CMA stated resident #2 was observed to have had one leg over resident #1 and resident #2 had her hands on resident #1's breasts. The CMA stated the staff separated the residents and assisted resident #2 back to her bed. CMA stated she reported the incident to LPN #1.

On 08/29/18 at 9:30 a.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure resident #1 was free from abuse. Oklahoma State Department of Health (OSDH) was notified and verified the IJ situation. On 08/21/18, licensed practical nurse (LPN) #1 was the evening shift charge nurse for the facility. LPN #1 reported on 08/21/18 at 8:21 p.m., she was notified by certified medication aide (CMA) #1 that resident #2 was in resident #1's bed with one leg over the resident and was rubbing resident #1's breasts. LPN #1 reported she had notified the director of nursing (DON) immediately. LPN #1 reported the DON instructed her to only monitor resident #1 and resident #2. LPN #1 reported she was instructed by the DON to not write an incident report. LPN #1 reported she had instructed CMA #1 and the certified nurse aides (CNAs) to monitor the residents. LPN #1 reported she gave resident #1 an [MEDICATION NAME] (an anti-anxiety medication) after the resident was observed to have had increased anxiety after the incident. LPN #1 documented in the progress notes resident #2 was found in resident #1's bed, under the blankets, rubbing resident #1's breasts. The note documented when staff attempted to redirect resident #2, the resident stated she could do what she wanted. The note documented staff removed resident #2 and redirected the resident to her own bed in the same room. LPN #1 reported resident #1 and resident #2 were roommates. A family member for resident #1 reported resident #1 and resident #2 remained roommates from 08/21/18 until 08/27/18. The DON acknowledged in an interview resident #1 and resident #2 remained roommates from 08/21/18 until 08/27/18 when resident #1's family requested their loved one be moved from the room. The DON reported she had not considered the incident as abuse but rather behaviors exhibited by resident #2. On 08/29/18 at 8:00 a.m., the administrator (ADM) reported he was informed by the DON of the incident the day after it had happened. The ADM reported he was told by the DON the incident was considered a behavior and had not been considered as abuse by the DON. On 08/29/18 at 9:35 a.m., the ADM and DON were notified of the IJ situation related to the prevention of further potential abuse. On 08/29/18 at 2:55 p.m., the plan of removal for the Immediate Jeopardy related to abuse was accepted by the survey team. The plan of Removal for the Immediate Jeopardy documented: . Resident #1 was moved to a different room. Resident #2 was placed on 1:1 (one on one) and monitored by DON (Director of Nursing) or designee. (Name-deleted) a geri-psych unit was called for evaluation for placement and treatment. She was accepted by (Name-deleted geri-psych unit) and will be transported as soon as possible but will remain on 1:1 until she leaves the facility. (Name-deleted) was notified of room change and resident #2's family was notified of having her evaluated for geri-psych unit and were agreeable. The investigation process has begun by the Administrator, the Director of Nursing and the Assistant Director of Nursing (ADON) with interviewing staff and residents in regards to the alleged allegation of abuse from one resident to another. Resident #1 will be closely monitored with documentation every shift for 1 week and daily for two weeks until it is reported there is no decline in health or mental status for a total of 3 weeks ending on 09/19/18. All staff will be educated on abuse. Education will begin immediately and be completed by midnight (08/29/18) either face to face or verbally by telephone. Inservice and Training: All staff will be instructed and educated on Abuse and Neglect by midnight on 08/29/18. Instruction will be given by the DON, ADON, and the Administrator. This inservice and/or training will be done either face to face or verbally by telephone. Inservice will be documented with content and staff members attendance. Nursing staff will be inserviced on the importance of Abuse and Neglect the reporting process and the investigation. All staff members will be given a copy of the policy and procedure for Abuse and Neglect, signed a placed in the personnel file. QAPI (Quality Assurance and Performance Improvement) will be updated to add Abuse and Neglect to the root/cause analysis. Reports will be completed and sent to the appropriate agencies with a final investigation of the incident. The plan or correction (plan of removal) will be completed by 08/29/18. On 08/29/18 at 12:00 a.m. (midnight), the IJ was removed when all components of the plan of removal had been completed. The deficiency remained at a pattern level of actual harm. On 09/04/18 at 9:33 a.m., interviews were conducted with staff regarding the education in-services pertaining to abuse and reporting abuse. The staff reported an in-service was provided on 08/29/18. The staff was able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. Based on observation, interview, and record review, it was determined the facility failed to prevent abuse for one (#1) of three residents reviewed for abuse. On 08/21/18 at 8:21 p.m., LPN #1 was notified by CMA #1, resident #2 was in bed with resident #1 with her leg over resident #1 and rubbing resident #1's breasts. Resident #1 did not have the capacity to give consent. Resident #2 remained in the same room as resident #1 from 08/21/18 until 08/27/18. A progress note, dated 08/21/18 at 10:09 p.m., documented resident #1 received [MEDICATION NAME] (an antianxiety medication) due to increased anxiety. The facility identified no allegations of abuse in the past six months. Findings: The facility policy for abuse documented the facility would identify abuse. The policy documented it was committed to protecting residents from abuse including resident to resident abuse. The policy documented protection during an investigation would be provided. The policy documented resident to resident abuse would be immediately responded to and the needs of the injured party. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The re-admission assessment, dated 02/14/18, documented the resident was severely cognitively impaired. The admission assessment documented the resident required extensive to total assistance from staff for activities of daily living. The admission assessment documented the resident was not able to walk. A care plan, updated on 07/01/18, documented the resident was dependent on staff for assistance for activities of daily living. The care plan documented the resident was transferred from bed to a wheelchair by a hoyer lift. The care plan documented the resident was dependent on staff for meeting physical, emotional, intellectual, and social needs. The quarterly assessment, dated 07/05/18, documented the resident was severely cognitively impaired. The quarterly assessment documented the resident required extensive to total assistance from staff for activities of daily living. The admission assessment documented the resident was not able to walk. A progress note, dated 08/21/18 at 9:27 p.m., documented LPN #1 was told by CMA #1 and a CNA that resident #1's roommate (resident #2) was in her bed, laying under the blankets, and resident #2 was rubbing resident #1's breasts. The note documented the roommate was redirected back to her own bed. The progress note documented the LPN would continue to monitor. A progress note, dated 08/21/18 at 10:09 p.m., documented resident #1 received [MEDICATION NAME] (an antianxiety medication) due to increased anxiety. The medication administration report (MAR) documented resident #1 received [MEDICATION NAME] 0.5 milligrams (mg) in addition to [MEDICATION NAME] 25 mg for anxiety on 08/21/18 at 10:09 p.m. A communication with physician note, dated 08/26/18 at 8:24 a.m., documented a request to renew resident #1's [MEDICATION NAME] for another 14 days due to increased anxiety for the past week. 2. Resident #2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. An interim care plan, dated 08/21/18, documented the resident required limited assistance with activities of daily living; was cognitively impaired; was able to communicate easily with staff; and was independent with ambulation, locomotion, dressing, and toilet use. A progress note, dated 08/21/18 at 9:27 p.m., documented the resident was found in bed with her roommate lying under the blanket rubbing her roommate on the breasts. The progress note documented when staff attempted to redirect resident #2 she stated, I can do what I want. The progress note documented resident #2 did not want to move. The progress note documented resident #2 was redirected back to her bed. An comprehensive care plan, dated 08/25/18, documented resident #2 had a potential to be physically aggressive. The care plan documented the resident was prescribed an antipsychotic medication related to behavior management and delusional disorder. An admission assessment, dated 08/29/18, documented the resident was severely cognitively impaired. The admission assessment documented the resident exhibited physical behaviors towards others, put others at significant risk for physical harm, and significantly intruded on the privacy or activity of others. The admission assessment documented the resident required limited assistance with activities of daily living. The admission assessment documented the resident had no limitations in her arms or legs. On 08/29/18 at 4:10 a.m., resident #2 was observed in bed with her eyes closed. The resident had no roommate. On 08/29/18 at 4:30 a.m., CNA #2 reported staff was told when they came on duty about resident #2 in bed with resident #1 and grabbing her breast. The CNA reported the staff were not instructed to stay in the room with resident #1 and resident #2 and were only to check on them when they could. On 08/29/18 at 5:00 a.m., LPN #2 reported she was not at the facility when the abuse occurred but came on duty the following shift. The LPN stated the nurse going off duty told her that resident #2 had climbed in bed with resident #1, was rubbing resident #1 on the breast, and resident #1 was given an [MEDICATION NAME] for increased anxiety. LPN #2 stated it was not reported to her as sexual abuse. The LPN reported she was not sure if the DON or ADM had been notified of the abuse. The LPN stated she had not reported the abuse to the DON or ADM. On 08/29/18 at 5:45 a.m., CNA #1 reported the staff were told when they came on the shift on 08/21/18 night shift, one resident had touched another resident. The CNA reported resident #2 remained in the same room with resident #1. The CNA reported the following night, 08/22/18, after the abuse occurred, resident #2 was observed in resident #1's bed on two separate occasions. The CNA reported both times resident #1 was not in the bed. The CNA stated she was never instructed to stay one on one with either resident #1 or resident #2. The CNA confirmed resident #1 was not able to use her call light and was totally dependent on staff to get out of bed and to her wheelchair. On 08/29/18 at 7:10 a.m., resident #2 was observed in bed with her eyes closed. On 08/29/18 at 7:19 a.m., resident #1 was observed being assisted by staff eating breakfast. On 08/29/18 at 7:40 a.m., resident #1 was observed being assisted by staff in her room. On 08/29/18 at 7:50 a.m., the DON stated she was notified by LPN #1 regarding the abuse when it happened. The DON reported she had not consider the incident as abuse. The DON reported she had considered the incident as a behavior by resident #2. The DON reported resident #1 and resident #2 were left in the same room together until 08/27/18. The DON reported resident #1 was moved upon the family's request on 08/27/18. On 08/29/18 at 8:00 a.m., the ADM reported he was told of the abuse the next day but the DON considered it a behavior. He stated, I just go by what the DON decides. On 08/29/18 at 8:40 a.m., resident #2 was observed in the dining room sitting at a table. The resident's cane was by her side. The resident was asked simple questions and answered appropriately. On 08/29/18 at 2:20 p.m., resident #1's family member stated the family had requested for resident #1 to be removed from the same room as resident #2. The family member stated, I requested for the facility to move (name deleted resident #1) a couple of days before she was moved to another room. A progress note, dated 08/29/18 at 3:30 p.m., documented resident #2 was transferred to a geriatric psychiatric unit for evaluation. On 09/04/18 at 8:30 a.m., the DON reported resident #2 remained at the geriatric psychiatric unit. 09/06/18 at 11:30 a.m., CNA #6 had not responded to efforts to communicate via telephone call. It was reported to the surveyor CNA #6 witnessed the abuse. On 09/06/18 at 11:37 a.m., via telephone conference with LPN #1, the LPN reported she was the evening charge nurse on 08/21/18 when the abuse occurred. The LPN stated CMA #1 told her resident #2 was in the bed with resident #1 and was squeezing (name deleted resident #1's) boobs. LPN stated the DON was notified immediately. The LPN stated the DON told her to watch resident #1 and resident #2. The LPN stated the DON told her not to write an incident report, but to write a behavior note about the incident. The LPN stated she told the CMAs and the CNAs to watch resident #2. The LPN stated she considered the incident a sexual advance and it was not appropriate. On 09/06/18 at 1:30 p.m., a return telephone call was received from CMA #1. The CMA reported she had observed resident #2 in the bed of resident #1 on 08/21/18. The CMA stated resident #2 was observed to have had one leg over resident #1 and resident #2 had her hands on resident #1's breasts. The CMA stated the staff separated the residents and assisted resident #2 back to her bed. The CMA stated she reported the incident to LPN #1.

Based on record review, observation and staff interview, it was determined the facility failed to: a) Ensure smoking safety assessments had been completed for three (#4, 7 and #12) of three sampled residents identified as residents who smoked. Resident #12 had burned her finger while smoking and had not been assessed for safety while smoking. Resident #12 had harm from smoking by burning her finger. This had the potential to affect 12 residents identified by the DON as residents who smoked cigarettes and had not been assessed for safety while smoking. b) Ensure hazardous chemicals were maintained in a secure manner in one shower room located on Hall #4. There was a total of two shower rooms in the facility. There were three wandering residents who were unable to reach the chemicals. Findings: 1. Resident #12 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 12/05/11, a care plan documented, "Smoking: Instructed on smoking rules. Will holler to go smoke, until taken out...Staff educated to shut oxygen off while smoking, then on after cigarette is out..." On 08/03/12, a quarterly assessment documented the resident had inadequate short and long term memory, was severely cognitively impaired, was not ambulatory, required a moderate amount of assistance from staff for transfers and ADL's and had impaired ROM U & LE's on one side. On 09/07/12 at 11:10 a.m., an incident/accident report documented, "Resident touched cherry on end of cig when trying to flick her ashes...STPR: Educated resident on how to hold cig when flicking ashes." On 09/07/12, a fax to the physician documented, "(Name deleted) touched end of cig when she was flicking her ashes. 0 blister or open area. Small red spot." On 10/30/12 at 5:00 p.m., the DON was interviewed. The DON was asked if the resident had been assessed for smoking safety. She reported the facility did not have smoking assessments. The DON then stated she could see where a smoking assessment should be completed for all the residents who smoked for their safety. 2. Resident #4 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 09/15/12, a quarterly assessment documented the resident's cognition was intact, required extensive assistance with transferring between surfaces, was not ambulatory and had limitations in ROM of UE on one side. The October 2012, physician's orders [REDACTED]. "...Buspar 5 mg...TID: anxiety... MS Contin 60 mg...q 12 hours...at 8:30 a.m. & 8:30 p.m.; Hydrocodone/APAP 10/325 mg...q 4 hrs, hold if res asleep or lethargic (Dx: chronic pain)... 8:00 a.m., 12:00 p.m., 4:00 p.m., 8:00 p.m.;...Ambien 5 mg...at HS..." On 10/22/12 at 12:15 a.m., a nurse's note documented, "When resident was taken outside for a midnight smoke break, CNA reported that resident dropped cup of coffee on ground and 2 cigarettes..." On 10/29/12 at 11:00 a.m., the resident was observed in the smoking area smoking a cigarette. Staff were observed outside with the resident. Incident/accident reports were reviewed. The resident had 10 falls from April through October 2012. On 10/29/12 at 2:00 p.m., the resident was asked if she went outside and smoked alone. The resident stated, "No, not any more." On 10/30/12 at 10:00 a.m., the DON was interviewed. She was asked if a smoking assessment had been completed to assess the safety of the resident smoking. The DON reported the facility did not have a smoking assessment to use. 3. Resident #7 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 06/10/12, on the 11-7 shift a nurse's note documented, "Up ambulating from room to smoke area over and over. Noted to go to smoke area light cig. then put it out s smoking and returns to room. Noted to talk to self in quiet voice and snapped fingers frequently..." On 10/07/12, a nurse's progress note documented, "Resident amb around facility ad lib. Resp even & unlabored in & out to smoke ad lib..." A quarterly assessment, dated 10/13/12, documented the resident had intact cognition skills, was independent with bed mobility, ambulation and ADL's. On 10/17/12, a care plan documented, "...Potential for need of assist with decision making at times ([DIAGNOSES REDACTED]. Remind him to always make sure that he has a firm grip on cigarette before removing from his mouth..." On 10/28/12 at 11:30 a.m., the resident was observed sitting in front of the building smoking independently. No staff were present. On 10/29/12 at 2:00 p.m., the resident was observed sitting in front of the building smoking independently. No staff were present. On 10/29/12 at 12:00 p.m., the DON was interviewed. The DON was asked if the resident had been assessed for smoking safety. She reported the facility did not have smoking assessments. The DON then stated she could see where a smoking assessment should be completed for all the residents who smoked for their safety. 4. On 10/28/12 at 10:20 a.m., an initial tour of the facility was completed. LPN #2 was assisting with tour. She report the resident had fallen the previous night. On 10/28/12 at 10:20 a.m., an initial tour of the facility was completed. The shower room door on Hall #4 was observed unlocked. Inside the shower room was a cabinet mounted on the wall. The cabinet was observed to contain two spray bottles containing a light yellow substance. The label on the bottles documented, "Lemon Clear Disinfectant." The 'Material Safety Data Sheet', documented 'Clear Lemon', PPE- glasses...acute health effect- minimal...primary entry routes: skin & eye repeated contact with the skin may be irritating can be corrosive to the eyes...First Aid...ingestion give large volume of water. Do not induct vomiting, get medical attention..." LPN #2 was assisting with the tour and stated the cabinet was supposed to be locked. The LPN immediately locked the cabinet. At that time, LPN #2 was asked if the facility had any wandering residents. The LPN reported there were three wandering residents. The LPN stated, that all three residents were W/C bound, were not ambulatory or able to stand without assistance and were unable to reach the cabinet to get to the chemicals. During the four days of the survey, no ambulatory wandering residents were observed in the facility. During the remainder of the survey, the cabinet was observed locked. On 10/30/12 at 4:00 p.m., the DON was informed of the unlocked cabinet in the shower room on Hall 4 with the unsecured chemicals. She reported the cabinet should have been locked.