Every finding on record at Wewoka Healthcare Center

On 02/25/26 at 3:03 p.m., an IJ situation was determined to exist related to the facility's failure to implement written policies and procedures for reporting, prohibiting, and preventing the misappropriation of Res #6's controlled narcotic medications.On 02/26/26 at 11:46 a.m., the Oklahoma State Department of Health verified the existence of an IJ situation.On 02/26/26 at 12:05 p.m., the administrator was notified of the IJ situation and provided the IJ template. On 03/03/26 at 2:02 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility plan of removal showed the administrator was educated on policies and procedures that prohibited/prevented any misappropriation of controlled medications, investigated any allegations, and reported any allegations to the Oklahoma State Department of Health and law enforcement by the corporate administrator.The plan of removal showed all licensed nurses and CMAs would be re-educated by 3:00 p.m. on 03/04/26 by the corporate administrator, ADON, and LPN #4 on reporting requirements, controlled substance chain of command, and documentation requirements.The IJ was lifted, effective 03/04/26 at 3:00 p.m., when all components of the plan of removal had been completed. All in-services in the plan of removal were reviewed, and staff interviews were conducted regarding implementing policies/procedures and reporting/investigating allegations of misappropriation of controlled narcotic medications had been completed. The deficiency remained at a pattern with the potential for more than minimum harm. Based on record review and interview, the facility failed to:a. implement policies and procedures for misappropriation of a resident's controlled narcotic medications; andb. implement the policy for report and investigate allegations of misappropriation of controlled narcotic medications for 1 (#6) of 7 sampled residents reviewed for reporting misappropriation of controlled medications.The ADON identified 21 residents in the facility received controlled narcotic medications. Findings:An undated Abuse Policy and Procedure, read in part, It recognizes resident rights to be free from misappropriation of resident property .The administrator will immediately report the allegation to the Oklahoma State Department of Health and the local police. The administrator or administrative designee will conduct an immediate investigation of all alleged misappropriation of property.An undated diagnoses list showed Res #6 was admitted to the facility on [DATE] with diagnoses which included chronic pain, hypertension, and major depressive disorder.A pharmacy packing slip for Res #6, dated 12/15/25, showed 120 oxycodone/APAP were delivered for Res #6. There was no documentation to account for 90 of the 120 tablets delivered on 12/15/25.A physician's order for Res #6, dated 12/24/25, showed oxycodone/APAP (an opioid/non-opioid) 10-325mg, one tablet every six hours as needed. The physician's order showed the order was discontinued on 01/30/26.A multi-dated Medication Log of Receiving form for Res #6 did not log the oxycodone/APAP that was delivered on 12/15/25.A MAR for Res #6, dated 12/2025 and 01/2026, showed three doses were administered on 12/26/25, 12/31/25, and 01/05/26.A controlled drug count sheet for Res #6, with a received date of 12/15/25, showed 30 oxycodone/APAP 10-325mg were received. The form showed an additional 19 doses were administered that were not documented on the 01/2026 MAR.On 02/20/26 at 11:45 a.m., CMA #1 stated their name had been forged on the count sheet on multiple days. CMA #1 stated Res #6 never asked for pain medication and the only dose they took was the first dose. They stated Res #6 stated they did not like the way it made them feel. CMA #1 stated they informed the administrator and were told it would be taken care of.On 02/24/26 at 9:25 a.m., Res #6 stated they had not taken the oxycodone/APAP because they did not like the way it made them feel. Res #6 stated the last time they took the pain medication was about two months ago.On 02/24/26 at 10:48 a.m., LPN #1 stated CMA #1 had told them about the narcotic count sheet and advised CMA #1 to report it to the administrator.On 02/24/26 at 2:50 p.m., CMA #2 stated the issue was found during a count of the medication cart on 01/16/26. CMA #2 stated CMA #1 immediately went to the administrator to report it.On 02/24/26 at 3:42 p.m., the administrator stated they were never informed about the issue with the narcotic count sheet for Res #6 and the OSDH and law enforcement were not notified.On 02/25/26 at 11:34 a.m., LPN #1 stated they did not feel like it was their place to follow up because the DON was usually responsible for that.On 02/25/26 at 11:46 a.m., the ADON stated they only made sure the count on the sheet and the card matched then it went into lock up in the DON's office. The ADON stated it was usually the RN's responsibility to perform the medication reconciliation.On 02/25/26 at 12:09 p.m., the administrator stated it should be the RN or charge nurse reconciling the count sheet with the MAR record. The administrator stated it would be the DON going forward.On 02/25/26 at 12:35 p.m., LPN #2 stated they did not administer Res #6 any narcotic and they did not sign the count sheet.On 02/25/26 at 2:20 p.m., phone interview with pharmacy staff confirmed 120 oxycodone/APAP 10-325mg were delivered to the facility on [DATE] for Res #6.On 02/26/25 at 8:45 a.m., an anonymous staff member stated they witnessed CMA #1 report to the administrator and ADON that someone signed their name on the narcotic count sheet.

On 02/26/26, an IJ situation was determined to exist related to the facility's failure to have effective administration who utilized its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility administration failed to:a. ensure residents' controlled medications were not misappropriated;b. establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation;c. ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled; andd. report an allegation of misappropriation of controlled medications to law enforcement and the state survey agency.On 02/26/26 at 3:26 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On 02/26/26 at 3:52 p.m., the administrator was notified of the IJ situation and the IJ template was provided.On 03/05/26 at 10:40 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Reporting: On 02/26/2026, the Administrator was re educated and immediately began following the requirement to report all allegations or indications of misappropriation of controlled medications to the Oklahoma State Department of Health and local law enforcement.Document Routing: On 02/27/2026, all Licensed Nurses and CMAs were educated that all pharmacy medication receipts, completed narcotic count sheets, and any drug related documents must be turned in to the DON immediately at the end of each shift.Controlled Medication Receipt Process: On 02/26/2026, Licensed Nurses and CMAs were trained that all controlled medications are received from the pharmacy by a Licensed Nurse only (no CMA may accept, store, or sign for controlled substances).Administration Responsibilities: On 02/27/2026, Licensed Nurses were re educated that only Licensed Nurses may dispense/administer controlled substances, ensuring secure chain of custody.Facility Wide Narcotic Audit: Between 02/26/2026 and 02/27/2026, Consultant Nurse completed a full controlled substance audit to ensure all narcotics were present and available according to current physician orders for all residents.Record Reconciliation: The DON reconciled all current narcotic records, aligning count sheets and MARs with current physician orders and physical stock.Pharmacy Consultant Audit: On 03/02/2026, the pharmacy consultant conducted an additional reconciliation of controlled substance records to validate accuracy and identify any irregularities.Pharmacy Notification System: Effective 03/02/2026, the pharmacy will notify the governing body and the Administrator of any out of sync or irregular narcotic requests/deliveries to detect and prevent misappropriation.Physician Notification: The attending physician was notified by the Administrator regarding the allegation, investigation, and medication availability to ensure uninterrupted pain management.QA Committee Review: On 03/02/2026, the findings, corrective actions, reconciliation outcomes, and reporting steps were presented to the Quality Assurance Committee for review and ongoing monitoring.Completed by 03/05/2026 at 5:00 PM.The IJ was lifted, effective 03/05/26, when all components of the plan of removal had been verified as completed. Multiple certified and licensed staff on different shifts were interviewed regarding the in-services they received. Pharmacy audits, police reports, state reported incidents, and QA agendas were reviewed. The deficiency remained at widespread level with the potential for more than minimal harm.Based on observation, record review, and interview, the facility failed to have effective administration who utilized its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility administration failed to:a. ensure residents' controlled medications were not misappropriated;b. establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation;c. ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled; andd. report an allegation of misappropriation of controlled medications to law enforcement and the state survey agency.The administrator identified 61 residents resided in the facilityFindings:An Administrator policy, revised 04/2007, read in part, The Administrator is responsible for, but not limited to: Managing the day-today functions of the facility.Implementing, established resident care policies, personnel policies, safety and security policies, and other operational policies and procedures necessary to remain in compliance with current laws, regulations, and guidelines governing long-term care facilities.1.The facility failed to ensure controlled medications were not misappropriated for 2 (#2 and #6) of 5 sampled residents who were reviewed for medication misappropriation. Res #6 had 120 oxycodone/APAP tablets delivered, but 90 tablets were unaccounted for, with discrepancies between the medication administration record, count sheets, and receiving logs, as well as allegations of forged staff signatures and lack of follow-up on reported concerns. Res #2 had 90 hydrocodone/APAP tablets delivered, but 30 tablets were missing, with no documentation of receipt and missing count sheets. Staff were unable to locate the missing medications, and responsibilities for reconciliation were unclear. The ADON identified 21 residents received controlled pain medication.2. The facility failed to ensure written policies and procedures that prohibit and prevent misappropriation of residents' controlled medications were implemented for 1 (#6) of 7 sampled residents reviewed for reporting misappropriation of controlled medications. Res #6 had 120 oxycodone/APAP tablets delivered, but 90 tablets were unaccounted for, with discrepancies between medication records and count sheets, including undocumented administrations. A staff member reported that their signature had been forged on narcotic count sheets and stated the resident had only taken one dose; however, although this concern was reportedly brought to leadership, the administrator denied being notified, and no reports were made to state authorities or law enforcement as required by policy. Additionally, staff expressed confusion regarding responsibility for medication reconciliation and follow-up, further demonstrating a breakdown in oversight and adherence to facility procedures. The ADON identified 21 residents received controlled pain medication. 3. The facility failed to ensure a system was in place for receipt, disposition, and reconciliation of controlled narcotic medications for 2 (#2 and #6) of 5 sampled residents reviewed for medication misappropriation. Res #6 had 120 oxycodone/APAP tablets delivered; however, 90 tablets could not be accounted for, with missing medication cards, lack of documentation on the medication receiving log, and discrepancies between the count sheet and MAR, including undocumented doses and allegations of forged signatures. Res #2 had 90 hydrocodone/APAP tablets delivered, but 30 tablets were unaccounted for, with missing count sheets and no documentation of receipt. Staff interviews showed confusion regarding responsibility for reconciliation. The ADON identified 21 residents received controlled pain medication. On 02/27/26 at 1:15 p.m., the administrator stated they were responsible for ensuring freedom of misappropriation of controlled medications and accurate narcotic counts. They stated they had not monitored narcotics because they thought the nursing staff was monitoring them. The administrator stated the DON was responsible for controlled drug receipt, storage, and disposition but the facility had been without a DON during the months of December 2025 and January 2026. They stated relying on the medication staff to ensure proper accounting and reconciliation of controlled drugs was inappropriate. The administrator stated they had never been made aware of concerns regarding missing medications or allegations of misappropriation. They stated the pharmacy consultant periodically audits medications and had never voiced any concerns.On 03/02/26 at 11:20 a.m., the corporate administrator stated the facility was using an RN to fill in for the lack of a DON during the time the misappropriation occurred. They stated they assumed the RN would have overseen the controlled medication receipt, storage, and disposition process. The corporate administrator stated there was a breakdown in the chain of command which allowed misappropriation of medications to occur without anyone noticing immediately. They stated the break in processes was ultimately the administrator's responsibility.On 03/03/26 at 10:05 a.m., the COO stated the administrator communicated with them daily through phone calls and emails. They stated they had never been made aware of concerns regarding misappropriation of medications or the accuracy of narcotic counts until now. The COO stated the pharmacy consultant had conducted a drug audit the day before, but they were not aware of the results of the audit at this time.

On 02/25/26 at 3:03 p.m., an IJ situation was determined to exist related to the facility's failure to have an effective quality assurance program that acted on identified concerns and developed a plan of action to correct identified quality of care issues. On 02/26/26 at 3:26 p.m., the Oklahoma State Department of Health verified the existence of an IJ situation.On 02/26/26 at 3:48 p.m., the administrator was notified of the IJ situation and the IJ template was provided.Administrator was educated on having an effective QAPI program that identifies and implements corrective action for quality-of-care issues that include but not limited to reporting allegations of misappropriation of controlled medications to the Oklahoma State Department of Health and Law Enforcement. Inservice completed by corporate administrator on 2/27/26QA Committee Review: On 03/02/2026, the facility plan of removal showed the findings, corrective actions, reconciliation outcomes, and reporting steps were presented to the Quality Assurance Committee for review and ongoing monitoring. On 03/03/26 at 2:02 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health.The IJ was lifted, effective 03/05/26, when all components of the plan of removal had been verified as completed. Multiple certified and licensed staff on different shifts were interviewed regarding the in-services they received. Pharmacy audits, police reports, state reported incidents, and QA agendas were reviewed. The deficiency remained at widespread level with the potential for more than minimal harm.Based on record review and interview, the facility failed to have an effective quality assurance program that acted on identified concerns and developed a plan of action to correct identified quality of care issues. The administrator identified 61 residents resided in the facility. Findings:A facility policy titled Policy and Procedure manual for Quality Assurance Performance Improvement, dated 11/01/17, read in part, addresses clinical care-monitoring existing QM results, falls, medication errors, pressure ulcers, incident reports, resident/guests/families concern brought up, and review grievances. The committee will meet quarterly or more often.An undated diagnoses list for Res #6 showed the resident was admitted to the facility on [DATE] with diagnoses which included chronic pain, hypertension, and major depressive disorder.A physician's order for Res #6, dated 12/24/25, showed oxycodone/APAP (pain medication) 10-325mg, one tablet every six hours as needed. The physician's order showed the order was discontinued on 01/30/26.A 5-day MDS assessment for Res #6, dated 02/04/26, showed the resident had a BIMS score of 15 which indicated the resident was cognitively intact for daily decision making.A pharmacy packing slip for Res #6, dated 12/15/25, showed 120 oxycodone/APAP were delivered for Res #6. There was no documentation to account for 90 of the 120 tablets delivered on 12/15/25.A controlled drug count sheet for Res #6, with a received date of 12/15/25, showed 30 tablets oxycodone/APAP 10-325mg were received. The form showed an additional 19 doses were administered that were not documented on the MAR as being administered to the resident.A multi-dated Medication Log of Receiving form for Res #6 did not log the oxycodone/APAP that was delivered on 12/15/25.A MAR for Res #6, dated 12/2025 and 01/2026, showed three doses were administered.On 02/20/26 at 11:45 a.m., CMA #1 stated their name had been forged on the count sheet on multiple days. CMA #1 stated the resident never asked for pain medication and the only dose they took was the first one. They stated Resident #6 did not like the way it made them feel. CMA #1 reported they informed the administrator and was told it would be taken care of.On 02/24/26 at 9:25 a.m., Res #6 stated they had not taken the oxycodone/APAP because they did not like the way it made them feel. Res #6 stated the last time they took the pain medication was about two months ago. At 10:48 a.m., LPN #1 stated CMA #1 had told them about the narcotic count sheet and advised CMA #1 to report it to the administrator.On 02/24/26 at 2:50 p.m., CMA #2 stated the issue was found while counting out the medication cart with CMA #1. CMA #2 stated CMA #1 immediately went to the administrator to report it.On 02/24/26 at 3:42 p.m., the administrator stated they were never informed about the issue with the narcotic count sheet for Res #6 and the OSDH and law enforcement were not notified.On 02/25/26 at 11:34 a.m., LPN #1 stated they did not feel like it was their place to follow up because the DON was usually responsible for that. At 11:46 a.m., the ADON stated they only make sure the count on the sheet and the card match then it goes into lock up in the DON's office. The ADON stated it was usually the RN's responsibility to perform the medication reconciliation. At 12:09 p.m., the administrator stated it should be the RN or charge nurse reconciling the count sheet with the MAR. The administrator stated it would be the DON going forward. At 12:35 p.m., LPN #2 stated they did not administer Res #6 any narcotics and they did not sign the count sheet.An interview with a pharmacy staff confirmed 120 tablets oxycodone/APAP 10-325mg were delivered to the facility on [DATE] for Res #6.No documentation present that an investigation or PIP was implemented with the QAPI committee.

On 02/25/26, an IJ situation was determined to exist related to the facility's failure to ensure controlled medications were not misappropriated for Res #2 and Res #6.On 02/26/26 at 11:25 am., the Oklahoma State Department of Health verified the existence of an IJ situation.On 02/26/26 at 11:57 a.m., the administrator was notified of the IJ situation and an IJ template was provided.On 03/03/26 at 2:02 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility's plan of removal showed a full audit of all controlled substances (all units and all shifts) was completed immediately by the on-sight nurse consultant. Law enforcement and physician were notified. The administrator was educated by the corporate administrator on policies and procedures to prohibit/prevent any misappropriation of controlled medications, investigate any allegations, and report any allegations to the Oklahoma State Department of Health and law enforcement.The plan of removal showed the licensed nurses and CMAs were in-serviced, in person or by phone, by the administrator, they would be responsible for accepting medications from the pharmacy and signing verification of what was delivered. All licensed nurses and CMAs were in-serviced to properly log controlled medications on the narcotic count sheets, checking/documenting on the MAR when administered, verifying count was correct at shift change, and narcotic count sheets that were completed will be given to the DON with any discrepancies reported to the administrator immediately. In-serviced by phone/in-person by the administrator by 3:00 p.m. on 02/26/26.The plan of removal showed all licensed nurses and CMAs educated by administrator and ADON on turning in all medication receipts from the pharmacy, completed narcotic count sheets, and any other drug records into the DON immediately. The facility's plan of removal, read in part, All licensed nurses and CMAs will be re-educated by the pharmacy consultant on controlled substance regulations and drug diversion. The ADON will educate on proper narcotic count procedures, documentation requirements, chain-of-custody, identifying and reporting drug diversion, reporting requirements for unusual occurrences, steps required when a discrepancy is found, and consequences of noncompliance will be completed by 5:00 p.m. on 03/04/26.The IJ was lifted, effective 03/04/26 at 5:00 p.m., when all components of the plan of removal had been completed. All in-services and training reviewed. Staff interviews regarding misappropriation of controlled medications had been completed. The deficiency remained at a pattern with the potential for more than minimum harm.Based on record review and interview, the facility failed to ensure controlled medications were not misappropriated for 2 (#2 and #6) of 5 sampled residents reviewed for misappropriation.The ADON identified 21 residents with controlled medications resided in the facility. Findings: An undated policy titled Abuse Policy and Procedure, read in part, It recognizes resident rights to be free.from misappropriation of resident property.1. An undated diagnoses list showed Res #6 was admitted to the facility on [DATE] with diagnoses which included chronic pain, hypertension, and major depressive disorder.A pharmacy packing slip for Res #6, dated 12/15/25, showed 120 oxycodone/APAP (opioid/non-opioid) were delivered for Res #6. There were no documentation, narcotic count sheets or medication logs, to account for 90 of the 120 tablets delivered on 12/15/25.A physician's order for Res #6, dated 12/24/25, showed oxycodone/APAP 10-325mg, one tablet every six hours as needed. The physician's order showed the order was discontinued on 01/30/26.A multi-dated Medication Log of Receiving form for Res #6 did not show the oxycodone/APAP was logged as being delivered on 12/15/25.A MAR for Res #6, dated 12/2025 and 01/2026, showed three doses were administered on 12/27/25, 12/31/25, and 01/05/26.A controlled drug count sheet for Res #6, with a received date of 12/15/25, showed 30 oxycodone/APAP 10-325 mg were received. The form showed an additional 19 doses were administered which were not documented on the MAR.On 02/20/26 at 11:45 a.m., CMA #1 stated their name had been forged on the count sheet on multiple days. CMA #1 stated Res #6 never asked for pain medication and the only dose they took was the first dose. CMA #1 stated Res #6 said they did not like the way it made him feel. CMA #1 stated they informed the administrator and were told it would be taken care of.On 02/24/26 at 9:25 a.m., Res #6 stated they had not taken the oxycodone/APAP because they did not like the way it made them feel. Res #6 stated the last time they took the pain medication was about two months ago.On 02/24/26 at 10:48 a.m., LPN #1 stated CMA #1 had told them about the narcotic count sheet and advised CMA #1 to report it to the administrator.On 02/24/26 at 2:50 p.m., CMA #2 stated the issue was found during a count of the medication cart on 01/16/26. CMA #2 stated CMA #1 immediately went to the administrator to report it.On 02/24/26 at 3:42 p.m., the administrator stated they were never informed about the issue with the count sheet for Res #6.On 02/25/26 at 11:34 a.m., LPN #1 stated they did not feel like it was their place to follow up because the DON was usually responsible for that.On 02/25/26 at 11:46 a.m., the ADON stated they only made sure the count on the sheet and the card matched, then it went into lock up in the DON's office. The ADON stated it was usually the RN's responsibility to perform the medication reconciliation.On 02/25/26 at 12:09 p.m., the administrator stated it should be the RN or the charge nurse who reconciled the count sheet with the medication administration record. They stated it would be the DON going forward.On 02/25/26 at 12:35 p.m., LPN #2 stated they did not administer Res #6 any narcotics and they did not sign the count sheet.On 02/25/26 at 2:20 p.m., pharmacy staff confirmed 120 oxycodone/APAP (opioid/non-opioid) 10-325mg were delivered to the facility on [DATE] for Res #6.On 02/26/25 at 8:45 a.m., an anonymous staff member stated they witnessed CMA #1 report to the administrator and ADON that someone signed their name on the narcotic count sheet. 2. An undated diagnoses list showed Res #2 admitted to the facility with diagnoses which included chronic pain and major depressive disorder.A physician's order for Res #2, dated 09/21/25, showed hydrocodone/APAP 7.5-325 mg, one tablet by mouth three times a day.A pharmacy packing slip for Res #2, dated 01/08/26, showed 90 hydrocodone/APAP 7.5-325 mg were delivered to Res #2. There was no documentation to account for 30 of the 90 tablets delivered on 01/08/26.A multi-dated Medication Log of Receiving form for Res #2 did not show the hydrocodone/APAP 7.5-325 mg 90 were logged in.An interview with pharmacy staff confirmed #90 Hydrocodone/APAP 7.5-325 mg 90 were delivered to the facility on [DATE] for Res #2.On 02/27/26 at 2:55 p.m., Res #2's controlled drug count sheets for 11/2025, 12/2025, 01/2026, and 02/2026 with packing slips from the pharmacy were reconciled with the ADON. The count showed 30 hydrocodone/APAP 7.5-325 mg were unaccounted for. The ADON stated there should have been three count sheets for 01/2026 and they only located two.On 02/27/26 at 3:00 p.m., the DON stated they went through all the medications in lock up and the missing medications for Res #2 could not be located.

On 02/25/26, an IJ situation was determined to exist related to the facility's failure to ensure a system was in place to reconcile controlled narcotic medications to prevent misappropriation of Res #2 and Res #6 controlled narcotic medications.On 02/26/26 at 3:24 p.m., the Oklahoma State Department of Health verified the existence of an IJ situation.On 02/26/26 at 3:46 p.m., the administrator was notified of the IJ situation and the IJ template was provided.On 03/04/26 at 2:13 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility's plan of removal showed on 02/27/26 the administrator and DON were in-serviced by the corporate administrator regarding the facility's controlled-substance reconciliation system. The in-service included mandatory reporting and record keeping requirements.The plan of removal showed effective 02/26/26, all narcotic deliveries received would be verified against the pharmacy delivery receipt and signed into the controlled drug count sheets by a licensed nurse at the time of receipt. Delivery receipts were attached to the unit's narcotic packet and routed to the DON by end of shift.The plan of removal showed on 02/26/26 through 02/27/26 the nurse consultant completed a full scope audit of all units and verified medication availability for all residents with active orders. No current stock discrepancies affecting resident care were identified. Access to controlled substances were immediately restricted to licensed nurses only. CMAs would no longer receive or administer controlled substances. On 02/26/26, the medication storage for controlled substances was verified as double locked and functional, and end of shift dual signature counts by two licensed nurses were implemented.The plan of removal showed all licensed nurses and CMAs were re educated by the ADON and LPN #4 on reconciliation, documentation, chain of custody, discrepancy escalation, and reporting expectations. This was to be completed by 5:00pm 03/04/26.The IJ was lifted, effective 03/04/26 at 5:00 p.m., when all components of the plan of removal had been completed. All in-services and training was reviewed. Staff interviews regarding reconciliation, documentation, chain of custody, discrepancy escalation, and reporting expectations of controlled narcotic medications. The deficiency remained at a pattern with the potential for more than minimum harm.Based on record review and interview, the facility failed to ensure a system was in place for receipt, disposition, and reconciliation of controlled narcotic medications for 2 (#2 and #6) of 7 sampled residents reviewed for misappropriation of medications.The administrator identified 21 residents with controlled narcotic medications resided in the facility. Findings: An undated Controlled Substance (Narcotic) Counting and Accountability Policy, read in part, The facility shall maintain a system for the receipt, storage, administration, counting, reconciliation, investigation of discrepancies, and destruction of all controlled substances. Upon delivery from pharmacy, two authorized staff members shall verify medication name, strength, quantity, and resident name, Initial count shall be documented and signed. 1. An undated diagnoses list showed Res #6 was admitted to the facility on [DATE] with diagnoses which included chronic pain, hypertension, and major depressive disorder. A pharmacy packing slip for Res #6, dated 12/15/25, showed 120 oxycodone/APAP were delivered for Res #6. Count sheets and medication cards for 90 tablets were unable to be located.A controlled drug count sheet for Res #6, with a received date of 12/15/25, showed 30 oxycodone/APAP 10-325mg were received. The form showed an additional 19 doses were administered that were not documented on the MAR as administered to the resident.A physician's order for Res #6, dated 12/24/25, showed oxycodone/APAP (an opioid/a non-opioid) 10-325mg, one tablet every six hours as needed. The physician's order showed the order was discontinued on 01/30/26.A multi-dated facility Medication Log of Receiving form for Res #6 did not log the oxycodone/APAP that was delivered on 12/15/25.A MAR for Res #6, dated 12/2025 and 01/2026, showed three doses were administered 12/27/25, 12/31/25, and 01/05/26.On 02/20/26 at 11:45 a.m., CMA #1 stated their name had been forged on the count sheet on multiple days. CMA #1 stated the resident never asked for pain medication and the only dose Res #6 took was the first one. CMA #1 stated Res #6 did not like the way it made them feel. CMA #1 stated they informed the administrator and was told it would be taken care of.On 02/24/26 at 9:25 a.m., Res #6 stated they had not taken the oxycodone/APAP because they did not like the way it made them feel. Res #6 stated the last time they took the pain medication was about two months ago.On 02/24/26 at 12:58 p.m., the administrator stated the facility was without a full-time DON from 12/02/25 through 02/09/26.On 02/24/26 at 2:50 p.m., CMA #2 stated the issue was found during a count of the medication cart with CMA #1. CMA #2 stated CMA #1 immediately went to the administrator to report it.On 02/25/26 at 11:46 a.m., the ADON stated they only made sure the count on the sheet and the card matched, then it went into lock up in the DON's office. The ADON stated it was usually the RN's responsibility to perform the medication reconciliation.On 02/25/26 at 12:09 p.m., the administrator stated it should be the RN or charge nurse who reconciled the count sheet with the MAR. They stated it would be the DON going forward.On 02/25/26 at 12:35 p.m., LPN #2 stated they did not administer Res #6 any narcotics and they did not sign the count sheet.On 02/25/26 at 2:20 p.m., pharmacy staff confirmed 120 oxycodone/APAP 10-325mg were delivered to the facility on [DATE] for Res #6.On 02/26/25 at 8:45 a.m., an anonymous staff member they stated they witnessed CMA #1 report to the administrator and ADON that someone signed their name on the narcotic count sheet. 2. An undated diagnoses list showed Res #2 admitted to the facility with diagnoses which included chronic pain and major depressive disorder.A physician's order for Res #2, dated 09/21/25, showed hydrocodone/APAP 7.5-325 mg, one tablet by mouth three times a day.A pharmacy packing slip for Res #2, dated 01/08/26, showed 90 hydrocodone/APAP 7.5-325 mg were delivered to Res #2. A count sheet and a medication card for 30 tablets were unable to be located.A multi-dated Medication Log of Receiving form for Res #2 did not show the hydrocodone/APAP 7.5-325 mg 90 were logged in.On 02/24/26 at 12:58 p.m., the administrator stated the facility was without a full time DON from 12/02/25 through 02/09/26.On 02/27/26 at 10:30 a.m., pharmacy staff confirmed 90 hydrocodone/APAP 7.5-325 mg 90 were delivered to the facility on [DATE] for Res #2.On 02/27/26 at 2:55 p.m., Res #2's controlled drug count sheets for 11/2025, 12/2025, 01/2026, and 02/2026 with the packing slips from the pharmacy were reconciled with the ADON. The reconciliation showed 30 hydrocodone/APAP 7.5-325 mg were unaccounted for. The ADON stated there should have been three count sheets for 01/2026 and they located two.

Based on record review and interview, the facility failed to employ a full-time DON and ensure RN coverage for eight consecutive hours, seven days a week.The administrator identified 61 residents resided in the facility. Findings:A PBJ Staffing Data Report, dated 07/01/25 through 09/30/25, the fourth quarter of fiscal year 2025, showed the facility did not provide RN coverage on 18 of the 92 days in that quarter. The dates identified on the PBJ report as not having RN coverage in 07/2025, 08/2025, and 09/2025 were 07/05/25, 07/06/25, 07/20/25, 07/27/25, 08/03/25, 08/10/25, 08/23/25, 08/24/25, 09/05/25, 09/07/25, 09/08/25, 09/09/25, 09/13/25, 09/14/25, 09/16/25, 09/19/25, and 09/23/25.A facility document titled Springhill time clock report, dated 07/01/25 through 02/24/26, showed there was not a RN on duty on 07/05/25, 07/06/25, 07/20/25, 07/27/25, 08/03/25, 08/10/25, 08/23/25, 08/24/25, 09/05/25, 09/07/25, 09/08/25, 09/09/25, 09/13/25, 09/14/25, 09/16/25, 09/19/25, and 09/23/25.On 02/24/26 at 12:49 p.m., the BOM stated there was no RN coverage on 07/05/25, 07/06/25, 07/20/25, 07/27/25, 08/03/25, 08/10/25, 08/23/25, 08/24/25, 09/05/25, 09/07/25, 09/08/25, 09/09/25, 09/13/25, 09/14/25, 09/16/25, 09/19/25, and 09/23/25.On 02/24/26 at 12:49 p.m., the BOM stated the last day of employment for DON #1 was on 09/04/25. Former DON #2's employment dates were 09/10/25 through 12/02/25.They stated the current DON began employment on 02/09/26.On 02/24/26 at 12:58 p.m., the administrator stated the facility was without a full-time DON from 09/04/25 through 09/10/25 and 12/02/25 through 02/09/25.

Based on observation, record review, and interview, the facility failed to ensure dishes were air dried.The dietary manager identified 61 residents received dietary services from the kitchen. Findings: On 02/17/26 at 10:57 a.m., a tour of the kitchen was conducted. Bowls and cups were observed to be stacked inside each other and were still wet. On 02/19/26 at 2:25 p.m., plates and pans were observed to have water in between each dish and pan. The pans were stored inside a larger metal square pan with standing water in the bottom of the square pan. On 02/19/26 at 2:28 p.m., dietary aide #1 stated they knew the policy for storing dishes and pans and they should be dry before being put away, but sometimes the dishes got put away wet if they were in a hurry. A facility report titled Food Safety and Sanitary Checklist from the dietician, dated 10/23/25, showed a checkmark on the No column that dishes and pans were not air dried and stored dry. On 02/20/26 at 1:00 p.m., the dietary manager stated to ensure staff was following the policy and procedures to prevent foodborne illnesses, dishes and cooking utensils were to be clean and stored in sanitary conditions. The dietary manager stated, I just keep working with them and reminding them. I have new ones that I'm working with.

Based on record review and interview, the governing body failed to oversee the facility and coordinate with the facility administrator to ensure:a. residents were free from misappropriation of controlled medications;b. a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation;c. drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled;d. allegations of misappropriation of controlled medications were reported to law enforcement and the state survey agency; e. allegations of misappropriation of controlled medications were investigated per the facility's abuse prevention policy; andf. an effective quality assurance program that acted on identified concerns and developed a plan of action to correct identified quality of care issues. The administrator identified 61 residents resided in the facility.Findings:An Administrative Management (Governing Board) policy, revised 10/2017, read in part, The governing board is responsible for, but is not limited to: Oversight of facility care and services in accordance with professional standards of practice and principles.Establishment of a system whereby the Administrator reports to the governing body, including: method of communication from the administrator, frequency of reports, specific information that will be reported, how and when the governing body will respond to the Administrator's reports; and how the Administrator will be held accountable for facility management and operations.1.The facility failed to ensure controlled medications were not misappropriated for 2 (#2 and #6) of 5 sampled residents who were reviewed for medication misappropriation. Res #6 had 120 oxycodone/APAP tablets delivered, but 90 tablets were unaccounted for, with discrepancies between the medication administration record, count sheets, and receiving logs, as well as allegations of forged staff signatures and lack of follow-up on reported concerns. Res #2 had 90 hydrocodone/APAP tablets delivered, but 30 tablets were missing, with no documentation of receipt and missing count sheets. Staff were unable to locate the missing medications, and responsibilities for reconciliation were unclear. The ADON identified 21 residents received controlled pain medication.2. The facility failed to ensure written policies and procedures that prohibit and prevent misappropriation of residents' controlled medications were implemented for 1 (#6) of 7 sampled residents reviewed for reporting misappropriation of controlled medications. Res #6 had 120 oxycodone/APAP tablets delivered, but 90 tablets were unaccounted for, with discrepancies between medication records and count sheets, including undocumented administrations. A staff member reported that their signature had been forged on narcotic count sheets and stated the resident had only taken one dose; however, although this concern was reportedly brought to leadership, the administrator denied being notified, and no reports were made to state authorities or law enforcement as required by policy. Additionally, staff expressed confusion regarding responsibility for medication reconciliation and follow-up, further demonstrating a breakdown in oversight and adherence to facility procedures. The ADON identified 21 residents received controlled pain medication. 3. The facility failed to ensure a system was in place for receipt, disposition, and reconciliation of controlled narcotic medications for 2 (#2 and #6) of 5 sampled residents reviewed for medication misappropriation. Res #6 had 120 oxycodone/APAP tablets delivered; however, 90 tablets could not be accounted for, with missing medication cards, lack of documentation on the medication receiving log, and discrepancies between the count sheet and MAR, including undocumented doses and allegations of forged signatures. Res #2 had 90 hydrocodone/APAP tablets delivered, but 30 tablets were unaccounted for, with missing count sheets and no documentation of receipt. Staff interviews showed confusion regarding responsibility for reconciliation. The ADON identified 21 residents received controlled pain medication. 4. The facility failed to have a quality assurance program that acted on identified concerns and developed a plan of action to correct identified quality of care issues. There was no evidence the concerns of medication discrepancies were addressed through the QAPI process. Although staff reported the issue to leadership, the administrator denied awareness, and no action plan, performance improvement project (PIP), or documentation of review by the QAPI committee was found. The administrator identified 61 residents resided in the facility.On 03/02/26 at 11:20 a.m., the corporate administrator stated their role in the facility was to provide support to the administrator in all care areas. They stated the administrator would contact them via the phone or emails with concerns. The corporate administrator stated the facility had no DON for several weeks and they assumed the RN providing shift coverage for the role of the DON would ensure proper receipt, storage, and accounting of controlled medications. They stated the administrator was ultimately responsible for the breakdown of the chain of custody of the controlled medications.On 03/02/26 at 2:45 p.m., the administrator stated the COO was the only member of the governing body. They stated having reported any problems or concerns to the COO on a regular basis through phone conversations and emails. The administrator stated they were not aware of the allegations of misappropriated or missing controlled medications prior to the survey.On 03/03/26 at 10:05 a.m., the COO stated they provided oversight of daily operations and was considered the governing body. They stated the administrator communicated with them daily through phone calls and emails. The COO stated the administrator had not reported any allegations of misappropriated controlled drugs or missing controlled medications until the immediate jeopardy situation was communicated to them. They stated the pharmacy consultant had been present in the building the day before to audit medication counts, but the results of the audit had not been reported to them at this time.

Based on observation, record review, and interview, the facility failed to maintain an effective pest control program.The administrator identified 61 residents resided in the facility. Findings: On 02/17/26 at 10:30 a.m., a tour of the kitchen and dining room was conducted. The following observations were made:a. a pile of mouse droppings mixed with chewed wall particles were observed on the floor under the dishwasher,b. dead roaches were observed along the baseboards in the kitchen and dining room and inside the ice machine, andc. live roaches were observed crawling on the floor and walls around the tables storing coffee cups and the ice machine. On 02/18/26 at 9:20 a.m., the following was observed in Resident #6's room:a. dead roaches and mouse droppings were on the floor and sticky traps in the closets and bathroom, and b. a live roach was crawling in the room refrigerator. On 02/24/26 8:30 a.m., live roaches were observed around ice machine and on the walls and floors in the dining room. An undated facility policy titled Pest Control, read in part, This facility maintains an on-going pest control program to ensure their building is kept free of insects and rodents. Resident #6's admission record showed resident was admitted on [DATE] with diagnoses which included dysphagia, hemiplegia, sequelae of cerebral infarction, chronic pain syndrome, supra pubic catheter status, and open wound of buttocks. A 5-day MDS assessment for Res #6, dated 02/04/26, showed the resident had a BIMS score of 15 indicating intact cognition. A care plan for Res #6, updated 02/06/26, showed the resident was bed/chair bound and required moderate assistance with all activities of daily living. A facility pest sighting log, dated 09/24/25 through 02/20/26, showed mice and roach sightings in resident rooms and the dining room. The pest sighting log showed last preventive treatment was 02/17/26. The log did not document every pest sighting was treated after the sightings were recorded on the log. On 02/17/26 at 10:30 a.m., the dietary manager was asked if there was a roach and mouse problem. They stated, Yes ma'am, there is.On 02/19/26 at 11:20 a.m., the administrator was shown the live roaches. They stated they would contact their exterminator immediately. On 02/20/26 at 02:20 p.m., the maintenance supervisor was asked how often they cleaned the ice machine and if they had been told there were dead roaches inside the machine. The maintenance supervisor stated it was cleaned once monthly and whenever the staff reported a problem. They stated dead roaches were reported this morning and the ice machine was cleaned.

Based on record review and interview, the facility failed to transmit resident MDS assessments to CMS within 14 days of completion for 3 (#15, 26, and #28) of 16 sampled residents reviewed for resident assessments.The administrator identified 61 residents resided in the facility.Findings:A MDS Completion and Submission Timeframes policy, revised July 2017, read in part, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes.1. An undated face sheet showed Res #15 was admitted to the facility on [DATE].Res #15's quarterly assessment showed completion on 12/16/25.A CMS submission report showed the assessment was submitted on 02/23/26.2. An undated face sheet showed Res #26 was admitted to the facility on [DATE].Res #26's quarterly assessment showed completion on 12/23/25.A CMS submission report showed the assessment was submitted on 02/23/26.3. An undated face sheet showed Res #28 was admitted to the facility on [DATE].Res #28's annual assessment showed completion on 12/16/25.A CMS submission report showed the assessment was submitted on 02/23/26.On 02/24/26 at 2:46 p.m., the corporate MDS coordinator stated all three of the MDS assessments had been flagged by the computer system for possible quality measures upon completion and should have been reviewed at that time. They stated the error was just identified and the assessments were submitted on 02/23/26. The corporate MDS coordinator stated the assessments were not submitted within required 14-day time frame.

Based on observation, record, review, and interview, the facility failed to ensure a medication error rate of less than five percent for 2 (#34 and #43) of 3 sampled residents observed receiving medications. The facility had 3 errors out of 26 opportunities resulting in a 11.54% error rate.The administrator identified 61 residents resided in the facility. Findings:An Administering Medications policy, dated 12/2022, read in part, Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) or the facility is on block times.1.On 02/20/26 at 9:15 a.m., CMA #5 was observed to administer Depakote (an anticonvulsant) 500mg and Gabapentin (an anticonvulsant) 300mg to Res #34. An undated face sheet showed Res #34 was admitted to the facility with diagnoses which included bipolar, anxiety, and post-traumatic stress disorder.A physician order for Res #34, dated 02/01/26, showed to administer Depakote delayed release 500mg, give one tablet by mouth two times a day.A physician order for Res #34, dated 02/02/26, showed to administer Gabapentin 300mg, one capsule by mouth three times a day.A MAR for Res #34, dated 02/01/26 through 02/28/26, showed Depakote delayed release 500 mg, give one tablet by mouth two times a day at 8:00 a.m. and 2:00 p.m.A MAR for Res #34, dated 02/01/26 showed 02/28/26, showed Gabapentin 300 mg, give 1 tablet by mouth three times a day at 8:00 a.m., 2:00 p.m., and 8:00 p.m.2. On 02/20/26 at 9:25 a.m., CMA #5 was observed to administer Depakote 125mg to Res #43. An undated face sheet showed Res #43 was admitted to the facility with diagnoses which included major depressive disorder, schizophrenia, and anxiety disorder.A physician order for Res #43, dated 02/02/26, showed to administer Depakote delayed release 125 mg by mouth three times a day.A MAR for Res #43, dated 02/01/26 through 02/28/26, showed Depakote 125 mg by mouth three times a day at 8:00 a.m., 2:00 p.m., and 8:00 p.m.On 02/20/26 at 9:33 a.m., CMA #5 stated the medications that were scheduled at 8:00 a.m. were late. On 03/05/26 at 1:33 p.m., the ADON stated the medications were late and they only had an hour before or an hour after the scheduled time.

Based on record review and interview, the facility failed to ensure an immediate written notice of discharge was provided to a hospital upon transfer for 1 (#24) of 2 sampled residents reviewed for unplanned discharges.The administrator identified 17 residents had been discharged in the last 30 days. Findings:An Emergency Transfer or Discharge policy, dated 08/2023, read in part, Emergency transfers or discharge may be necessary to protect the health and/or well-being of the resident(s).Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: notify the receiving facility that the transfer is being made.prepare a transfer form to send with the resident.others as appropriate or as necessary.A medical diagnosis sheet for Res #24, dated 02/05/26, showed the resident was admitted with diagnoses which included traumatic brain injury with loss of consciousness and mood disorder.An admission assessment for Res #24, dated 02/05/26, showed the resident was awake, alert, and oriented to person, place, time, and situation. The assessment showed the resident rejected care and had physical and verbal behaviors.A BIMS evaluation for Res #24, dated 02/06/26, showed the resident was cognitively intact with a BIMS score of 14. Nurse notes for Res #24, dated 02/06/26, showed the resident had been upset most of the shift and was yelling and cursing at facility staff with continued requests to be discharged from the facility. The notes showed Res #24 was placed on one on one monitoring and then continued to yell, curse, hoard medications, and attempted to throw themself onto the floor from the bed. The notes showed Res #24 attempted to hit staff members and threatened with suicide if they were not allowed to leave the facility. An immediate discharge written notice for Res #24, dated 02/06/26 at 10:30 p.m., showed the facility's intent to discharge Res #24 from the facility. The notice showed Res #24's drastic violent episodes endangered the health and safety of others in the facility. The notice showed Res #24 required police intervention for removal from the facility for the attempted assault on staff.A police report, dated 02/06/26, showed an officer was dispatched to the facility due to a resident threatening staff, damaging property, and making threats of suicide. The report showed Res #24 reiterated their plan of self-harm and desire to leave the facility to the responding officer. The note showed the police officer transported Res #24 to the hospital for further evaluation per Res #24's request.On 02/18/26 at 3:00 p.m., the administrator stated Res #24 was provided with an immediate written discharge notice prior to leaving the facility with the police because their presence endangered the safety and health of others in the facility. They stated Res #24 requested to be discharged repeatedly during their stay in the facility. On 02/19/26 at 9:04 a.m., LPN #1 stated they provided Res #24 with the immediate written discharge notice on 02/06/26. LPN #1 stated having explained the contents of the letter to Res #24 prior to handing the notice to them. LPN #1 stated Res #24 then threw the notice on the ground and stated they did not care about the notice as long as they were able to leave the facility and not have to come back. On 02/20/26 at 9:40 a.m., the administrator stated a hospital case manager contacted them on 02/08/26 and stated Res #24 would be discharged back to the facility. They stated the case manager was made aware Res #24 had been discharged from the facility prior to leaving with the police officer on 02/06/26. The administrator stated the police officer had been made aware Res #24 was discharged from the facility and they assumed all medical transfer forms which included the immediate discharge notice had been sent with the resident to the hospital.On 02/20/26 at 2:09 p.m., LPN #2 stated they had discharged Res #24. They stated a face sheet, medical diagnosis list, and list of medications were sent with the resident. LPN #2 stated they did not send a copy of the immediate discharge notice with the other transfer documentation.On 02/23/26 at 9:30 a.m., the administrator stated the nurse should have sent the immediate discharge notice with Res #24 to ensure the receiving facility knew the resident had been discharged from the facility.On 02/23/26 at 10:33 a.m., the medical director stated Res #24 had become a threat to themself and others which necessitated an emergency discharge. They stated they agreed with the discharge and felt the resident was inappropriate to live in the facility. The medical director stated the immediate notice of discharge should have been sent with the resident to ensure the receiving facility was aware of the situation. On 02/23/26 at 1:30 p.m., the hospital case manager stated the hospital did not receive a copy of the resident's immediate discharge notice until they contacted the facility in an attempt to discharge Res #24 back to the facility on [DATE]. The hospital case manager stated Res #24 remained in the hospital at this time.

Based on observation, record review, and interview, the facility failed to accurately code MDS data for 1 (#38) of 6 sampled residents reviewed for MDS accuracy. The administrator identified 61 residents resided in the facility. Findings: On 02/23/26 at 2:09 p.m., LPN #3 was observed to administer one carton of Isosource liquid nutrition, 1.5 calorie/milliliter, and one capsule of Benadryl 25mg per PRN orders for right leg itching, via PEG tube to Resident #38. The admission record dated 12/30/25, showed Resident #38 was admitted [DATE] with diagnoses which included cerebral palsy, achalasia of cardia, dysphagia, and bipolar disorder. An admission MDS assessment for Res #38, dated 01/05/26, showed the resident had a BIMS score of 14 indicating intact cognition. Section K of the MDS did not indicate resident having a feeding tube while a resident. A care plan for Res #38, updated 01/08/26, showed the resident would maintain adequate nutritional status by receiving ordered PEG tube feedings, and could receive pureed meals as tolerated in the dining room. Physician's orders for Res #38, dated 02/2026, showed the resident could be served a diet as tolerated. Res #38 had an order for Isosource, 1.5 calorie/milliliter, administer one carton, three times daily via PEG tube.medications included:a. Ingrezza 40mg daily used to treat tardive dyskinesia,b. Clozaril 100mg at bedtime, antipsychotic used to treat schizophrenia, c. Clozaril 25mg at bedtime, d. Flonase nasal spray daily, corticosteroid to treat allergic rhinitis, e. Lithium 300mg (3 tabs) daily, a mood stabilizer to treat bipolar disorder, f. Lamictal 100mg (2 tabs) daily, used to treat epileptic seizures, g. Trintellix 10mg every evening, used to treat major depressive disorder,h. Clonidine 0.1mg twice daily, used to treat high blood pressure, i. Miralax daily, a laxativej. Tricor 145mg daily, used to reduce tryglycerides in the blood,k. Pepcid 40mg daily, used to treat/prevent stomach ulcers, and l. PRN Benadryl (antihistamine), Tylenol(pain relief), and Milk of Magnesia (constipation relief) All crushable medications given via PEG. Capsules are opened and given via PEG. On 02/24/26 at 12:41 p.m., MDS coordinator #1 verified the question in Section K of the MDS should have been checked Yes indicating Res #38 did have a feeding tube.

Based on record review and interview, the facility failed to ensure a clinical rationale from the physician was provided on a gradual dose reduction request for an antipsychotic and an antidepressant medication for 1 (#30) of 6 sampled residents reviewed for unnecessary medications. The ADON identified 47 residents received psychotropic medications. Findings: An undated facility policy titled Gradual Dose Reduction (GDR) Policy-Oklahoma Nursing Facility, read in part, To ensure residents prescribed psychotropic medications receive appropriate gradual dose reductions and non-pharmacologic interventions consistent with CMS guidance. The physician will document a rationale if contraindicated. Res #30's admission record dated 10/16/23, showed the resident was admitted on [DATE] with diagnoses which included paranoid schizophrenia, chronic pain, restless leg syndrome, paraplegia, major depressive disorder, obsessive compulsive disorder, hypertension, catheter status, and anxiety. A quarterly MDS assessment for Res #30, dated 12/16/25, showed the resident had a BIMS score of 15 which indicated intact cognition. Medications included:D-Mannose 500mg (2) caps twice daily, for urinary tract support,NAC 600mg twice daily, decrease liver damage,Depakote 500mg twice daily, for behavior management,Trazodone 150mg daily, for sleep, Trintellix 20mg daily, to treat major depressive disorder, Desvenlafaxine 50mg daily, to treat depression,Meloxicam 15mg daily, for arthritis, Olanzapine 5mg daily, antipsychotic used to treat schizophreniaFesoterodine 8mg daily, used to treat neurogenic bladder, Quetiapine 300mg daily, used to treat schizophrenia, and PRN hydrocodone (pain relief), milk of magnesia (constipation), ibuprofen (pain), tylenol (pain), narcan (opioid overdose), and zofran (nausea) A GDR request by pharmacy consultant, on 12/31/25, showed the physician declined the GDR request but did not document the rationale. A Medication Regimen Review dated 12/31/25, read in part, please consider if appropriate, a reduction of one of these agents:Quetiapine 300mg at bedtime (4-2024)Trintellix 20mg daily was added (8-2024) Is a reduction attempt in Quetiapine to 250mg at bedtime appropriate?A line was checked no, a reduction is contraindicated due to:, but no rationale was documented in the space provided. Is a reduction attempt in Trintellix 20mg daily appropriate? The physician had checked no, a reduction is contraindicated due to:, but no rationale was documented in the space provided On 03/02/26 at 3:24 p.m., the ADON verified the GDR request for Quetiapine and Trintellix was signed by the physician who declined a dose reduction request, but no rationale was documented. They verified the GDR request was noted by a nurse and there was no documentation asking the physician about a rationale for declining dose reduction request.

Based on observation, record review, and interview, the facility failed to ensure expired medications/supplies were removed from the medication/supply room for 1 of 1 medication storage room observed.The administrator identified 61 residents resided in the facility. Findings: A policy titled Storage of Medications, dated 04/2019, read in part, Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. On 02/23/26 at 1:48 p.m., the North medication and supply room was observed with CMA #2.The following supplies were found to be expired:a.one central line tray w/chloraprep with an expiration date of 03/31/25,b. one IV administration set with an expiration date of 12/14/24,c. one IV administration set with an expiration date of 03/11/25,d. eight no-sting skin barrier film wipes with an expiration date of 06/09/23,e. three boxes of Gelocast with an expiration date of10/10/24,f. three packages of Statlock stabilization devices with an expiration date of 06/28/25,g. three Assure ID - tuberculin safety syringes with an expiration date of 01/05/23,h. one ESwab collections and transport system with an expiration date of 07/29/25, [NAME]. 4 boxes of Glucocard Vital, blood glucose strips, with and expiration date of 11/02/25. On 02/23/26 at 2:05 p.m., the ADON stated the expired items should have been removed by the nurses.

Based on observation, record review and interview, the facility failed to protect residents from physical abuse for 3 (#1, 2, and #4) of 3 sampled residents reviewed for abuse.The administrator identified 59 residents resided in the facility. Findings: An undated facility Abuse Prevention Program policy, read in part, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but not limited to freedom from verbal, mental, sexual or physical abuse. 1. A nurse's note, dated 10/24/25 at 12:40 p.m., read in part, Noise was heard from this resident room, when approached door, [Resident #3] coming out of room. [Resident #4)] reported that [they] was in [their] room and all of a sudden the [Resident #3] came in and then started waving arms around and cussing. [Resident #3] then made contact with their left arm, resulting in small bruise to left forearm. [Resident #3] taken back to room. Call placed to [name withheld] Police department, Admin [administrator] notified. No family listed to notify. Also notified ADON [assistant director of nursing]. [Resident #3] to be moved to front of building, currently placed on 1:1. An Initial State Reportable Incident form, dated 10/24/25, showed physical harm. The form showed Resident #3 entered Resident #4's room and began waving their arms and cussing. The form showed Resident #3 made physical contact with Resident #4's arm resulting in a small bruise to their left arm. Resident #4's quarterly resident assessment, dated 10/28/25, showed the resident's cognition was intact with a BIMS of 15. The assessment showed the resident had diagnoses which included depression, schizophrenia, and bipolar disorder. The assessment showed the resident was ambulatory and independent in most activities of daily living. On 11/17/25 at 4:00 p.m., Resident #4 stated Resident #3 went into their room. They stated they informed Resident #3 they were in the wrong room and Resident #3 hit them twice on their left arm. They stated it resulted in a bruised. On 11/18/25 at 11:05 a.m., LPN #1 stated Resident #4 reported to them Resident #3 stroked them on their arm when they informed Resident #3 to get out of their room. On 11/18/25 at 11:08 a.m., LPN #1 stated the incident between Resident #3 and Resident #4 could be considered physical abuse. 2. Resident #1's care plan, revised 9/17/25, showed the resident had limited physical mobility related to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Resident #1's significant change in status resident assessment, dated 10/22/25, showed the resident's cognition was intact with a BIMS of 14. The assessment showed the resident had diagnoses which included hemiplegia or hemiparesis and anxiety. The assessment showed the resident needed partial to moderate assistance with most activities of daily living. A nurse's note, dated 11/03/25 at 12:10 p.m., read in part, This nurse [LPN #2] was in the dining room when I heard screaming. [CNA #1] arrived at the [Resident #1] first. [CNA #1] stated, 'When they walked in, they were swinging on each other.' When [LPN #2] arrived, residents had been separated. When [LPN #2] ask [Resident #1] what happened, the resident stated, '[Resident #3] came in my room. I turned around and put my hand out to stop [them] and [Resident #3] started hitting me.' Head to assessment complete .Resident has a ST [small tear] on LT [left] arm.2.5x1x0.1. An Initial State Reportable Incident form, dated 11/03/25, showed certain injuries. The form showed Resident #3 roamed the hallway and diverted into Resident #1's room. The form showed Resident #1 attempted to redirect Resident #3, it was unsuccessful and the residents had a physical altercation. On 11/18/25 at 9:17 a.m., LPN #2 stated Resident #3 was blind. They stated the resident got away from them and roamed into Resident #1's room. They stated by the time they made it to Resident #1's room, the residents were already separated. On 11/18/25 at 9:42 a.m., CNA #2 stated they heard Resident #1 and Resident #3 getting loud. They stated by the time they made it to Resident #1's room, Resident #1 was holding on to Resident #3's shirt. They stated Resident #3 was swinging at Resident #1 making physical contact. On 11/18/25 at 10:52 a.m., Resident #1 stated Resident #3 came into their room. They stated they told the resident to get out of their room twice and they did not. Resident #1 stated they tried to push Resident #3 out using their wheelchair and the resident swung at them hitting them. 3. On 11/17/25 at 3:52 p.m., Resident #2 was observed sitting in the dining room visiting with another resident. On 11/18/25 at 8:50 a.m., Resident #2 was observed in their room on their bed. An annual assessment, dated 08/19/25, showed Resident #2 had a BIMS score of 11, which indicated the resident was moderately impaired in cognition for daily decision making, and had a diagnoses of Alzheimer's disease and schizophrenia. A care plan, dated 08/28/25, showed Resident #2 had the potential to be physically and verbally aggressive related to Alzheimer's disease and schizophrenia. A state report, with an incident date of 11/04/25, showed Resident #3 was in the dining room requesting coffee and had wheeled over to Resident #2. The report showed Resident #2 had become verbally loud and staff separated the residents. A nurse progress note, dated 11/17/25 at 4:02 p.m., showed Resident #2 and Resident #3 were observed arguing in the dining room. The note showed Resident #2 was hit on the right side of their head during the altercation and the residents were separated. The note showed there were no visible injuries to Resident #2. On 11/18/25 at 8:53 a.m., LPN #1 stated on 11/04/25, Resident #2 and Resident #3 had been involved in a verbal altercation in the dining room and Resident #3 hit Resident #2 on the right side of their head. They stated the residents were separated and Resident #2 had been assessed for injuries. On 11/18/25 at 8:59 p.m., LPN #2 stated after the incident, Resident #3 was placed on 1:1 with staff until they were sent to the hospital for in-patient psychiatric treatment. LPN #2 stated Resident #2 had been assessed for injuries related to being hit in the head by their assigned nurse. On 11/18/25 at 9:55 a.m., the administrator stated Resident #2 and Resident #3 had been involved in a resident-to-resident abuse incident on 11/04/25. They stated Resident #3 had been placed on 1:1 with staff until they had been admitted to the hospital for in-patient psychiatric services. They stated Resident #2 had not sustained injuries from the altercation.

Based on record review and interview, the facility failed to ensure:a. an abuse allegation was reported to the State Agency within two hours for 1 (#1); andb. a final report was submitted to the State Agency within five business days for 3 (#1, 2 and #3) of 3 sampled residents reviewed for abuse.The administrator identified 59 residents resided in the facility. Findings: An undated facility Abuse Prevention Program policy, read in part, When the allegation involves abuse or results in serious bodily injury you must report within 2 hours of notification of incident .The Administrator or Administrative Designee will complete the Investigation Report within five (5) working days .The investigation Report . shall be faxed within five (5) working days of submission of the incident and accident report. 1. A nurse's note, dated 11/3/25 at 12:10 p.m., read in part, This nurse [LPN #2] was in the dining room when I heard screaming. [CNA #1] arrived at the [Resident #1] first. [CNA #1] stated, 'When they walked in, they were swinging on each other.' When [LPN #2] arrived, residents had been separated. When [LPN #2] ask [Resident #1] what happened, the resident stated, '[Resident #3] came in my room. I turned around and put my hand out to stop [them] and [Resident #3] started hitting me.' Head to assessment complete .Resident has a ST [small tear] on LT [left] arm.2.5x1x0.1. An Initial State Reportable Incident form, received 11/03/25 at 3:22 p.m., showed certain injuries. The form showed Resident #3 roamed the hallway and diverted into Resident #1's room. The form showed Resident #1 attempted to redirect Resident #3, it was unsuccessful and the residents had a physical altercation. The initial state reportable was not submitted within 2 hours of the incident which occurred on 11/03/25 at 12:10 p.m. There was no documentation the State Agency received a final report. On 11/18/25 at 9:17 a.m., LPN #2 stated the incident occurred on 11/03/25 at 12:10 p.m. On 11/18/25 at 9:19 a.m., LPN #2 stated they notified the administrator at the time of the incident. On 11/18/25 at 9:31 a.m., the compliant and incident coordinator for the State Agency stated the State did not receive a final report on Resident #1 and Resident #3. On 11/18/25 at 9:50 a.m., the administrator stated timely reporting of abuse allegations to the State was two hours. On 11/18/25 at 9:51 a.m., the administrator stated they were not sure of the exact time, but pretty sure they were notified immediately of the incident between Resident #1 and Resident #3. They stated they would have to look at the nurse's notes. On 11/18/25 at 9:54 a.m., the administrator stated they would have to look at the incident report to know when they submitted the final report to the State. They stated the timeframe to submit a final report was five business days. On 11/18/25 at 2:09 p.m., the administrator reviewed the facility's fax machine logs. They stated the initial was submitted at 3:36 p.m. on 11/03/25 and the final was sent in on 11/07/25 at 4:21 p.m. On 11/18/25 at 2:13 p.m., the administrator stated if the incident between Resident #1 and Resident #3 occurred at 12:10 p.m., then the report was not submitted in a timely manner. On 11/18/25 at 2:32 p.m., the administrator stated they were notified of the incident at 2:30 p.m. On 11/18/25 at 2:35 p.m., the administrator stated the incident between Resident #1 and Resident #3 was resident to resident abuse. On 11/18/25 at 2:36 p.m., the administrator stated there must be a miscommunication on when the incident between Resident #1 and Resident #3 occurred. 2. A state report, with an incident date of 11/04/25, showed Resident #3 was in the dining room requesting coffee and had wheeled over to Resident #2. The report showed Resident #2 had become verbally loud and staff separated the residents. The incident report form showed it was an initial and final report with an attached fax transmission report dated 11/04/25 at 5:26 p.m. On 11/18/25 a review of incident reports, in the State Agency's data base, was conducted. The data base did not show a final incident report for the incident on 11/04/25 for Resident #2 and Resident #3. A fax transmission log, dated 11/18/25, provided by the administrator showed a fax had been sent to the State Agency's fax number on 11/10/25 with a code NG beside the transmission. On 11/18/25 at 9:55 a.m., the administrator stated the fax transmission report, dated 11/04/25 at 5:26 p.m. was for the initial state report. The administrator stated they had check marked final on the incident report form, completed part C, and faxed it to the state agency on 11/10/25. The administrator stated they did not have a fax confirmation for the final incident report. On 11/18/25 at 4:33 p.m., the administrator stated the code NG indicated the communication between the facility's fax machine and the state agency's fax machine had not been transmitted successfully. They stated when faxes were successfully transmitted the code on the log would show OK.

On 09/03/25, a past noncompliance Immediate Jeopardy (IJ) was determined to exist related to resident-to-resident abuse.An incident report form, submitted to OSDH on 08/14/25, showed on approximately 06/21/25, Resident #2 pushed Resident #1 down on the bed, laid on top of them, and tried to kiss them several times.Based on record review and interview, the facility failed to ensure a resident was free from abuse for 1 (#1) of 3 sampled residents reviewed for abuse.The DON identified 71 residents resided in the facility.Findings:An undated facility policy titled Abuse Policy and Procedure, read in part, The administrator or Administrative Designee will conduct an investigation of all alleged or actual incidents of abuse, neglect, or misappropriation of property. The investigation should determine whether an incident has occurred, to what extent the resident was mistreated, by whom, and the measures needed to protect occupants from further incidents. If the person is able to communicate, the Administrator or Administrative designee shall document, in sufficient detail, the resident's account of the incident, including a description of the perpetrator.If a person alleges abuse, they should be assessed for mood and behavior changes that may indicate abuse, such as fear, isolation, depression, withdrawal, or other new signs. Findings will be documented in the medical record.An undated admission record showed Resident #1 had diagnoses which included anoxic brain damage, major depressive disorder, and anxiety disorder.A quarterly assessment, dated 06/24/25, showed Resident #1 was cognitively intact with a BIMS of 15. The assessment showed over the last two weeks Resident #1 had several days with little interest or pleasure in doing things and feeling down, depressed, or hopeless.An initial incident report, sent to OSDH on 08/14/25, showed an incident date of approximately 06/21/25. The report showed Resident #1 stated during an interview they had been sexually assaulted by Resident #2 approximately two months ago.A fax transmission report, dated 08/14/25 at 2:48 p.m., showed OSDH was sent a fax from the facility administrator.An incident note, dated 08/14/25, showed the nurse was informed Resident #1 made an allegation of abuse. The note showed Resident #1 stated they were held down on the bed by another resident and attempted to be kissed several times. The note showed local law enforcement, the physician, and physician assistant for mental health was notified. A police incident/offense report, dated 08/14/25, showed the local police was dispatched to the facility in reference to a possible sexual assault. The report showed Resident #1 stated they were in Resident #2's room sitting on the bed and Resident #2 was kissing them on the neck. The report showed Resident #1 could not leave the room because Resident #2 was lying on them. The report showed Resident #1 told Resident #2 their back was hurting and they left the room. The report showed Resident #1 stated they had told a staff member at the facility. The report showed the identified staff member was interviewed by police and they denied any knowledge of sexual assault between Resident #1 and Resident #2.A care plan, dated 08/14/25, showed Resident #1 was at risk for unwanted physical contact. The goal was for Resident #1 to remain safe from further unwanted contact.A facility in-service education report, dated 08/14/25, showed the administrator was educated on properly/thoroughly investigating abuse allegations.An untitled document, dated 08/14/25, showed six staff members were interviewed regarding knowledge of Resident #1's statement of rape and if Resident #2 was ever sexually inappropriate with any (resident of the opposite sex) in the facility.A record dated 08/14/25, read in part, Quality issue/problem. The record showed a meeting was conducted on 08/14/25 regarding resident-to-resident abuse.On 08/14/25 the facility completed a questionnaire with residents. The questionnaire asked if they had been sexually abused in the facility. Residents responded they had not been sexually assaulted in the facility. Resident #1 responded to the questionnaire they had been sexually assaulted by Resident #2 and had reported the incident to staff. A psychiatric exam report, dated 08/15/25, showed a psychiatric visit was completed for Resident #1 by the nurse practitioner. The report showed the visit was prompted by prior allegations made regarding a male peer entering their room. The report showed Resident #1 stated they and the peer of the opposite sex were friends. The report showed Resident #1 stated they did not feel threatened and enjoyed the attention the peer of the opposite sex gave them and valued their conversations.A facility in-service education report, dated 08/16/25, showed the facility staff were educated on Recognizing Indicators of Sexual Misconduct by a Resident.The administrator provided an untitled document, dated 08/20/25, that showed a referral was submitted to the abuse and neglect hotline regarding Resident #1's allegation of abuse by Resident #2.On 08/26/25 at 11:25 a.m., Resident #1 stated sometime in July, Resident #2 invited them to their room to play video games. Resident #1 stated Resident #2 pushed them down on the bed, positioned on top of them, and tried to kiss them. Resident #1 stated they told Resident #2 no. Resident #1 stated after a few minutes, Resident #2 moved and they exited the room. Resident #1 stated someone told the staff what happened, and the administrator asked them about the incident. Resident #1 stated they told the administrator Resident #2 tried to kiss them and they did not like it. Resident #1 stated for two weeks following the incident Resident #2 would try and approach them in common areas. Resident #1 stated Resident #2 was a big person and they were afraid of Resident #2, so they just stayed in their room. A care plan, dated 08/26/25, showed Resident #1 had the potential to be at risk for sexual assault related to decreased awareness of personal boundaries or vulnerability.On 09/02/25 staff were interviewed and stated in August 2025 an in-service was completed regarding resident sexual abuse.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to prevent delay in care when Resident #11 was unresponsive.On [DATE] at 2:01 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On [DATE] at 2:07 p.m., the administrator was notified of the IJ situation and the IJ template was provided.On [DATE] at 5:39 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part,On [DATE], a review of all current residents' code status verified, and electronic records updated, and care plans updated. A list of all residents with current code status maintained at each nurse's station.All staff In-Serviced on calling 911 immediately when a resident is found unresponsive regardless of code status and resident code status list will be maintained at each nurse's station labeled Resident Code StatusAll Licensed nurses In-Serviced on immediately initiating CPR on any resident that is a full code and continuing until emergency services arrives.Any employee that can't be reached for In-Service will be inactive and taken off the schedule until education is provided.Completed by [DATE] 5 PM.The IJ was lifted, effective [DATE], when all components of the plan of removal had been verified as completed. Multiple staff on different shifts were interviewed regarding the in-service they received. Residents code status and care plan audit reviewed. Resident code status list placed at the nurse's station reviewed. The deficiency remained at an isolated level with the potential for more than minimal harm.Based on record review and interview, the facility failed to prevent delay in care when a resident was unresponsive for 1 (#11) of 5 sampled residents reviewed for abuse and neglect.The DON identified 71 residents resided in the facility.Findings:An Emergency Procedure-Cardiopulmonary Resuscitation policy, revised 02/2018, read in part, If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR .If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR.Call 911.A care plan, initiated [DATE], showed Resident #11 had diagnoses which included unspecified dementia and Wernicke's encephalopathy. The care plan showed the resident was a full code and wished to have CPR performed on them. Resident #11's death in the facility resident assessment, dated [DATE], showed the resident was deceased .A nursing note, dated [DATE] at 4:43 a.m., read in part, This nurse was notified by CNA that resident did not appear to be breathing when CNA was performing last rounds. upon entering room [ROOM NUMBER] at 0443 [4:43 a.m.] Resident was found unresponsive. assessment revealed no respirations, no palpable carotid pulse and no heart or breath sounds on auscultation. resident is full code status CPR initiated and continued while other nurse called 911. EMT here and began to use AED but was unsuccessful Death was confirmed by EMT at 0521 [5:21 a.m.]. Dr. [name withheld], DON [name withheld], Administrator notified as well as family [name withheld]. body released to funeral home at 0703 [7:03 a.m.] [name withheld].An EMS Patient Care Record, dated [DATE], showed a primary impression as obvious death and secondary impression as cardiac arrest-withholding resuscitative efforts. The report showed the facility called them at 5:06 a.m. and they were on scene at 5:12 a.m. The report showed the facility did not start resuscitation efforts.On [DATE] at 11:40 a.m., the ADON stated all residents were full code unless they had a signed DNR on file. They stated a resident's code status would be in the electronic health record under the resident's name and on a list at the nurses station they implemented recently. They stated they were not sure when the list was implemented.On [DATE] at 11:45 a.m., the ADON stated if a resident was found unresponsive, the immediate action would be to get the crash cart, check code status, and begin CPR.On [DATE] at 11:46 a.m., the ADON stated staff were to notify EMS immediately.On [DATE] at 11:49 a.m., the ADON stated according to the nursing note on [DATE], the staff had performed CPR and notified EMS when the resident was found unresponsive. They stated anyone certified in CPR could perform CPR.On [DATE] at 11:51 a.m., the ADON stated they were not sure how Resident #11's code status was determined on [DATE].On [DATE] at 11:53 a.m., the ADON stated Resident #11's code status was not listed under their name in the electronic health record.On [DATE] at 3:38 p.m., CNA #3 stated a resident's code status would be located on their electronic health record. They stated they worked on [DATE] when Resident #11 was found unresponsive. CNA #3 stated they worked on a different hall and the agency nurse had instructed them to continue their rounds because CNA #2 and LPN #3 were with the resident.On [DATE] at 5:37 p.m., CNA #2 stated LPN #3 notified them they thought Resident #11 had passed and they were not sure what the resident's code status was because it was not listed under the resident's name in the electronic health record. CNA #2 stated they reviewed Resident #11's Kardex and informed LPN #3 the resident was a full code. CNA #2 stated they both went to the resident and put them on the floor and started CPR.On [DATE] at 5:40 p.m., CNA #2 stated LPN #3 had notified them of the incident around 5:00 a.m. because it was around the time they had started doing morning rounds. They stated EMS was called shortly after that, but not sure exactly what time.On [DATE] at 5:41 p.m., CNA #2 stated they may have started the CPR around 5:12 a.m. to 5:15 a.m., but it was just around the time EMS came to the room.

On 09/09/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide necessary care and treatment for Resident #17 who had mental health disorders and threatened to harm themself and others.On 09/09/25 at 2:14 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On 09/09/25 at 2:27 p.m., the administrator was notified of the IJ situation and the IJ template was provided.On 09/09/25 at 5:19 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part,On 9/9/25, A review of all resident records was conducted to identify those with mental health disorders that may exhibit behaviors related to those disorders. All residents identified will have care plans updated to reflect mental health disorder/behavior. PCP and mental health will be aware of the identified residents to ensure all are evaluated and referred for services. To be completed by 9pm on 9/9/25All staff in-serviced that a current list of residents with mental health disorders is maintained at each nurse's desk. To be completed by 9pm on 9/9/25.All staff in-serviced that when a resident displays that he/she is a harm to themselves or others and to report behavior immediately to nurse supervisor/administrator. To be completed by 9pm on 9/9/25.Nursing staff will be in-serviced to notify the physician and mental health provider of the harmful behaviors immediately. To be completed by 9pm 9/9/25.The nursing staff will be in-serviced to request medication reconciliation with the physician and mental health provider following harmful/ mental health behaviors. To be completed by 9pm 9/9/25.Department supervisors are responsible for ensuring all in-services are completed by 9pm 9/9/25.Employees who are unable to be reached by 9pm on 9/9/25 will be required to in-service upon return to the facility.The IJ was lifted, effective 09/09/25, when all components of the plan of removal had been verified as completed. Multiple staff on different shifts were interviewed regarding the in-service they received. Resident audits for mental health disorders and behaviors were reviewed. A current list of residents with mental health disorders placed at the nurse's station was reviewed. Care plans for residents with mental health disorders and behaviors were reviewed. The deficiency remained at an isolated level with the potential for more than minimal harm.Based on record review and interview, the facility failed to provide the necessary care and treatment for a resident with mental health disorders and behaviors for 1 (#17) of 5 sampled residents reviewed for abuse and neglect.The DON identified 71 residents resided in the facility.Findings:A facility assessment, dated 04/16/24, read in part, Manage the medical conditions and medication-related issues causing psychiatric symptoms and behaviors, identify and implement interventions to help support individuals with issues .care of individuals with depression, trauma/PTSD, other psychiatric diagnoses.An undated admission Record, showed Resident #17 had diagnoses which included schizoaffective disorder bipolar type, other hallucinations, unspecified psychosis not due to a substance or known physiological condition, and unspecified depression.A nursing note, dated 08/17/25 at 5:05 a.m., showed Resident #17 was at the nurses' station screaming and cussing, threatening to kill themself and others. The note showed the resident stated they were hearing voices and evil spirits and was very aggressive to staff. The note showed Resident #17 was put on one-on-one monitoring and 911 was called.A nursing note, dated 08/17/25 at 6:40 a.m., showed the police and emergency medical service refused to take Resident #17 to the emergency room.A care plan, initiated 08/18/25, showed Resident #17 would not harm themself or others. Resident #17's admission resident assessment, dated 08/19/25, showed the resident's cognition was intact with a BIMS of 14. The assessment showed the resident had hallucinations, delusions, and verbal behavioral symptoms directed towards others. The assessment showed the resident received antipsychotic, antianxiety, and antidepressant medications.A nursing note, dated 08/26/25 at 4:01 p.m., showed Resident #17 had conversations with themself. The note showed the resident stated their medications made them crazy. The nursing note showed the physician was notified.There was no documentation the resident was evaluated by a psych provider or had a medication reconciliation after the incident.A nursing note, dated 09/06/25 at 4:17 a.m., showed Resident #17 was cussing, being loud and aggressive. The note showed a nurse attempted to calm the Resident #17 and the resident shoved the nurse into the wall and was holding them against the wall. Resident #9 came to intervene and was held by the arm and neck and pushed onto the sofa by Resident #17. The note showed staff separated the residents. A nursing note, dated 09/06/25 at 6:50 a.m., read in part, Resident #17 received an immediate discharge from the facility due to violently attacking the staff and choking another resident.An Initial State Reportable Incident form, dated 09/06/25, showed suspected criminal act. It showed Resident #17 attacked a night shift nurse by violently shoving them against the wall and pinning them. The form showed Resident #17 choked Resident #9.On 09/09/25 at 10:29 a.m., CNA #1 stated Resident #17 paced the halls and talked to themself.On 09/09/25 at 10:31 a.m., CNA #1 stated Resident #17 was not on any behavior monitoring.On 09/09/25 at 11:27 a.m., LPN #1 stated Resident #17 had threatened to kill themself on 08/03/25. They stated the resident was sent to a psychiatric facility on emergency order of detention. LPN #1 stated Resident #17 re-admitted to the facility on [DATE]. On 09/09/25 at 11:31 a.m., LPN #1 stated if a resident threatened to kill themself or others, they were to notify the psych doctor, fill out an emergency order of detention form, initiate one-on-one monitoring, and send them to the emergency room.On 09/09/25 at 11:40 a.m., LPN #1 stated other preventive measures for residents with behavior issues would be to notify the psychiatric doctor for medication evaluation, find the root cause of the behavior, and put them on one-on-one monitoring.On 09/09/25 at 11:40 a.m., LPN #1 stated Resident #17 should have been sent to a psychiatric hospital on [DATE]. LPN #1 stated they did not believe the facility environment was safe for a resident who threatened to kill themself and others.On 09/09/25 at 12:00 p.m., the ADON stated Resident #17 was aggressive towards a nurse and Resident #9 on 09/06/25. They stated police and EMS were notified, and the resident was discharged from the facility for resident safety.On 09/09/25 at 12:03 p.m., the ADON stated the resident had a history of hollering and saying things that may not be appropriate or make sense.On 09/09/25 at 12:05 p.m., the ADON stated Resident #17 was not on any special monitoring since their re-admission on [DATE]. On 09/09/25 at 12:10 p.m., the ADON stated they were not aware if the resident had any interventions in place for self-harm, or physical and verbal abuse since their return to the facility. On 09/09/25 at 12:25 p.m., the ADON stated Resident #17 should have received higher level of care for threats of killing themself and others. On 09/09/25 at 12:30 p.m., the ADON stated Resident #17 did not receive a psychiatric evaluation after the incident on 08/17/25. They stated the resident had a medication order for Tylenol (an analgesic) and no other medication adjustments were completed. On 09/09/25 at 12:30 p.m., the ADON stated the facility's environment was not equipped with safety measures for a resident who verbalized threats of killing themself and others.

Based on observation, record review, and interview, the facility failed to ensure a resident was not touched sexually by another resident for 1 (#5) of 5 sampled residents reviewed for abuse. The ADON identified 82 residents resided in the facility. Findings: 1. On 06/16/25 at 9:30 a.m., Res #5 was observed sitting on a couch in the common area of the facility. Res #5 was observed smiling, but showed limited communication due to cognitive impairment. An Abuse Policy and Procedure, updated 07/23/21, read in part, We will endeavor to protect our occupants from maltreatment, which means adult abuse, exploitation, neglect, physical abuse, sexual abuse, neglect, and the misappropriation of resident property. An undated sexual consent policy, read in part, This policy recognizes and supports the older adult's right to engage in sexual activity, so long as there is consent among those involved. Consent may be demonstrated by the words and/or affirmative actions of an older adult with intact decision-making ability. An undated face sheet showed Res #5 had diagnoses which included focal traumatic brain injury and frontotemporal neurocognitive disorder. A quarterly assessment, dated 05/13/25, showed Res #5 had a BIMS score of 7 and was severely cognitively impaired. A nurse note, dated 06/08/25 at 9:32 p.m., showed Res #5 was sitting on the sofa in the back common area when Res #4 sat down beside them and placed their hand down in their pants on their private area. The note showed Res #4 placed their other hand on Res #5's private area. The note showed staff immediately separated Res #4 from Res #5 and placed Res #4 on 1:1 monitoring. The note showed Res #5 was assessed and had no physical injuries. An Oklahoma State Department of Health initial report, dated 06/08/25, showed a staff member witnessed Res #4 sit down beside Res #5 on the sofa in the common area. The report showed Res #4 leaned down and kissed Res #5 on the cheek while placing one of their hands down the front of their pants onto their private area and the other hand onto Res #4's private area. The report showed the staff member immediately told Res #4 to stop, separated the residents, and began 1:1 monitoring of Res #4. A care plan, updated 06/09/25, showed Res #5 was at risk for inappropriate touching due to cognitive impairment with an actual incident having occurred on 06/08/25. A mental health care provider note, dated 06/09/25, showed Res #5 voiced occasional anxiety and was unable to elaborate on the incident of inappropriate touching that had occurred the previous day. On 06/16/25 at 9:35 a.m., Res #5 was asked about the incident of inappropriate touching on 06/08/25. Res #5 was unable to recall the event or participate in the interview due to cognitive impairment. On 06/17/25 at 1:09 p.m., family member #1 stated Res #5 was not able to give consent to sexual advances due to cognitive impairment. They stated Res #5 would have been extremely upset and would have never allowed the inappropriate touching in the first place if they were in their right mind at the time of the incident. 2. An undated face sheet showed Res #4 had diagnoses which included schizoaffective disorder and bipolar disorder. An admission assessment, dated 06/05/25, showed Res #4 had a BIMS score of 15 and was cognitively intact. A resident interview statement, dated 06/09/25, showed Res #4 declined to comment on the incident with Res #5. A census tab in Res #4's medical record showed they were discharged from the facility on 06/09/25. On 06/17/25 at 1:00 p.m., certified nursing assistant #1 stated Res #5 never had a relationship or any interaction with Res #4 other than an occasional hello in the hallway prior to the incident. On 06/17/25 at 2:01 p.m., the ADON stated the ability to consent to sexual advances was based off a resident's intact decision-making ability. They stated Res #5 was severely cognitively impaired was not capable of consent. They stated Res #5 was touched inappropriately by Res #4.

On 05/12/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure a resident was free from abuse. On 05/12/25 at 3:59 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On 05/12/25 at 4:25 p.m., the administrator was notified of the immediate jeopardy situation. An immediate jeopardy template was provided to the administrator. On 05/13/25 at 2:41 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The facility plan of removal, read in part, Corrective Action: Plan of Removal On,5/12/2025, Resident #2 was placed on 1:1 continuous supervision until placement secured for inhouse treatment due to aggressive behaviors. 1. Administrative staff In-Serviced on following 1:1 monitoring policy and reviewing documentation daily during morning meeting to ensure staff is following protocol. 2. All staff educated on following 1:1 monitoring policy when a resident is placed on 1:1 supervision related to aggressive behaviors. 3. HR [human resources]/BOM [business office manager] educated on educating all new hires of facility policy on proper monitoring of residents that are on 1:1 supervision with an acknowledgement page. 4. MDS [minimum data set]/Care Plan Coordinators educated on ensuring new interventions are care planned after each aggressive behavior. 5. Any employee that can't be reached for In-Service will be inactive and taken off the schedule until education is provided. 6. All cognitive residents interviewed to ensure they feel safe in the facility with no negative findings. 7. The 1:1 policy was revised to reflect the charge nurses monitoring the effectiveness/appropriateness of interventions for residents with aggressive behaviors. 8. All licensed nurses in-serviced on 1:1 policy update of the monitoring of the effectiveness/appropriateness of interventions for residents with aggressive behaviors. 9. Body audits performed on all non-cognitive residents for signs of abuse with no negative findings. The IJ was lifted, effective 05/13/25 at 12:45 p.m., when all the components of the plan of removal had been completed. Resident assessments and interviews regarding abuse were verified as completed. An updated Safety and Supervision of Residents policy was reviewed and staff education regarding abuse was verified as completed. The deficient practice remained as isolated level with potential for more than minimal harm. Based on observation, record review, and interview, the facility failed to ensure a resident was free from abuse for 1 (#1) of 5 sampled residents reviewed for abuse. The administrator identified 85 residents resided in the facility. Findings: On 05/08/25 at 9:12 a.m., Resident #1 was ambulating in the hall where they resided. Resident #2, who did not reside on the hall, was ambulating aimlessly on the resident hall. An undated facility policy titled Abuse Policy and Procedures, read in part, 2. Care Plan. Care Plans will address interventions designed to prevent occurrences, and may include: a) 'At risk' people to be visually monitored by nursing personnel for occurrences that could trigger abusive behavior; and b) Each person who is at risk for abusive behavior will be reassessed for preventative interventions at least quarterly.5. Documentation. Nursing staff shall document the incident and interventions in the Medical Record. 6. Investigation/Interviews: Admin/Designee will interview other cognitive residents and witnesses in the instance of resident-to-resident abuse so that the facility is aware of the scope and/or severity of the allegations. When a resident is not cognitive nursing staff may conduct a head-to-toe assessment for signs of injury if indicated as necessary. A facility policy titled Guidelines/Policy For Reportables:, effective November 2024, read in part, ABUSE: Resident to Resident: 1 Initial report 2 Aggressor immediately placed on 1:1 .Care plan must be updated for both residents with measures to protect from further abuse from the aggressor and measure to prevent further abuse to the victim.8 Must do a QAPI every time An undated facility admission record showed Resident #1 had diagnoses which included frontotemperal neurocognitive disorder, psychosis, persistent mood disorders, anxiety disorder, and focal traumatic brain injury with loss of consciousness. A quarterly assessment, dated 02/11/25, showed Resident #1 was severely impaired cognitively with a BIMS of 3. The assessment showed the resident did not have verbal and/or physical behaviors towards others. An OSDH incident report, dated 04/29/25, showed Resident #1 was punched in the face by Resident #2. The report showed Resident #1 had a red discharge from their nose and swelling to the head. The report showed Resident #1 was sent to the emergency room for further evaluation. The report showed Resident #2 was placed on one-on-one safety observations. A hospital discharge instruction form, dated 04/29/25, showed instructions for care regarding facial or scalp contusion and hematoma for Resident #1. A care plan, dated 04/30/35, showed Resident #1 was a recipient of physical aggression. The care plan showed interventions were to move the resident to a different resident hall and remove from proximity to aggressor. 2. An undated facility admission record showed Resident #2 had diagnoses which included dementia without behavioral disturbances, major depression, psychotic disorder, psychosis, and mental disorder. A care plan, initiated 09/16/24, showed Resident #2 had physically aggressive behaviors related to dementia and a history of harm to others. The care plan showed Resident #2 had physical aggression toward a peer on 04/11/24, physical aggression toward a staff member on 07/13/24, physical aggression toward a peer on 09/13/24, physical aggression toward a peer 09/28/24, physical aggression with a peer on 11/17/24, and physical aggression with another resident on 04/30/25. A quarterly assessment, dated 04/08/25, showed Resident #2 was severely impaired cognitively and had a BIMS score of 4. The assessment showed the resident did not have verbal and/or physical behaviors toward others. A progress note, dated 04/30/25, showed Resident #2 punched Resident #1 four to five times in the face. The note showed Resident #1 was taken by emergency medical services to the hospital for evaluation. The note showed Resident #2 was redirected and was placed on one-on-one observation. On 05/08/25 at 11:10 a.m., LPN/charge nurse #1 stated if a resident-to-resident incident occurred they would separate the residents and place the aggressor on every 15 minute visual checks for 72 hours. On 05/08/25 at 11:55 a.m., the administrator reviewed the investigation documentation regarding the abuse allegation on 04/29/25 for Resident #2. The administrator stated documentation did not show the resident was placed immediately on one-on-one safety observations per facility policy. The administrator stated there were no resident and/or staff witness statements documented regarding the incident. On 05/12/25 at 1:00 p.m., care plan coordinator #1 reviewed Resident #2's plan of care. The coordinator stated there was not a new intervention put in place after each physical aggressive incident involving Resident #2 and should have been. Care Plan Coordinator #1 stated the intervention one-on-one observation had been used many times.

On 04/17/25 at 2:22 p.m., the Oklahoma State Department of Health was notified and verified the existence of and immediate jeopardy situation related to the facility's failure to provide supervision to prevent elopement from the facility. 1. Resident #26 had moderate impairment for decision making, was a fall risk, and ambulated with a wheel chair. A visitor notified the facility Resident #26 was walking down the road. A CNA went and picked up the resident and returned them to the facility. 2. Resident #30 was identified as being a high risk for elopement. Resident #30 was able to leave the facility without staff aware and was located walking down the state highway in a construction zone three miles from the facility by an off duty staff member and returned to the facility in the staff members vehicle. On 04/17/25 at 2:43 p.m., the administrator, the ADON, and corporate nurse #1 were notified of the immediate jeopardy situation and provided the immediate jeopardy template. On 04/18/25 at 8:46 a.m., an amended plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, On 4/17/2025, elopement risk assessments were initiated on all residents with care plans updated to identify any at risk residents. 1. A notification sign will be placed on entrance/exit doors to alert visitors and vendors to not let anyone out without notifying/asking facility staff first. 2. All staff to include nursing, dietary, housekeeping/laundry, maintenance In-Serviced on elopement risk policy, ensuring that identified elopement risk residents are redirected away from doors, and location of list at each nurse's station and in employee break room of wandering/elopement risk residents and to check list at beginning of shift, educated on the reporting party to fill out an incident reporting form with the charge nurse signature, and to place under the Administrators door, and ensuring that doors completely close/latch when entering/exiting the facility. 3. HR [human resources]/BOM in-serviced on all newly hired personnel will be educated on elopement policy, location of list of at risk for elopement residents with an acknowledgement page and ensuring that doors completely close/latch when entering/exiting the facility. 4. All Licensed nurses In-Serviced on elopement policy with emphasis on immediately reporting to the Administrator the instance of an elopement, assessing the resident for injuries with documentation in the progress note of measures put in place to protect resident from further potential elopement with notifications to physician, family, and law enforcement. 5. Administrative staff In-Serviced on reviewing elopement risk resident list/any new admissions and updating list accordingly 5 times weekly during clinical meeting. 6. DON/Designee will report any negative findings quarterly to QAPI [quality assurance performance review]. 7. Any employee that can't be reached for In-Service will be inactive and taken off the schedule until education is provided. 8. Maintenance Supervisor will inspect all exit doors 5 times weekly to ensure doors are closing/latching properly. On 04/18/25, facility staff were interviewed by phone and in person. Staff were interviewed regarding inservices completed on elopement. Staff were interviewed and able to communicate elopement prevention strategies, identify residents at risk for elopement, and elopement response policies and procedures. All residents health records were reviewed and verified they contained elopement risk assessment and the ones with a risk were care planned to prevent elopement. Notifications signs for staff, residents, and visitors were verified to be posted on all exits. All doors were verified to be in good working order and locks were in good repair. On 04/18/25, after interviews with staff, review of resident elopement wander risk assessments and care plans, posted signage, and inservices, the immediacy was lifted effective 04/18/25 at 4:54 p.m The deficient practice remained at a pattern with potential for more than minimal harm. Based on record review and interview, the facility failed to: a. prevent elopement for 2 (#26 and #30) of 3 sampled residents reviewed for elopement b. document an unwitnessed fall for 1 (#31) of 2 sampled residents reviewed for falls. The ADON identified five residents at risk for elopement and 25 residents were at risk for falls. Findings: A facility policy titled Wandering and Elopements, revised 03/2019, read in part, 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety .c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident is attempting to leave or has left the premises. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative, the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e. [that is/in other words], Emergency Management, Rescue Squads, etc.) .a. Examine the resident for injuries; b. Contact the Attending Physician and report findings and conditions of the resident; c. Notify the resident's legal representative (sponsor); d. Notify search teams that the resident has been located; e. Complete and file an incident report; and f. Document relevant information in the resident's medical record. A facility policy titled Falls-Clinical Protocol, revised 03/2022, read in part, staff and physician will document in the medical record a history of one or more recent falls .The staff will evaluate and document falls that occur while the individual is in the facility .falls should be identified as witnessed or unwitnessed events .the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. 1. Resident #26's admission record, dated 04/03/24, showed the resident was admitted with diagnoses which included vascular dementia and aftercare following surgery on the digestive system. Resident #26's elopement assessment, dated 04/03/25, showed the resident was not at risk for elopement. Resident #26's admission assessment, dated 04/10/25, showed the resident had a BIMS score of 9 indicating moderate cognitive impairment, no history of wandering, ambulated with a wheel chair, and had a history of falling. A weather report on 04/15/25 showed night temperatures of 40 degrees Fahrenheit. Resident #26's elopement assessment, dated 04/16/25, showed the resident was a high risk for elopement. There was no documentation in Resident #26's health record of an elopement. On 04/16/25 at 11:50 a.m., the DON stated Resident #26 was at risk for elopement and had never been reported to elope. On 04/16/25 at 12:17 p.m., LPN #1 was asked about any elopements involving Resident #26. They stated on 04/15/25 around 7:00 p.m., CNA #1 went in the transport van and picked up Resident #26 and returned the resident. LPN #1 stated they reported the elopement to the ADON and the administrator. LPN #1 stated they were not made aware Resident #26 had eloped until CNA #1 went and picked up the resident and returned to the facility with the resident. LPN #1 stated they did not document anything in the resident's health record or complete an incident report. On 04/16/25 at 2:07 p.m., CNA #1 was asked about the elopement. They stated a visitor came in and notified them a resident was about one quarter a mile away from the facility walking on the side of the road. CNA #1 stated they went in the transport van and found Resident #26 walking down the road and picked them up and returned to the facility and notified LPN #1 who was the charge nurse. CNA #1 was asked how they identified what residents were elopement risk. They stated there was a list, but it was not there anymore. CNA #1 stated they relied on the charge nurse to communicate which residents were allowed to leave. They stated the administrator was aware of the elopement and spoke with the resident when they returned. On 04/16/25 at 2:26 p.m., CNA #7 stated a third party notified them Resident #26 eloped on 04/15/25. CNA #7 stated CNA #1 went in the transport van and picked up Resident #26 and they had no idea how the resident got out of the facility. CNA #7 stated the charge nurse let them know who could leave the facility without supervision. On 04/16/25 at 2:40 p.m., CMA #1 stated a visitor from outside came in and notified them on 04/15/25 around 7:30 p.m. an unnamed resident was walking down the road. They stated a CNA went and picked up Resident #26 and notified LPN #1 when they returned. 2. Resident #30's admission record, dated 08/23/24, showed the resident was admitted with diagnoses which included schizo-affective disorder, hypothyroidism, and gout. Resident #30's care plan, dated 11/27/24, showed the resident was an elopement risk with interventions including: assess for fall risk and monitor fatigue and weight loss. Resident #30's elopement risk assessment, dated 12/02/24, showed the resident was at risk for elopement and their BIMS score was 14 indicating their cognition was intact. Resident #30's quarterly assessment, dated 02/25/25, showed the resident's BIMS score was 13 indicating their cognition was intact and they no history of wandering. A weather report on 04/07/25 showed night temperatures of 33 degrees Fahrenheit. Resident #30's behavior note, dated 04/07/25 at 9:45 p.m., showed the resident attempted to elope from the building 10 times. The note showed the resident was redirected with minimal effectiveness and was argumentative with staff. Resident #30's elopement risk assessment, dated 04/09/25, showed the resident was at risk for elopement and had BIMS score of 12 indicating moderate cognitive impairment. There was no documentation in Resident #30's health record they eloped on 04/07/25. On 04/16/25 at 7:21 a.m., LPN #5 was asked how they identified residents at risk for elopement. They stated there was no set list and if a resident did not have a power of attorney or guardian, they assumed the resident could leave unsupervised. LPN #5 was asked if any assessment identified residents at risk for elopement. They stated they were not aware of an assessment. LPN #5 was asked about Resident #30 and if they ever eloped. They stated on 04/07/25 at around 9:45 p.m., they were the charge nurse on duty and when the smokers came in they noticed the resident was missing. LPN #5 stated a CMA came and alerted them the resident was missing during a medication pass. LPN #5 stated they started to look for the resident when an off duty CNA called and they stated they found the resident walking down the road. They stated when the resident returned, the resident was covered with fecal matter from incontinence. LPN #5 stated they cleaned up the resident, notified the DON, but did not document anything in the resident's health record. On 04/16/25 at 2:42 p.m., CMA #3 was asked about Resident #30's elopement. They stated on 04/07/25 they were passing medications and could not locate Resident #30 for medication pass. CMA #3 stated they started to look for the resident and then received a phone call from a facility worker (name unknown). CMA #3 stated the facility worker stated the resident was seen on the highway and was picked up and returned to the facility. They stated the resident had mud on their leg like they had a fall. CMA #3 stated the resident was showered and they notified LPN #5. They were asked what the elopement policy was. They stated they were unsure. CMA #3 was asked how they identified residents at risk for elopement. They stated the charge nurse verbally informed them. They stated the resident could of been hit by a car and seriously harmed. On 04/16/25 at 3:59 p.m., Resident #30 was asked to discuss what happened last week. Resident #30 stated they got out of the facility and escaped because they did not want to be there anymore. They stated they were walking down the highway and fell in the mud and a staff member brought them back to the facility. 3. Resident #31's admission record, dated 11/06/24, showed the resident was admitted with diagnoses which included personal history of traumatic brain injury and dementia. Resident #31's care plan, revised 11/15/24, showed the resident was at risk for falls due to impaired mobility. Resident #31's significant change assessment, dated 03/19/25, showed the resident's BIMS score was 9 indicating moderate cognitive impairment. The assessment showed they ambulated with a wheel chair and required supervision or touching assistance for all transfers. On 04/20/25 at 11:06 p.m., the Oklahoma State Department of Health received an anonymous email. The email, read in part, This resident laid in the floor for a long time even when the nurse qas (sic) notified and CNAs were notified. The email had a picture of an unnamed resident on the floor in a hospital gown looking at the camera with their exposed buttocks redacted. The image was of Resident #31. There was no documentation in Resident #31's health record a fall occurred over the weekend on 04/19/25. On 04/16/25 at 10:39 a.m., the ADON stated Resident #26 had never eloped and residents with a BIMS score of 13 or more could leave without supervision. The ADON stated Resident #30 had interventions for elopement in their care plan which included assessing for fall risk and monitor for fatigue and weight loss. The ADON stated the interventions in Resident #30's care plan were not appropriate interventions to prevent elopement. They stated they were unaware of Resident #26's elopement on 04/15/25, they were unaware of Resident #30's elopement on 04/07/25, and there was no documentation in the residents electronic health record of the elopements. On 04/16/25 at 3:39 p.m., CNA #4 was asked about Resident #30's elopement. They stated 04/07/25 at 9:30 p.m. they were off duty and heading home on the state highway about three miles from the facility. CNA #4 stated they saw Resident #30 heading away from the facility walking on the highway in the construction area. CNA #4 stated Resident #30 stated they were cold, they were covered in mud, and had soiled themselves with urine and fecal matter. They were asked how they identify which residents were at risk for elopement. They stated there was a scoring system and charge the charge nurse verbally informs them. On 04/16/25 at 5:20 p.m., the DON was asked how staff identified residents at risk for elopement. They stated it was based on a BIMS score of 12 and below and the charge nurse decided who could leave without supervision. They stated they did not have a good system in place to prevent elopement due to residents' mental health diagnosis and the residents did not follow the rules. They stated if the resident was assessed as an elopement risk it was easier to let them leave or they will just crawl out the window. The DON stated there was no documentation Resident #26 eloped, they were unsure why LPN #1 completed an elopement assessment for Resident #26 on 04/16/25, and they did not know anything about Resident #26's care. The DON stated Resident #30 was an elopement risk, the resident could not leave unsupervised, and they were unaware the resident had eloped on 04/07/25. They stated residents who eloped were at risk for harm. On 04/16/25 at 6:10 p.m., the administrator was asked about their elopement policy. They stated they should be notified of all elopement and complete a state reportable. They were asked about Resident #26's elopement on 04/15/25 and Resident #30's elopement on 04/07/25. They stated there was no documentation Resident #26 and Resident #30 eloped and they were not notified Resident #26 and Resident #30 eloped. They stated residents who had a BIMS score of 13 or above could leave unsupervised. They were asked if Resident #30 who had a BIMS score of 13 could leave unsupervised. They stated no due to Resident #30's mental health diagnosis. They stated Resident #26 had a BIMS score of 9 and should not be allowed to leave unsupervised. On 04/21/25 at 9:35 a.m., the ADON was shown the image from the anonymous email received on 04/20/25 at 11:06 p.m., and asked which resident was on the floor in the image. The ADON stated it was Resident #31. They stated the resident was looking at the camera and could tell their picture was being taken. On 04/21/25 at 10:25 a.m., the administrator was asked if they were notified Resident #31 had a fall over the weekend. The administrator stated the facility was unaware Resident #31 had a fall. On 04/21/25 at 12:14 p.m., LPN #1 was asked if they were the charge nurse over the weekend and if Resident #31 had a fall. LPN #1 stated they were the charge nurse over the weekend. LPN #1 stated Resident #31 was observed on the floor in their room on 04/19/25 due to an unwitnessed fall. LPN #1 was asked what they did after finding the resident on the floor. LPN #1 stated they first took a picture of the resident on the floor, assessed the resident, but they did not document the fall in the resident's health record because they thought Resident #31 was care planned to be on the floor.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to assess, monitor, and provide interventions for Res #144, who was found in the floor after being there for an unknown period of time and had been reported to have a change in baseline status related to being cold to the touch and minimally responsive, at shift change around 6:00 a.m., on [DATE]. The resident was moved to a wheelchair and placed in the lobby and was not assessed for close to two and a half hours. EMS was contacted at 8:30 a.m., for him becoming unresponsive and being unable to obtain vital signs. Staff interviews conducted with those present at the time stated CPR was not initiated due to unknown code status of resident. Hospital records documented the resident was hypothermic, hypotensive, and hypoglycemic and .must have been in a cool environment without being found down for a fairly long period of time before discovery . Res #144 expired in the hospital on [DATE]. On [DATE] at 3:13 p.m., the Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. On [DATE] at 3:19 p.m., the administrator was notified of the IJ situation related to quality of care for Res #144. On [DATE] at 6:40 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal read in entirety: Corrective Action: Plan of Removal On,[DATE], All staff In-serviced on Facility Policy and Procedure regarding code status and where code status is located. 1. All newly hired personnel will be educated on location of resident code status 2. DON/Designee will review new hire packets to ensure all training is completed. 3. Up to date code status will be maintained on resident charts and on 24- hour report sheet for quick reference. 4. DON/Designee will review physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. DON/Designee will report any negative findings quarterly to QAPI Completed by 8 p.m. [DATE] On [DATE], All nursing staff educated on how to recognize change in resident baseline condition\orientation and\or change in vital signs. 1. All newly hired direct care staff will be educated on how to recognize change in resident baseline condition\orientation and\or change in vital signs. 2. All facility staff will be in-served quarterly on how to recognize change in resident baseline condition\orientation and\or change in vital signs. Completed by 8:00 pm [DATE] On [DATE], all licensed RN/LPN In-serviced on Facility Policy and Procedure properly assessing, monitoring, and intervening effectively and timely in the event of change in resident condition, and completion of Incident reports. 1. All licensed new hires will be educated on Facility Policy and Procedure on properly assessing, monitoring, intervening effectively and timely in the event of change in resident condition, and completion of incident reports. 2. Don/designee will review all new hire packets to ensure all training is completed. 3. Don/designee will report any negative findings quarterly to QAPI Completed by 8 p.m. [DATE] On [DATE] Chart review of all 35 resident's code status orders were reviewed and code status stickers and 24 -hour report sheet updated Completed by 8p.m. [DATE] The immediacy was lifted, effective [DATE] at 11:03 a.m., when all elements of the plan of removal had been implemented. The deficiency remained at a potential for harm at an isolated level. Based on record review, observation, and interview, the facility failed to provide needed care and services in accordance with professional standards of practice for three (#144, #16, and #43) of six residents reviewed for quality of care issues. The facility failed to: a. assess, monitor, and provide interventions for Res #144 who was found on the floor around 6:00 a.m., cold to the touch and minimally responsive, on [DATE]. EMS was not notified until 8:30 a.m. The resident was admitted to the hospital and records documented the resident was hypothermic, hypotensive, and hypoglycemic. Res #144 expired in the hospital on [DATE]. b. conduct wound assessments and follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] c. conduct an admission assessment for Res #43. Findings: 1. Res #144 admitted to the facility from the hospital on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Base line care plan, dated [DATE], documented Res #144 was a full code. An admission assessment, dated [DATE], documented the resident was severely impaired with cognition and was independent with bed mobility, transfer, walking, and eating. The assessment documented the resident required limited asssistance with dressing, toilet use, and personal hygiene. The assessment documented a bath did not occur for the look back period. A care plan, dated [DATE], documented the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The plan documented to observe for signs and symptoms of [CONDITION(S)]. The care plan documented to monitor for signs of hypertension and [CONDITION(S)]. A nurse paper note, dated [DATE] at 8:20 a.m., documented the following: Res #144 was sitting up in the lobby in a wheelchair waiting for breakfast to be served. This nurse called resident's name with no response and watched resident's chest rise and fall. Res #144 was snoring every other inhale. This nurse started a full assessment on the resident, no vital signs were obtained. The vital machine wound not read, pulse faint, sternum rub performed and resident responded. Weakness still noted. A nurse paper note, dated [DATE] at 8:30 a.m., documented EMT called. The note documented the nurse continued sternum rubs and the resident was placed in supine position on the floor in case CPR needed to be performed. The note documented the nurse continued to talk to the resident and moaning sounds were noted. A nurse paper note, dated [DATE] at 8:40 a.m., documented EMT arrived and took resident to hospital. The note documented the family, DON, and administrator were notified at that time. A nurse paper note, dated [DATE] at 12:50 p.m., documented the nurse spoke with the hospital staff and stated Res #144 had been sent to a hospital in Tulsa via med flight. The note documented hospital staff stated the resident was sent due to hypothermia, hypovolemia, and [CONDITION(S)]. Local hospital records, dated [DATE], documented the following: Resident was found down on the floor at local nursing home with low BP and low blood sugar according to EMS. Code status was unknown. Patient only responsive to painful stimuli. At 9:41 glucose was 58. At 9:46 a.m. BP ,d+[DATE], P 51, R 18. At 10:56 a.m. resident was intubated. At 11:08 compressions initiated. At 11:10 a.m. temperature 84 degrees F. At 11:22 compressions initiated. Time of transfer to Tulsa hospital 12:53 p.m. Tulsa hospital records, dated [DATE], documented on page 12, on arrival to the ICU, the patient was unresponsive, intubated, temperature 84.2 F, systolic blood pressure was ,d+[DATE], bilateral breath sounds present, heart regular rate and rhythm, nontender abdomen, cool skin, no visible skin [CONDITION(S)], and trace bilateral lower extremity [CONDITION(S)]. The patient is admitted for treatment status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Tulsa hospital records, dated [DATE], read in part on page 16, .hypothermia likely secondary to septic shock. Must have been in a cool environment without being found down for a fairly long period of time before discovery and eventually being taken to the other facility . Tulsa hospital records, dated [DATE], documented on page 46, the resident's time of death as 5:59 a.m. on [DATE]. On [DATE] at 9:36 a.m., CNA #10 stated when she came in for her day shift, she found Res #144 that morning on his roommate's side of the room on the floor ice cold. CNA #10 stated she notified the night shift charge nurse LPN #3, who she stated did not assess the resident. CNA #10 stated the day nurse arrived and talked to the night nurse then they had us put Res #144 in his wheelchair and put him in the living area of the facility. On [DATE] at 9:49 a.m., the resident's roommate, Res #1, stated he was hard of hearing. Res #1 stated his roommate laid on the floor all night long. He stated he did not think any one ever came down to check on them that night and Res #144 did not say anything to him. He was asked if he used his call light for help. Res #1 stated he did not think he called for help. He stated he didn't know what happened after someone got Res #144 off of the floor. He stated he got very cold in his room. The resident was observed to have at least four blankets on his bed. Res #1 stated he could use another blanket. On [DATE] at 10:02 a.m., the temperature in the residents' room was 69.7 degrees. On [DATE] at 10:15 a.m., CNA #11 stated she was working on [DATE], the 6 a.m. to 2 p.m. shift. She stated her and another aide went to check on the residents that morning and Res #144 was on the floor in his room. CNA #11 stated his roommate told her he was on the floor all night long and didn't know if he should have used the call light. CNA #11 stated the nurse got his vital signs and then the other aids helped get him up into a wheel chair to the lobby. She stated she believed the day nurse was the one who got the vital signs. CNA #11 stated Res #144 was sent out to the ER. On [DATE] at 10:23 a.m., CNA #9 stated the morning of [DATE] was a complete[OBSCENITY]show. CNA #9 stated wouldn't let him do CPR and they didn't know if he was a full code or DNR. The CNA stated When he was found on the floor in his room there was a nurse from the night shift who did full ROM, he was still responsive and they brought him up to the lobby so he could be monitored frequently. The CNA stated the resident eventually became unresponsive, he was still breathing, but they couldn't get an O2 or pulse on him. The CNA stated they had me help him into the floor and eventually told me to just go back into the dining room. The CNA stated we came in at 6:00 a.m. and breakfast was usually done by nine, so he sat in the lobby around three hours before he was sent out. The CNA stated It was terrible. I left that place because my license was not worth it. On [DATE] at 11:04 a.m., LPN #6 stated the following: When she first got there she received report then the aides were getting everyone up for breakfast. They had wheeled Res #144 to the front lobby. It was cold and he had a blanket over him. She stated she was doing fingersticks and everyone was waiting for breakfast. The resident was sitting with his head down and the blanket wrapped around his shoulders. The resident did not respond to me when I called his name, so I touched his hands and they were very cold, freezing. I told people I needed oxygen, I could not get a SPO2 or a BP on him. I had a CNA to help me lower the resident to the floor while we were getting everything together. I did a sternal rub on him and constantly talked to him and he was not saying anything. He started moaning and I was about to perform CPR. The facility did not have the code status available. I had an RN with me at the time and she was looking through the charts while I was doing this. I already had the EMT's on the phone and they were in route. The resident was responding with the sternal rubs with moaning. He reached up to move my hand but was not strong enough to move my hand. I did not have to do CPR on him, but the vitals were still not reading. I put the oxygen on him because I still couldn't get the SPO2. I continued doing sternal rubs on him since I was still getting a response out of him and I wanted to keep getting a response. I could not get a blood pressure on him with the machine. The manual BP cuff was gone. I did not check his FSBS. It was not reported to me that he was on the floor in his room. The resident's chart did not have the code status. During this time RN #1 was there. The EMT came and took him out. On [DATE] at 11:32 a.m., CNA # 12 stated the following: She saw the resident in a wheelchair but he usually walks. The other CNA went over to get the resident and bring him to breakfast from the lobby. CNA #12 stated the resident was not responsive so the other CNA notified the RN and LPN. At some point they got him on the floor. They did not perform CPR because right as they were about to the ambulance arrived. On [DATE] at 12:15 p.m., CNA #13 she stated she remembered Res #144 was sent out in the morning on a Sunday due to being unresponsive. She stated the nurse got him on the ground and was calling his name until the EMT got there. CNA #13 state she was pretty sure he was in a wheelchair but he usually walked. On [DATE] at 12:16 p.m., RN #1 stated she did not recall resident Res #144. On [DATE] at 12:34 p.m., the DON stated the resident did not have an incident report for [DATE]. The DON stated she did not start at the facility until [DATE]. On [DATE] at 12:41 p.m., the administrator stated she started at the facility the end of July. She stated she got a phone call that morning from the nurse saying that she had brought him up front because he was kind of lethargic and not acting himself and wanted to watch him. I got a text message that he was going out to the hospital. We heard from the hospital that he had passed. She stated there was not an incident report. She stated she was not aware that he was found in the floor in his room. On [DATE] at 9:32 a.m., the DON stated an unresponsive resident should immediately be assessed, the physician notified, and the resident sent out if required. 2. Res #16 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated [DATE], documented weekly skin audits on Mondays a.m. shift. An admission assessment, dated [DATE], documented the resident was moderately impaired with cognition and was independent with most activities of daily living. The assessment documented the resident had no skin issues. A care plan, dated [DATE], documented open skin [CONDITION(S)]. A quarterly assessment, dated [DATE], documented the resident was moderately impaired with cognition and was independent with most activities of daily living. The assessment documented the resident did not have a pressure ulcer but had other wounds/skin problems/open [CONDITION(S)]. The assessment documented application of nonsurgical dressings and ointments. A physician order, dated [DATE], documented to cleanse bilateral lower legs with wound cleanser, pat dry, apply medi honey to open areas and paint scabs with [MEDICATION(S)] wrap with kerlix every day and PRN for soiling. Weekly wound assessments were reviewed. There were no wound assessments for the weeks of [DATE] and [DATE]. A nurse noted, dated [DATE], documented the wound care physician was here today and was unable to see the resident due to being on the COVID unit. A physician wound assessment, dated [DATE], documented the resident had a non pressure wound of the left anterior shin for at lest 141 days duration. The assessment documented wound #1 was non pressure to the left anterior shin with partial thickness measuring 20 x 16 x not measurable cm cluster wound with no exudate. The assessment documented a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The new order was not changed on the October TAR and was not documented as completed. A physician wound assessment, dated [DATE], documented wound #2 skin tear to right shin full thickness, wound size 34 x 16 x 0.1 cm clustered wound. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 4:09 p.m., Res #16 stated he was not sure why he had bandages to his right arm and left leg. The bandages were observed to be dated [DATE]. Res #16 stated the staff were treating his wounds. On [DATE] at 9:50 a.m. the DON stated she looked in the chart and could not find the skin assessments for October. On [DATE] at 11:13 a.m., the ADON stated it looked like the change in the would care order was missed on [DATE] to the left leg. 3. Resident #43 admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The baseline care plan did not include interventions related to cognition, behaviors, assistance required with ADLs, pressure ulcer risk, fall risk, or high risk medications. An admission assessment, dated [DATE] documented the resident was severely cognitively impaired, had behaviors that interfered with resident care and social activities, had rejection of care, required extensive assistance of one staff with dressing, toileting, personal hygiene and bathing, was always incontinent of bowel and bladder, was at risk for developing pressure ulcers, and received antipsychotic and antidepressant medications. A nurse progress note, dated [DATE] at 9:21 p.m., documented the CNA notified the nurse the Res #43 had fallen. The note documented when the nurse entered the room the resident was laying on his right side next to the sink on the ground with a sheet under his head. The note documented the nurse noticed the resident was having periods of apnea. The note documented she rolled the resident onto his back and was able to find a pulse. The note documented when she applied the blood pressure cuff the resident no longer had a pulse and CPR was initiated. The note documented another nurse took over compressions and 911 was contacted. The note documented upon EMS arrival the paramedics took over CPR and transferred resident out of the facility. On [DATE] Res #43's medical record was reviewed for nursing assessments. The medical record did not contain documentation of nursing assessments of the resident. On [DATE] at 12:37 p.m., the DON was asked to double check to ensure all documentation pertaining to Res #43 was provided to surveyors. On [DATE] at 12:50 p.m., the DON provided documentation regarding Res #43's fall and stated there were no further records for the resident available. On [DATE] at 3:15 p.m., the DON stated upon admission a resident should receive a head to toe assessment and orders should be reviewed. She stated a fall risk assessment should be completed at least quarterly. She stated she had not been in the facility long enough to figure out what their system was. She stated the resident should have had a fall risk assessment initially documented either in the computer or in the paper chart. She stated she was unsure who was responsible for the assessments. She stated after a fall a resident is supposed to be assessed to see if they need to be sent out or for injury and there should have been a post-fall assessment that included the interventions on either the nurses progress note or on the incident report. She stated she was unaware if the MDS coordinator was doing the fall risk assessments. On [DATE] at 3:45 p.m., the MDS coordinator stated it was likely there had not been any RN assessments completed for Res #43. He stated the nurses on the floor were supposed to do the fall risk assessments. On [DATE] at 4:11 p.m., the MDS coordinator stated there was a corporate nurse helping with MDS assessments, but the assessments she completed did not include a fall risk assessment or a head-to-toe assessment of the resident upon admission or throughout the resident's stay. On [DATE] at 10:17 a.m., the MDS coordinator stated the baseline care plan was completed prior to his employment but fall risk and interventions were not care-planned. He stated falls should have been on the baseline care plan and any other concerns based on what was in the resident's referral, but he doesn't think that the prior MDS coordinator was scrubbing the referrals as they were supposed to when residents were admitted . He stated the prior MDS coordinator was using a template and failed to customize the responses to the resident.

A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective the evening of 08/03/21 related to the facility's failure to ensure interventions were in place to prevent one resident from elopement. Resident #1 was last seen by staff between 8:30 p.m. and 9:30 p.m. CNA #1 stated at 8:30 p.m. he had returned from break and notice the back lobby door was propped open with a metal plate. He stated he looked outside the door and did not see anyone. He stated he closed the door and reported the incident to the charge nurse. Interviews from staff, written statements by staff and other documentation reported varied times of when the resident was last seen. No staff was able to report a definite time the resident was reported missing to the charge nurse. Upon report an immediate search was started and the resident was found outside in the back of the facility sitting on the ground at approx. 12:15 a.m. on 08/04/21. On 08/12/21 at 3:20 p.m., the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to have interventions in place to prevent the resident's elopement. The past noncompliance IJ was removed, effective 08/05/21 at 9:00 p.m., after the facility had put interventions into place to prevent recurrence and educated staff on not propping doors open and through in-services. The facility notified the Oklahoma State Department of Health, Adult Protective Services, family, physician, and the Local Law Enforcement of the elopement. Upon location of the resident, vital signs were taken and a head to toe nursing assessment was completed with no injuries noted. The resident was placed on 1:1 monitoring. An emergency Q.A.P.I. Meeting was held on 08/04/21, minutes documented the following: identified issues - staff propped open smoking doors-resident was missing; safety plan for residents identified - resident found, no injuries, body audit negative for any signs of injury, 1:1 during investigations, all exit door codes changed, verified all other residents accounted for in facility; system changes identified and education plan - conduct elopement drill, staff in-serviced-not propping doors open in facility; and monitoring system - facility management to observe all entrance/exits of the facility to ensure properly closed and secure 3 x daily x 7 days then daily x 14 days. The facility conducted in-services which included an elopement drill and educating staff on not propping doors open on 08/05/21 at 8:00 a.m., 12:00 noon, 3:00 p.m. and 8:00 p.m. to accommodate all shifts. The in-services were mandatory and included all staff. Based on observation, record review, and interview, it was determined the facility failed to ensure interventions were in place to prevent elopement for one (#1) of three residents sampled for elopement. Resident #1 eloped from the facility through a door, which had been propped open. The resident was not noticed missing for approx. 1.75 hrs and was not found for approx. 3.75 to 4.25 hrs. The resident had no comprehensive care plan with interventions for wandering to prevent elopement. The facility identified 36 residents who resided in the facility. Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)] with behavioral disturbances, unspecified mood disorder and [CONDITION(S)]. A Wandering Risk Assessment was completed on 06/11/21 and documented the resident had a score of 11.0 and was a high risk for wandering. The following items were documented concerning the resident which led to the score: ~ the resident was forgetful with short attention span and had poor decision making ability, ~ she did not understand surroundings, ~ was admitted within the last month, ~ was independent with no assistance, ~ had a diagnosis of dementia with [CONDITION(S)], ~ she was taking antipsychotics, and ~ had a known hx of wandering. The resident's care plan, initiated 06/15/21 and last updated on 07/27/21, did not address wandering or preventing elopement. A comprehensive admission assessment, dated 06/18/21, documented the resident was severely cognitively impaired, had trouble concentrating on things, such as reading the newspaper or watching television nearly every day, had no potential indicators of [CONDITION(S)], had not exhibited rejection of care, had wandered on a daily basis and the wandering placed .the resident at significant risk of getting to a potentially dangerous place [e.g., stairs, outside of the facility] . A written witness statement by CNA #4, dated 08/03/21 [sic][08/04/21], documented, Approximately 10:15 [p.m.] we noticed that [Res #1] was not in her room and whenever we spoke with 2-10 [2:00 p.m. - 10:00 p.m.] staff they were walking and checking rooms. The 2-10 staff said last time they seen [Res #1] was between 8:30-9:30 pm not sure how long she was actually missing but we all started searching for her and contacted police after checking the biding [building] several time's [sic] in-and out behind the building . An undated 'Resident Incident Report [Facility name deleted],' documented, .[Res #1] .Incident Date: 8-3-24 [sic] Time: 10: pm .Category .[box unchecked] Elopement .X Off Premises .Describe Injury [symbol for none] Location of Occurrence: [line left blank] .Incident Reported by: [LPN #1] .Immediate Actions Taken .Temp 98.2 Pulse 88 Resp 20 B/P 157/100 Pain Scale [0] SpO2-100 .Notified: Physician [Physician name deleted] [Date/Time Contact Initiated] 8/4/21 0015 [12:15 a.m.] [Date/Time Responded] 8/4/21 0015 Family [Family name] [ .Initiated] 8/4/21 0000 [12:00 a.m./midnight] [ .Responded] 8/4/21 0000 Other [COO name deleted] [ .Initiated] 8/3/21 2145 [9:45 p.m.] [ .Responded] 8/3/21 2245 [10:45 p.m.] Exam by Physician: No .Taken to Hospital No .Disposition .X In-house Tx X Observation .X reportable Person reported to [CCO]Date: 8/3/21 Time: 2245 Resident Condition at Time of Incident .Meds taken during last 8 hrs: .X Analgesics/Narcotics .Mobility: Ambulatory .Other current conditions: .X Inability to understand directions X Confusion/Disorientation X B & B Urgency .Narrative of incident and description of injuries (Use additional pages, if needed): No apparent injuries were noted at the time she was brought back into facility p being missing for approx. 3 hrs - 1:1 initiated Witnessed by: [left blank/not signed or dated] .Prepared by: [left blank/not signed or dated] .Reviewed by: [left blank/not signed or dated] . Attached additional page attached to 'Resident Incident Report' above documented, [cut off on copy received] returned resident back inside facility via back door at [a]pprox 12:15 AM.-upon return resident rec'd Head to toe assment [sic] c no injuries noted-[symbol for no] s/s of pain/discomfort noted- ROM WNL per her baseline - [no] s/s hyperthermia, [no] new skin issues noted-weather at time of occurrence was warm & mild- Resident was offered food/fluids upon return - Resident was placed on 1:1 observation upon return to facility-[LPN #1 signed without date]. An initial OSDH Incident Report Form (fax sheet dated 08/04/21 at 2:32 a.m.), documented an incident date of 08/04/21 with final report checked (Part C not completed, which identifies it as an initial report) documented, .At 2145 [9:45 p.m.] notified by Charge Nurse that [Resident #1 name deleted] was missing from facility. She was last seen around 9pm [sic]. Complete sweep of facility was done X3 with 34 residents accounted for and 1 missing. It is not known how [Res #1] went missing at this time. Police Notified, Physician, [Family member name deleted] was notified. Resident was wearing jeans, tennis shoes, and a short sleeve green top. The weather was clear and haze temp. [Res #1] was found by staff members behind the nursing home at 12:15pm [sic] sitting on the ground. Brought back where Charge Nurse Completed vitals and full assessment with no visiual [sic] signs of brusing [sic], scratches. Physician Notified she was back no new orders recived [sic]. Facility Maintenance was called in and changed exit codes. Extra staff came in and [Res #1] willl [sic] be monitored 1:1 until investigation is compelted [completed]. Facility Cameras will be utilized in investigation .Current diagnosis [CONDITION(S)], with behavioral disturbance Unspecified [sic] mood disorder, [CONDITION(S)] . The report documented the following notifications were made: physician, family, DHS: Adult Protective Services, Local Law Enforcement (police department date 08/04/21 at 9:30 p.m.). The above report was refaxed to the OSDH on 08/04/21 at 2:52 a.m. with corrected incident date of 08/03/21, police department date of 08/03/21) and most typos. A progress note, dated 08/04/21 at 6:18 a.m., documented, At the end of 2-10 [2:00 p.m. - 10:00 p.m.] shift staff reports resident had not been seen since 8:30-9:00 pm staff members x 6 did search 5x around the building bedrooms, closets and bathrooms. staff members walked around outside building and was unable to find her. police was notified also corp personal [sic] phys [physician] and daughter notified. At approx. 12:15 am staff members found her behind the building sitting on the ground on buttock assisted up into standing position, ambulated back into building with assist. Head to toe skin assessment reveal no injuries. She is alert and confusion 'normal for her' to bed with assist. She is smiling and watch T.V., all responsible parties were notified. A written 'Investigative Witness Statement' by CNA #1, dated 08/04/21 at 8:30 p.m., documented, .I was going to south and seen that the exit .door was open with a metal plate. I looked outside & didn't see anyone outthere [sic] so, I closed the door shut. This happened on 8/3/21 around 8:30 p.m A written 'Investigative Witness Statement' by CMA #1, dated 08/04/21 at 9:30 p.m., documented, .An employee [CNA #2] Prompt [sic] the door open when she took pt.'s [sic] out to smoke for there [sic] break on 8-3-21 . 'Emergency Q.A.P.I. Meeting Minutes,' dated 08/04/21, documented, Identified Issues Staff propped open Smoking doors- Resident was missing Safety Plan for Residents Identified Resident found, no injuries, body audit negative for any signs of injury 1:1 during investigations All exit door codes changed Verified All other residents accounted for in facility System changes Identified and Education Plan Elopement drill Staff inserviced -not propping doors open in facility Monitoring System Facility Management to observe all entrance/exits of the facility to ensure properly closed and secure 3 x daily x 7 days then daily x 14 days. Date: 08/04/2021 Date of compliance: 08/24/2021 Members in attendance: [fours signatures deleted]. A log titled '1:1 Monitoring for Resident Safety,' with resident #1's name, documented visual checks on the resident with her location approx. q hr, on 08/04/21 from 12:15 a.m. through 1:42 p.m., with staff initials with each entry. A care plan for res #1, dated 08/04/21, documented, .Wandering: Unsafe situations ELOPEMENT PRECAUTIONS!!! .Category Behaviors .Goal Wandering will not contribute to injury .Intervention .Place resident in area where frequent observation is possible .Provide diversional activities .Note which exits resident favors for elopement from facility. Alert staff working near those areas .Monitor and document target behaviors .Implement facility protocol for locating an eloped resident .If wandering away from unit, instruct staff to stay with resident, converse and gently persuade to walk back to designated area with them .Approach wandering resident in a positive, calm, and accepting manner .Alert staff to wandering behavior . A written witness statement by CMA #2, dated 08/05/21, documented, At approximately 10:15pm [sic] We noticed that [Res #1] was not in her room and Whenever we spoke with the 2-10 [2:00 p.m. - 10:00 p.m.] shift they were walking and checking rooms. They stated that the last time they had seen [Res #1] was between 8:30 - 9:30pm [sic] .not sure how long she was actually uncounted [sic] for but we all started searching for her and contacted the police after checking the building 5x also outside of the building and around 11:45pm-12:15am We started back searching and found he outside behind the building unharmed. But im [sic] not sure what time she got out of the facility it was before shift change . Five 'Inservice Education Reports,' dated 08/05/21, documented that RN #1 conducted in-services titled Do Not ever prop doors open at any time and Elopement Drill. The sheets contained signatures and titles of employees from all departments. A final OSDH Incident Report Form, faxed on 08/09/21 at 12:09 p.m., documented the following summary of the investigation: .Due to the residents [sic] [CONDITION(S)] she does not have the ability to use the door code to get out on her own, and upon further investigation it was discovered that some of the evening shift staff has been propping the back door to the smoke area open when taking the smoking residents out. All staff were immediately educated on not propping any door open, additional education was provided on elopement and an elopement drill was also conducted. The elopement book was updated at the nurses' station as well as a list of residents that are an elopement risk that will be maintained and updated as needed at the nurses [sic] as well as the employee break room for a quick reference . Upon entrance to the facility, on 08/11/21 at 7:35 p.m., LPN #2 was identified as the charge nurse. LPN #2 reported their current census was 35. She notified corporate staff covering as interim administrative personnel at the current time and informed surveyor it would be two hrs before their arrival. Requested resident smoke times and was informed they were 9:00 a.m., 11:00 a.m., 1:00 p.m., 3:00 p.m., 6:00 p.m., 8:00 p.m. and 10:00 p.m. She stated smoke times could vary slightly usually within half an hr before to half an hour after designated times. She provided a copy of the 'Temperature Entry' sheet she had printed out with resident names and room numbers, the daily staffing sheet showing which staff were there for the shift. She stated CNA #2 was a no call no show and that CMA #3 was the only facility staff there (others were agency staff) and would be my best resource for any facility specific information needed until corporate staff arrived. From 7:55 p.m. to approx. 9:52 p.m., the surveyor made round through the facility and was able to identify all staff identified as being present on the daily staffing sheet, visualized all but one resident on the sheet and observed/check all entrances/exits to ensure they were closed/locked. During these rounds two residents were identified by the surveyor as wanderers, one of which was res #1. At 8:43 p.m., the corp consultant BOM arrived and verified census was 35. At 9:52 p.m., CMA #3 identified residents in the front lobby for surveyor. When asked about the one resident not observed, CMA #3 stated he was in the hospital. LPN #2, who was on the other side of the nurse's desk, was asked if the census was 35 or 34 since res #4 was in the hospital. She stated, 34. At 9:53 p.m., res #1 was observed wandering in the front lobby. The surveyor asked theresident if she would sit and talk with her. The res went over and sat down by the fireplace. The surveyor asked her what her name was and she replied with only her first name. When asked what her last name was she looked blankly at the surveyor and then got up and started wandering again. On 08/12/21 at 8:35 a.m., the elopement book was provided to surveyors. The book contained one 'Exit Seeking Information Sheet' in the book. The Sheet was for res #1 and contained her picture, medical information, age, height, weight, vision, hearing, contact persons with phone numbers, physician and her exit seeking behaviors. At 9:25 a.m., res #1 was observed sleeping in bed on top of covers with a blanket covering her. At 11:02 a.m., an interview was conducted with CMA #4. When asked if he had been working when the elopement occurred, he stated he worked the morning shift and left at 2:30 p.m. on the days he worked. He was asked if he had attended an in-service last week r/t the elopement. He stated he had and was able to tell the surveyor what was said in the in-service, what the procedure was for when a resident went missing, they were to never prop doors open and identified the two wanderers in the facility, along with the interventions they were to use to prevent elopement. At 11:19 a.m., an interview was conducted with DA #1. When asked if she had been in the facility the evening of the elopement, she stated the latest she worked was 7:30 p.m. and she was already gone. She stated res #1 would try to follow anyone out of the door, so she always looked over her shoulder when going out a door and turned around when out to check that the door locked and that no one came out behind her. She stated she had attended the in-service and that they had went through the elopement procedure and did a drill, also that they were to always immediately notify the nurse in charge. At 11:40 a.m., an interview was conducted with DA #2, who stated he had only been there for two pay periods and he was not in the facility when the incident occurred. He was asked if he had attended an in-service r/t elopement recently. He stated he had about a week ago. He was able to tell what they were told in the in-service and was able to describe the two wanderers in the facility even though he did not know their names. He stated they had emphasized checking behind us to not prop doors, make sure the doors lock and no one sneaks out behind you. At 11:48 p.m., a phone interview was conducted with CNA #4, who stated she had worked the night shift on 08/03/21 and had just got on shift and about 10:09 p.m., they were checking heads and they could not find res #1. She stated they checked the building three or four times then went out with flash lights and she was eventually found out back of the building sitting on the ground. She stated prior to the incident no one had ever told her anything special they were to do about her wandering. She stated she did not know how she got out. She stated she was not able to attend the in-service because she was at her other job and could not leave. At 12:00 p.m., an interview was conducted with the interim admin. She stated she was from corporate and had been the interim admin as of yesterday (08/11/21). She stated she was not there when the incident occurred, however she knew a little bit about it. She was asked about the elopement book. She stated she had looked at the updated one. She was asked if that was the one she had brought us. She stated, Yes. She was asked how many residents were in the book. She stated, Just one, from my understanding they haven't had a history of elopement. She was asked if only residents who had actually or tried to elope went in the book. She stated, Yes. She was asked if someone who scored as a high risk for wandering/elopement on their 'Wandering Risk Assessment' should go in the book. She stated, Good practice, yes. Mandatory, no. The interim admin was asked if a resident is high risk for wandering on their wandering assessment, should they have wandering/elopement on their care plan. She stated, Yes. She was asked if she was aware res #1 did not have wandering/elopement care planned. She stated, No. She then stated it was part of their correction and all they could do is correct it. She was asked how long the 1:1 observation occurred following the elopement. She stated, she was not sure. She was asked if all of the staff had attended the in-services. She stated, As far as I'm aware all were, with the exception of two staff out on quarantine for COVID. At 12:37 p.m., a phone interview was conducted with CMA #2, who stated she worked the 10 to 6 shift and was just coming on shift when she and other night staff were going down the hall to check on their residents and the evening staff came down and was looking for res #1 so we joined in looking for her. She stated res #1 would wander an hr or two, or sometimes all night. When asked what they did to intervene and prevent wandering/elopement, she stated they would redirect her with snacks, sometimes they would just follow her around-they would take turns and sometimes if we would sit down, she would sit with us. She stated she attended the in-service and was able to tell what was discussed and stated that they were to make sure all res was accounted for and if we did not see for 10 to 15 minutes to notify the nurse. At 2:40 p.m., the interim admin was asked to provide any documentation she had of any monitoring they might have done following the elopement. She stated it should be in the QAPI book, she would look. At 2:46 a.m., CNA #3 was informed res #1 was not in her room and surveyor had not seen her for a couple of hrs and asked if she knew where she was. She stated, I don't know, I've been busy. She remained be. The interim DON was sitting at nurses' station next to where the CNA was standing and did not say or do anything. The interim DON then answered the phone. At 2:50 p.m., when the interim DON hung up the phone, she was asked if she knew where the resident was. She stated, The last time I saw her, she was in the dining room. She continued to sit at the desk. At 2:54 p.m., the interim DON got up from the nurses station and walked through the double doors towards her office. The surveyors then checked the nurses notes in the compute and found a nurses note for that day, documenting the resident had left the facility at 1:24 p.m. to a geri-psych facility for eval and tx. At 2:58 p.m., the interim admin informed surveyors she was not able to locate any documentation of monitoring. A typed and signed attestation by RN #1 (who conducted the in-services), dated 08/13/21, documented, In-service Times for elopement were at 0800 [8:00 a.m.], 1200 [12:00 p.m.], 1500 [3:00 p.m.], 2000 [8:00 p.m.] to accomodate [sic] all shifts. A log provided to the surveyor by the interim admin, on 08/13/21 at 9:00 a.m., documented Entrance/Exits were checked for proper closure three times daily on all of the dates from 08/04/21 through 08/11/21 by the maintenance supervisor. She also provided the above mentioned 'Emergency Q.A.P.I Meeting Minutes,' dated 08/04/21, at this time.

A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 07/22/21 related to the facility's failure to ensure a resident was free from abuse. The facility failed to prevent staff and visitors (a staff member's husband and son) from physically, verbally, and mentally abusing resident #1. On 07/29/21, the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to protect and prevent resident abuse. The past noncompliance IJ was removed effective 07/27/21 after the facility put measures in place to prevent recurrence. LPN #2, the charge nurse who allowed her family members to enter the facility, and declined to call medical assistance for the resident, was suspended and subsequently terminated 07/23/21, during the administrator's investigation of the incident. The business office manager, who witnessed the incident, and declined to call medical assistance for the resident, was suspended 07/23/21, during the corporate COO's investigation of the incident. The administrator, who submitted the initial Incident Report Form 07/23/21, was suspended 07/24/21, during the COO's investigation of the incident. The COO submitted an addendum to the Incident Report Form to the Oklahoma State Department of Health. The facility notified DHS: Adult Protective Services, the physician, local law enforcement, and the Oklahoma Board of Nursing for the LPN. The facility filed Notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment or Misappropriation of Property for the business office manager. The facility changed all exit door codes, conducted head to toe assessments of non-cognitive residents, questioned residents regarding physical or mental abuse by staff or their family members, interviewed cognitive residents who witnessed the incident, updated their abuse policy, conducted 1:1 staff training from 07/23/21 through 07/26/21 which covered examples of abuse, reporting resident maltreatment is the law, reporting all allegations of abuse immediately, reporting up the chain of command if necessary to include the governing body, and provided counseling services to residents. Based on interview and record review, it was determined the facility failed to ensure residents were free from abuse for one (#1) of nine sampled residents who were reviewed for abuse. The facility identified 36 residents who resided in the facility. Findings: A facility policy titled, Abuse Policy and Procedure, dated 07/23/21, documented, .We will endeavor to protect our occupants from maltreatment, which means adult abuse .physical abuse, sexual abuse, neglect .It recognizes resident rights to be free from physical or mental abuse .All allegations of maltreatment, including neglect, physical abuse, mental abuse, sexual abuse .verbal abuse .must be reported immediately to the administrator .Any employee who fails to report actual or suspected abuse, neglect, or misappropriation of property immediately upon discovery will be subject to disciplinary action up to and including termination . Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 05/06/21, documented, .Focus: Behavior .has a behavior problem and is at risk for decreased psychosocial well-being .Fluctuation and decline anticipated .Interventions: Assist .to develop more appropriate methods .to express feelings appropriately .caregivers to provide opportunity for positive interaction, attention . A quarterly assessment, dated 06/23/21, documented the resident's cognition was severely impaired, inattention, disorganized thinking, delusions, verbal and other behavioral symptoms, required supervision with ADLs and he was ambulatory. A nursing progress note, dated 07/22/21 at 18:00 (6:00 p.m.), electronically signed by LPN #2, documented, .noted to have scratches on his face. Stated he scratched himself. Refused to allow this nurse to evaluate . A nursing progress note, dated 07/23/21 at 08:50 (8:50 a.m.), electronically signed by RN #1, documented, .In DON office with gaqsh [gash, sic] under left eye, may need stitches, voices was beat up in his room last night about 7 p.m . A nursing progress note, dated 07/23/21 at 08:59 (8:59 a.m.), electronically signed by RN #1, documented, .Dr [name withheld] notified send to [name withheld] ER . An Initial Incident Report Form, dated 07/23/21, documented, .Incident Type .Certain Injuries .Administrator was just notified the resident has a cut on his left jaw. Resident has been sent to the hospital for further medical evaluation. Investigation initiated. Physician, family member notified. Resident is his own responsible party . The form documented the administrator as the reporting party. A resident witness statement, dated 07/23/21 at 11:00 a.m., documented resident #1 was in front of the nurse's station screaming about cigarettes. The statement documented resident #1 did not touch anyone. The statement documented a white truck pulled up in front of the main entrance. The statement documented an older man and a younger man were banging on the door and LPN #2 let them in. The statement documented the younger man was cursing wanting to know where they at, I will take care of them. The statement documented the younger man went into resident #1's room where a commotion and cursing was heard. The statement documented the younger man came out of resident #1's room with blood on his hand and his t-shirt. The document stated resident #1 asked for 911 to be called. The statement documented the police came but did not check on resident #1, they just wrote on a paper, stood by the front desk, and then left. LPN #2's witness statement, dated 07/23/21 at 11: 30 a.m., documented she was talking to her husband on the phone the evening of 07/22/21 when resident #1 came up by the nurse's station and started cursing at her. The statement documented her husband and son came to the facility and said if you ever talk to my mom like that again. The statement documented that her son said he never touched resident #1, he just got the resident off of him. Cook #1's witness statement, dated 07/23/21 at 1:10 p.m., documented resident #1 was upset about someone throwing away his cigarettes. The statement documented that LPN #2 told resident #1 he better quit talking to her like that, she would get her husband and son up there. The statement documented that resident #1 told LPN #2 to quit threatening him and call them which she did. The statement documented the husband and son showed up at the facility, banging on the door. The statement documented that LPN #2 and CMA #1 let them in. The statement documented that LPN #2's son was cursing asking where the one was that disrespected his mom. The statement documented LPN #2 took her son to resident #1's room. The statement documented there was yelling and cursing and LPN #2's son charged at resident #1 hitting him in the face. The statement documented LPN #2's son [name withheld] pushed resident #1 down in the hall. The statement documented residents witnessed this incident and some were saying that was not right. CMA #1's witness statement, dated 07/23/21 at 3:30 p.m., documented LPN #2's son [name withheld] came to facility beating on the door. The statement documented LPN #2 let him in the facility. The statement documented LPN #2's son was cursing wanting to know where he was. The statement documented LPN #2 pointed in the direction of resident #1's room. The statement documented LPN #2's son went to resident #1's room and slammed the door. The statement documented yelling and commotion could be heard. The statement documented LPN #2's son came out of resident #1's room with blood on his shirt and hand yelling you will not talk to my mama like that. The statement documented resident #1 came out of his room a little later and requested an ambulance. The statement documented both LPN #2 and the business office manager were told of resident #1's request for an ambulance and they both stated they were not calling an ambulance. A resident witness statement, dated 07/23/21, documented she was coming out of her room and two guys went into resident #1's room and shut the door. The statement documented resident #1 came out of his room with a wound on his face. The statement documented they told him to say he fell . The statement documented the short guy cursed telling resident #1 not to mess with him anymore, I will go to jail do not mess with me. An emergency room record, dated 07/23/21, documented resident #1's behavior was anxious, crying-consolable, and restless. Resident complained of pain in left eye 10 out of 10 on pain scale. The emergency room record documented a laceration to inner aspect of left eyebrow and left lower eyelid 0.5 to 2.5 cm long, sustained one day ago, bleeding small amount. The emergency room record documented wound repair of 0.5 cm avulsed laceration to left lower eyelid. Skin closed with 1 1-0 Dermabond using Simple sutures. The emergency room record documented CT of the head/brain without contrast and CT maxillofacial without contrast. The emergency room record documented data was reviewed, vital signs, nursing notes, radiologic studies, CT scan, and as a result, patient discharged . On 07/26/21 at 2:03 p.m., cook #1 was asked if she was aware of an incident that occurred at the facility the evening of 07/22/21. She stated yes. She stated about 6:15 p.m., resident #1 became upset because staff had thrown away his cigarettes. She stated the resident had asked the business office manager to buy him more cigarettes with his own money. Resident became angry when he was told he didn't have any cigarettes for a smoke break. She stated resident knocked book off medication cart. She stated the administrator told the resident to calm down. She stated LPN #2 was on the phone and the resident was loud in the background. She stated LPN #2 told the resident he better quit talking to her like that, stating that she had told him that her husband and son were going to come down there if he kept talking to her like that. She stated LPN #2's husband and son did show up at the facility. Cook #1 stated she informed the business office manager she better get out here then went to the kitchen to call 911. She stated LPN #2's son was cursing asking where the person was that was talking bad to his mom. She stated LPN #2 showed her son resident #1's room. She stated LPN #2's son [name withheld] went into the resident's room with LPN #2's husband. She stated LPN #2's son pushed the resident to the ground, there was blood on LPN #2's son's hand and shirt. She stated LPN #2's son commented it was not his blood. She stated the resident asked her to call an ambulance because he was bleeding from the face. Cook #1 stated she called both an ambulance and the police. She stated the resident was taken to the emergency roiagnom on Friday (07/23/21). On 07/26/21 at 2:30 p.m., the COO informed the surveyor that the administrator contacted her Friday evening (07/23/21) regarding the incident on 07/22/21. She stated the administrator told her it had been reported to her the resident fell . She stated LPN #2 did not work in the facility on Friday (07/23/21) but had completed her shift on Thursday (07/22/21). The COO stated Friday evening (07/23/21) she changed codes to all entry doors, reassigned licensed nurses from other facilities, assessed residents, updated the abuse policy, and initiated staff 1:1 individual training re-educating them on abuse protocol. On 07/28/21 at 11:50 a.m., CNA #2 was asked if she was aware of the incident that occurred at the facility the evening of 07/22/21. She stated yes, a staff member had contacted her that night. She stated the next day (07/23/21) she asked resident #1 what happened to him. She was asked why she asked the resident what happened to him. She stated because he had a gash under his eye and was bleeding. She stated the resident told her LPN #2's son hit him. She stated she noticed blood on the resident's door. She stated the resident told her he asked to be taken to the hospital but LPN #2 told him no. CNA #2 stated she reported it to the DON. She stated she asked the DON to contact the administrator. CNA #2 stated she informed the administrator that resident #1 told her he had been hit. She stated she talked to LPN #2 who told her maybe the resident fell . CNA #2 stated the ambulance was called Friday morning (07/23/21). On 07/29/21 at 12:08 p.m., CNA #1 was interviewed by telephone. She was asked if she was aware of the incident that occurred at the facility the evening of 07/22/21. She stated she was outside on a smoke break and when she returned inside she noticed blood on resident #1's floor. On 07/29/21 at 1:22 p.m., the administrator was interviewed by telephone. She was asked if she was aware of the incident that occurred at the facility the evening of 07/22/21. She stated she was at the facility on 07/22/21 until approximately 6:15 p.m. She stated when she left everything was calm and the nurse was in the facility. She stated prior to her arrival at the facility on 07/23/21, she had been contacted by the charge nurse (RN #1) who informed her that resident #1 had a cut on his jaw. The administrator stated RN #1 told her she had been told resident #1 fell but RN #1 stated she did not know what happened. The administrator stated she contacted LPN #2, on 07/23/21 at 1:06 p.m., to ask her what happened. She stated LPN #2 told her she did not do anything that her son had talked to resident #1 but did have blood on his hand.

A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 07/22/21 related to the facility's failure to implement their abuse policies and procedures. On 07/29/21, the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to implement their abuse policies and procedures. The facility failed to protect and prevent resident abuse, immediately report abuse, and report to the appropriate agencies within the required timeframe. The past noncompliance IJ was removed effective 07/27/21 after the facility put measures in place to prevent recurrence. LPN #2, the charge nurse who allowed her family members to enter the facility, declined to call medical assistance for the resident, and failed to report the abuse, was suspended and subsequently terminated 07/23/21, during the administrator's investigation of the incident. The business office manager, who witnessed the incident, declined to call medical assistance for the resident, and failed to report the abuse, was suspended 07/23/21, during the corporate COO's investigation of the incident. The administrator, who submitted the initial Incident Report Form 07/23/21, was suspended 07/24/21, during the COO's investigation of the incident. The COO submitted an addendum to the Incident Report Form to the Oklahoma State Department of Health. The facility notified DHS: Adult Protective Services, the physician, local law enforcement, and the Oklahoma Board of Nursing for the LPN. The facility filed Notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment or Misappropriation of Property for the business office manager. The facility changed all exit door codes, conducted head to toe assessments of non-cognitive residents, questioned residents regarding physical or mental abuse by staff or their family members, interviewed cognitive residents who witnessed the incident, updated their abuse policy, conducted 1:1 staff training from 07/23/21 through 07/26/21 which covered examples of abuse, reporting resident maltreatment is the law, reporting all allegations of abuse immediately, reporting up the chain of command if necessary to include the governing body, and provided counseling services to residents. Based on interview and record review, it was determined the facility failed to implement their abuse policy for one (#1) of nine sampled residents who were reviewed for abuse. The facility failed to: a. protect and prevent resident #1 from being verbally, mentally, and physically abused; b. immediately report an allegation of abuse to the administrator; and c. report an allegation of abuse of a resident to Oklahoma State Department of Health (OSDH) within the required time frame. The facility identified 36 residents who resided in the facility. Findings: A facility policy titled, Abuse Policy and Procedure, dated 07/23/21, documented, .We will endeavor to protect our occupants from maltreatment, which means adult abuse .physical abuse, sexual abuse, neglect .It recognizes resident rights to be free from physical or mental abuse .All allegations of maltreatment, including neglect, physical abuse, mental abuse, sexual abuse .verbal abuse .must be reported immediately to the administrator .All alleged or suspected incidents must be reported according to state and federal law .An Incident and Accident Report form will be completed .within 24 hours of the incident's discovery .When the allegation involves physical abuse .you must report within 2 hours of notification of incident .Any employee who fails to report actual or suspected abuse, neglect, or misappropriation of property immediately upon discovery will be subject to disciplinary action up to and including termination .reporting and investigation procedures will be used .to address abuse or neglect allegedly committed by a family member, resident, or visitors in the same manner as for alleged, suspected, or actual employee abuse situations . Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 05/06/21, documented, .Focus: Behavior .has a behavior problem and is at risk for decreased psychosocial well-being .Fluctuation and decline anticipated .Interventions: Assist .to develop more appropriate methods .to express feelings appropriately .caregivers to provide opportunity for positive interaction, attention . A quarterly assessment, dated 06/23/21, documented the resident's cognition was severely impaired, inattention, disorganized thinking, delusions, verbal and other behavioral symptoms, required supervision with ADLs, was ambulatory, received an antipsychotic medication seven days of the seven day look back period, and received an opioid three days of the seven day look back period. A nursing progress note, dated 07/22/21 at 18:00 (6:00 p.m.), electronically signed by LPN #2, documented, .noted to have scratches on his face. Stated he scratched himself. Refused to allow this nurse to evaluate . A nursing progress note, dated 07/23/21 at 08:50 (8:50 a.m.), electronically signed by RN #1, documented, .In DON office with gaqsh [sic] under left eye, may need stitches, voices was beat up in his room last night about 7 p.m . An Initial Incident Report Form, dated 07/23/21, documented, . Incident Type .Certain Injuries .Administrator was just notified the resident has a cut on his left jaw. Resident has been sent to the hospital for further medical evaluation. Investigation initiated. Physician, family member notified. Resident is his own responsible party . The form documented the administrator as the reporting party. A resident witness statement, dated 07/23/21 at 11:00 a.m., documented resident #1 was in front of the nurse's station screaming about cigarettes. The statement documented resident #1 did not touch anyone. The statement documented a white truck pulled up in front of the main entrance. The statement documented an older man and a younger man were banging on the door and LPN #2 let them in. The statement documented the younger man was cursing wanting to know where they at, I will take care of them. The statement documented the younger man went into resident #1's room where a commotion and cursing was heard. The statement documented the younger man came out of resident #1's room with blood on his hand and his t-shirt. The document stated resident #1 asked for 911 to be called. The statement documented the police came but did not check on resident #1, they just wrote on a paper, stood by the front desk, and then left. LPN #2's witness statement, dated 07/23/21 at 11: 30 a.m., documented she was talking to her husband on the phone the evening of 07/22/21 when resident #1 came up by the nurse's station and started cursing at her. The statement documented her husband and son came to the facility and said if you ever talk to my mom like that again. The statement documented that her son said he never touched resident #1, he just got the resident off of him. Cook #1's witness statement, dated 07/23/21 at 1:10 p.m., documented resident #1 was upset about someone throwing away his cigarettes. The statement documented that LPN #2 told resident #1 he better quit talking to her like that, she would get her husband and son up there. The statement documented that resident #1 told LPN #2 to quit threatening him and call them which she did. The statement documented the husband and son showed up at the facility, banging on the door. The statement documented that LPN #2 and CMA #1 let them in. The statement documented that LPN #2's son was cursing asking where the one was that disrespected his mom. The statement documented LPN #2 took her son to resident #1's room. The statement documented there was yelling and cursing and LPN #2's son charged at resident #1 hitting him in the face. The statement documented LPN #2's son [name withheld] pushed resident #1 down in the hall. The statement documented residents witnessed this incident and some were saying that was not right. CMA #1's witness statement, dated 07/23/21 at 3:30 p.m., documented LPN #2's son [name withheld] came to facility beating on the door. The statement documented LPN #2 let him in the facility. The statement documented LPN #2's son was cursing wanting to know where he was. The statement documented LPN #2 pointed in the direction of resident #1's room. The statement documented LPN #2's son went to resident #1's room and slammed the door. The statement documented yelling and commotion could be heard. The statement documented LPN #2's son came out of resident #1's room with blood on his shirt and hand yelling you will not talk to my mama like that. The statement documented resident #1 came out of his room a little later and requested an ambulance. The statement documented both LPN #2 and the business office manager were told of resident #1's request for an ambulance and they both stated they were not calling an ambulance. A resident witness statement, dated 07/23/21, documented she was coming out of her room and two guys went into resident #1's room and shut the door. The statement documented resident #1 came out of his room with a wound on his face. The statement documented they told him to say he fell . The statement documented the short guy cursed telling resident #1 not to mess with him anymore, I will go to jail do not mess with me. An emergency room record, dated 07/23/21, documented resident #1's behavior was anxious, crying-consolable, and restless. Resident complained of pain in left eye 10 out of 10 on pain scale. The emergency room record documented a laceration to inner aspect of left eyebrow and left lower eyelid 0.5 to 2.5 cm long, sustained one day ago, bleeding small amount. The emergency room record documented wound repair of 0.5 cm avulsed laceration to left lower eyelid. Skin closed with 1 1-0 Dermabond using Simple sutures. The emergency room record documented CT of the head/brain without contrast and CT maxillofacial without contrast. The emergency room record documented data was reviewed, vital signs, nursing notes, radiologic studies, CT scan, and as a result, patient discharged . On 07/26/21 at 2:03 p.m., cook #1 was asked if she was aware of an incident that occurred at the facility the evening of 07/22/21. She stated yes. She stated about 6:15 p.m., resident #1 became upset because staff had thrown away his cigarettes. She stated the resident had asked the business office manager to buy him more cigarettes with his own money. Resident became angry when he was told he didn't have any cigarettes for a smoke break. She stated resident knocked book off medication cart. She stated the administrator told the resident to calm down. She stated LPN #2 was on the phone and the resident was loud in the background. She stated LPN #2 told the resident he better quit talking to her like that, stating that she had told him that her husband and son were going to come down there if he kept talking to her like that. She stated LPN #2's husband and son did show up at the facility. Cook #1 stated she informed the business office manager she better get out here then went to the kitchen to call 911. She stated LPN #2's son was cursing asking where the person was that was talking bad to his mom. She stated LPN #2 showed her son resident #1's room. She stated LPN #2's son [name withheld] went into the resident's room with LPN #2's husband. She stated LPN #2's son pushed the resident to the ground, there was blood on LPN #2's son's hand and shirt. She stated LPN #2's son commented it was not his blood. She stated the resident asked her to call an ambulance because he was bleeding from the face. Cook #1 stated she called both an ambulance and the police. She stated the resident was taken to the emergency roiagnom on Friday (07/23/21). She was asked if she had been interviewed by staff regarding the incident. She stated the administrator interviewed her on Friday (07/23/21). On 07/26/21 at 2:30 p.m., the COO informed the surveyor that the administrator contacted her Friday evening (07/23/21) regarding the incident on 07/22/21. She stated the administrator informed her that a State reportable had been completed. She stated the administrator expressed the reportable and the witness statements did not appear to match. She stated the administrator told her it had been reported to her the resident fell . The COO stated she started her investigation of the incident the evening of 07/23/21. She stated she had completed interviewing residents but was still interviewing staff. She stated LPN #2 did not work in the facility on Friday (07/23/21) but had completed her shift on Thursday (07/22/21). On 07/28/21 at 11:50 a.m., CNA #2 was asked if she was aware of the incident that occurred at the facility the evening of 07/22/21. She stated yes, a staff member had contacted her that night. She stated the next day (07/23/21) she asked resident #1 what happened to him. She was asked why she asked the resident what happened to him. She stated because he had a gash under his eye and was bleeding. She stated the resident told her LPN #2's son hit him. She stated she noticed blood on the resident's door. She stated the resident told her he asked to be taken to the hospital but LPN #2 told him no. CNA #2 stated she reported it to the DON. She stated she asked the DON to contact the administrator. CNA #2 stated she informed the administrator that resident #1 told her he had been hit. She stated she talked to LPN #2 who told her maybe the resident fell . CNA #2 stated the ambulance was called Friday morning (07/23/21). On 07/29/21 at 12:08 p.m., CNA #1 was interviewed by telephone. She was asked if she was aware of the incident that occurred at the facility the evening of 07/22/21. She stated she was outside on a smoke break and when she returned inside she noticed blood on resident #1's floor. She was asked if she had reported the blood to anyone. She stated no, the charge nurse was there. She was asked if she had reported the blood to anyone else. She stated no. On 07/29/21 at 1:22 p.m., the administrator was interviewed by telephone. She was asked if she was aware of the incident that occurred at the facility the evening of 07/22/21. She stated prior to her arrival at the facility on 07/23/21, she had been contacted by the charge nurse (RN #1) who informed her that resident #1 had a cut on his jaw. The administrator stated RN #1 told her she had been told resident #1 fell but RN #1 stated she did not know what happened. The administrator stated she instructed RN #1 to call an ambulance and send the resident to the hospital. The administrator was asked, by the surveyor, if she had been contacted about the incident on 07/22/21. She stated no. She stated she contacted the COO, the corporate nurse, completed a state reportable, and initiated an investigation as a certain injury. She stated during the investigation everything got blurry. She stated she concluded that the resident did not fall, something else happened to him. The administrator stated she contacted LPN #2, on 07/23/21 at 1:06 p.m., to ask her what happened. She stated LPN #2 told her she did not do anything that her son had talked to resident #1 but did have blood on his hand. She was asked, by the surveyor, if she had submitted another state reportable. She stated no, she had already submitted one. On 08/02/21 at 1:40 p.m., cook #1 was asked was asked if she had reported the incident she witnessed on 07/22/21. She stated she reported it to the business office manager. She was asked how she knew the resident had been pushed to the ground. She stated she saw LPN #2's son push resident #1 to the ground. During the survey, LPN #2, CMA #1, and the business office manager could not be reached for interview.

A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 07/22/21 related to the facility's failure to report an allegation of abuse, to the administrator and other officials, within the required timeframe. On 07/29/21, the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to report abuse immediately. The past noncompliance IJ was removed effective 07/27/21 after the facility put measures in place to prevent recurrence. LPN #2, the charge nurse, who failed to report the abuse, was suspended and subsequently terminated 07/23/21, during the administrator's investigation of the incident. The business office manager, who failed to report the abuse, was suspended 07/23/21, during the corporate COO's investigation of the incident. The administrator, who submitted the initial Incident Report Form 07/23/21, was suspended 07/24/21, during the COO's investigation of the incident. The COO submitted an addendum to the Incident Report Form to the Oklahoma State Department of Health. The facility notified DHS: Adult Protective Services, the physician, local law enforcement, and the Oklahoma Board of Nursing for the LPN. The facility filed Notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment or Misappropriation of Property for the business office manager. The facility updated their abuse policy, conducted 1:1 staff training from 07/23/21 through 07/26/21 which covered examples of abuse and when to report, reporting all allegations of abuse immediately, and reporting up the chain of command if necessary to include the governing body. Based on interview and record review, it was determined the facility failed to ensure staff reported allegations of abuse immediately, but not later than two hours, to the administrator, Oklahoma State Department of Health (OSDH), and other officials for one (#1) of nine sampled residents who were reviewed for abuse. The facility identified 36 residents who resided in the facility. Findings: A facility policy titled, Abuse Policy and Procedure, dated 07/23/21, documented, .We will endeavor to protect our occupants from maltreatment, which means adult abuse .physical abuse, sexual abuse, neglect .It recognizes resident rights to be free from physical or mental abuse .All allegations of maltreatment, including neglect, physical abuse, mental abuse, sexual abuse .verbal abuse .must be reported immediately to the administrator .All alleged or suspected incidents must be reported according to state and federal law .An Incident and Accident Report form will be completed .within 24 hours of the incident's discovery .When the allegation involves physical abuse .you must report within 2 hours of notification of incident .Any employee who fails to report actual or suspected abuse, neglect, or misappropriation of property immediately upon discovery will be subject to disciplinary action up to and including termination .reporting and investigation procedures will be used .to address abuse or neglect allegedly committed by a family member, resident, or visitors in the same manner as for alleged, suspected, or actual employee abuse situations . Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 05/06/21, documented, .Focus: Behavior .has a behavior problem and is at risk for decreased psychosocial well-being .Fluctuation and decline anticipated .Interventions: Assist .to develop more appropriate methods .to express feelings appropriately .caregivers to provide opportunity for positive interaction, attention . A quarterly assessment, dated 06/23/21, documented the resident's cognition was severely impaired, inattention, disorganized thinking, delusions, verbal and other behavioral symptoms, required supervision with ADLs and he was ambulatory. A nursing progress note, dated 07/22/21 at 18:00 (6:00 p.m.), electronically signed by LPN #2, documented, .noted to have scratches on his face. Stated he scratched himself. Refused to allow this nurse to evaluate . A nursing progress note, dated 07/23/21 at 08:50 (8:50 a.m.), electronically signed by RN #1, documented, .In DON office with gaqsh [sic] under left eye, may need stitches, voices was beat up in his room last night about 7 p.m . An Initial Incident Report Form, dated 07/23/21, documented, . Incident Type .Certain Injuries .Administrator was just notified the resident has a cut on his left jaw. Resident has been sent to the hospital for further medical evaluation. Investigation initiated. Physician, family member notified. Resident is his own responsible party . The form documented the administrator as the reporting party. The COO provided the surveyors an addendum to the Initial Incident Report Form submitted to the Oklahoma State Department of Health. A fax transmission report reflected 07/26/21 at 08:30 (8:30 a.m.). The COO stated she knew it was submitted late but she was busy with the investigation. On 07/29/21 at 1:22 p.m., the administrator was interviewed by telephone. She was asked if she was aware of the incident that occurred at the facility the evening of 07/22/21. She stated prior to her arrival at the facility on 07/23/21, she had been contacted by the charge nurse (RN #1) who informed her that resident #1 had a cut on his jaw. The administrator stated RN #1 told her she had been told resident #1 fell but RN #1 stated she did not know what happened. The administrator was asked, by the surveyor, if she had been contacted about the incident on 07/22/21. She stated no. She stated she contacted the COO, the corporate nurse, completed a state reportable, and initiated an investigation as a certain injury. She stated during the investigation everything got blurry. She stated she concluded that the resident did not fall, something else happened to him. She was asked, by the surveyor, if she had submitted another state reportable. She stated no, she had already submitted one. During the survey, LPN #2, CMA #1, and the business office manager could not be reached for interview.

A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 07/22/21 related to the facility's failure to ensure resident #1's alleged abuse was thoroughly and timely investigated and the resident was protected against further potential resident abuse. On 07/29/21, the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to thoroughly and timely investigate abuse, and protect and prevent further potential resident abuse. The past noncompliance IJ was removed effective 07/27/21 after the facility put measures in place to prevent recurrence. LPN #2, the charge nurse who allowed her family members to enter the facility, declined to call medical assistance for the resident, and failed to report the abuse, was suspended and subsequently terminated 07/23/21, during the administrator's investigation of the incident. The business office manager, who witnessed the incident, declined to call medical assistance for the resident, and failed to report the abuse, was suspended 07/23/21, during the corporate COO's investigation of the incident. The administrator, who submitted the initial Incident Report Form 07/23/21, was suspended 07/24/21, during the COO's investigation of the incident. The COO submitted an addendum to the Incident Report Form to the Oklahoma State Department of Health. The facility changed all exit door codes, conducted head to toe assessments of non-cognitive residents, questioned residents regarding physical or mental abuse by staff or their family members, interviewed cognitive residents who witnessed the incident, updated their abuse policy, conducted 1:1 staff training from 07/23/21 through 07/26/21 which covered examples of abuse, reporting resident maltreatment is the law, reporting all allegations of abuse immediately, reporting up the chain of command if necessary to include the governing body, and provided counseling services to residents. Based on interview and record review, it was determined the facility failed to ensure an allegation of abuse was thoroughly and timely investigated and residents were protected against further potential abuse for one (#1) of nine sampled residents who were reviewed for abuse. The facility identified 36 residents who resided in the facility. Findings: A facility policy titled, Abuse Policy and Procedure, dated 07/23/21, documented, .We will endeavor to protect our occupants from maltreatment, which means adult abuse .physical abuse, sexual abuse, neglect .It recognizes resident rights to be free from physical or mental abuse .investigation procedures will be used .to address abuse or neglect allegedly committed by a family member, resident, or visitors in the same manner as for alleged, suspected, or actual employee abuse situations . Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 05/06/21, documented, .Focus: Behavior .has a behavior problem and is at risk for decreased psychosocial well-being .Fluctuation and decline anticipated .Interventions: Assist .to develop more appropriate methods .to express feelings appropriately .caregivers to provide opportunity for positive interaction, attention . A quarterly assessment, dated 06/23/21, documented the resident's cognition was severely impaired, inattention, disorganized thinking, delusions, verbal and other behavioral symptoms, required supervision with ADLs and he was ambulatory. A nursing progress note, dated 07/22/21 at 18:00 (6:00 p.m.), electronically signed by LPN #2, documented, .noted to have scratches on his face. Stated he scratched himself. Refused to allow this nurse to evaluate . A nursing progress note, dated 07/23/21 at 08:50 (8:50 a.m.), electronically signed by RN #1, documented, .In DON office with gaqsh [sic] under left eye, may need stitches, voices was beat up in his room last night about 7 p.m . On 07/26/21 at 2:03 p.m., cook #1 was asked if she was aware of an incident that occurred at the facility the evening of 07/22/21. She stated yes. She stated about 6:15 p.m., resident #1 became upset because staff had thrown away his cigarettes. She stated the resident had asked the business office manager to buy him more cigarettes with his own money. Resident became angry when he was told he didn't have any cigarettes for a smoke break. She stated resident knocked book off medication cart. She stated the administrator told the resident to calm down. She stated LPN #2 was on the phone and the resident was loud in the background. She stated LPN #2 told the resident he better quit talking to her like that, stating that she had told him that her husband and son were going to come down there if he kept talking to her like that. She stated LPN #2's husband and son did show up at the facility. Cook #1 stated she informed the business office manager she better get out here then went to the kitchen to call 911. She stated LPN #2's son was cursing asking where the person was that was talking bad to his mom. She stated LPN #2 showed her son resident #1's room. She stated LPN #2's son [name withheld] went into the resident's room with LPN #2's husband. She stated LPN #2's son pushed the resident to the ground, there was blood on LPN #2's son's hand and shirt. She stated LPN #2's son commented it was not his blood. She stated the resident asked her to call an ambulance because he was bleeding from the face. Cook #1 stated she called both an ambulance and the police. She stated the resident was taken to the emergency roiagnom on Friday (07/23/21). On 07/26/21 at 2:30 p.m., the COO informed the surveyor that the administrator contacted her Friday evening (07/23/21) regarding the incident on 07/22/21. The COO stated LPN #2 did not work in the facility on Friday (07/23/21) but had completed her shift on Thursday (07/22/21). On 07/28/21 at 11:50 a.m., CNA #2 was asked if she was aware of the incident that occurred at the facility the evening of 07/22/21. She stated yes, a staff member had contacted her that night. She stated the next day (07/23/21) she asked resident #1 what happened to him. She was asked why she asked the resident what happened to him. She stated because he had a gash under his eye and was bleeding. She stated the resident told her LPN #2's son hit him. She stated she noticed blood on the resident's door. She stated the resident told her he asked to be taken to the hospital but LPN #2 told him no. CNA #2 stated she informed the administrator that resident #1 told her he had been hit. She stated she talked to LPN #2 who told her maybe the resident fell . CNA #2 stated the ambulance was called Friday morning (07/23/21). On 07/29/21 at 12:08 p.m., CNA #1 was interviewed by telephone. She was asked if she was aware of the incident that occurred at the facility the evening of 07/22/21. She stated she was outside on a smoke break and when she returned inside she noticed blood on resident #1's floor. On 07/29/21 at 1:22 p.m., the administrator was interviewed by telephone. She was asked if she was aware of the incident that occurred at the facility the evening of 07/22/21. She stated prior to her arrival at the facility on 07/23/21, she had been contacted by the charge nurse (RN #1) who informed her that resident #1 had a cut on his jaw. The administrator stated RN #1 told her she had been told resident #1 fell but RN #1 stated she did not know what happened. The administrator was asked, by the surveyor, if she had been contacted about the incident on 07/22/21. She stated no. She stated during the investigation everything got blurry. She stated she concluded that the resident did not fall, something else happened to him. The administrator stated she contacted LPN #2, on 07/23/21 at 1:06 p.m., to ask her what happened. She stated LPN #2 told her she did not do anything that her son had talked to resident #1 but did have blood on his hand. During the survey, LPN #2, CMA #1, and the business office manager could not be reached for interview.

On 05/23/12, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure an allegation of abuse was investigated and residents were protected. At 4:00 p.m., the Oklahoma State Department of Health was notified. The immediate jeopardy situation was verified. At 4:15 p.m., the ADM and the DON were notified of the IJ situation. At 5:00 p.m., an acceptable plan of removal was presented to the survey team. The facility's plan of removal was as follows: "1. Upon receiving any allegation of abuse/neglect said employee will be immediately suspended pending and complete and thorough investigation and will not be allowed to return to the facility until the investigation has been completed and that any risk of harm to the resident can be removed. The resident will be assessed/evaluated for any signs of abuse/neglect. 2. A thorough investigation will be completed and include the review of the resident's medical record, interview of any person's reporting the incident, interviews of any witnesses to the incident, interview of the resident( if cognitive ability permits), interview with staff members ( on all shift) who have had contact with the resident during the period of the allegation, interview the resident's roommate if applicable, family members, and visitors as applicable, interviews of other residents to whom the accused employee provides care or services to, and review all events leading up to the incident. 3. All resident's whom have been alleged to have been abused will be protected from harm during the investigation. 4. All alleged violations of abuse/neglect will be reported to the OSDH and any CNA who has been found unfit for services will be reported to the State Nurse Aide Registry. Any licensed nurse found unfit for services will be reported to the OBN. 5. All allegations of abuse/neglect will be reviewed in QA during the next scheduled meeting to determine changes that are needed, if any in facility practices and policies and procedures will be amended of developed to prevent further occurrences. 6. This facility will also provide training and education in regards to identification of abuse/neglect and reporting process from staff to administration and will include. how to identify potential signs of abuse and to report to charge nurse and that all staff are to report to the abuse coordinator (i.e.. the Administrator) and Director of Nursing of any allegations of abuse/neglect." Based on record review, observation, resident and staff interviews, it was determined the facility failed to ensure an investigation was completed and reported in regard to an allegation of abuse by a staff member for one (#3) of one sampled resident, who alleged abuse. This had the potential to affect all 56 residents who resided in the facility. Findings: The investigation section of the facility policy on resident abuse, documented, "Any allegation of abuse will be investigated by the Administrator and the Director of Nursing. The Administrator and the Director of Nursing will, as a minimum: a. Review the resident's medical record looking for events leading up to the incident. b. Interview the person(s) reporting the incident. c. Interview any witnesses to the incident; d. Interview the resident ( if cognitive ability permits); e. Interview staff members ( on all shifts) who have had contact with the residents during the period of the alleged incident if necessary; f. Interview the resident's roommate, family members, and visitor as able and necessary; g. Interview other residents to whom the accused employee provides care or services; and h. Review all events leading up to the incident." The protection section of the resident abuse policy, documented, "Residents who have been alleged to have been abused will be protected from harm during the investigation. Employees of the facility who have been accused of resident abuse will be suspended from duty. This action will remain in effect until the investigation has been completed." The reporting/response section of the resident abuse policy, documented, "All alleged violations and all substantial incidents will be reported to the Oklahoma State Department of Health ..."Any C.N.A. who had been found unfit service by a court of law will be reported to the State Nurse Aide Registry. Any licensed nurse found unfit for service by a court of law will be reported to the Oklahoma Board of Nursing." Resident #3 had [DIAGNOSES REDACTED]. An admission assessment, dated 04/03/12, documented the resident was severely impaired with cognition, required extensive assistance of one person with transfers, dressing, personal hygiene and was always incontinent of bowel and bladder. Mood or behavior symptoms were not exhibited. A care plan, dated 4/13/12, documented, "Focus (resident's name deleted) uses [MEDICAL CONDITION] medications r/t Dx of [MEDICAL CONDITION] and receives Risperadol, Trazadone for Depression,[MEDICATION NAME] and [MEDICATION NAME] for [MEDICAL CONDITION] disorder. ( name deleted) has refused evening meal since Admission. "Goals (resident's name deleted) will be free of drug related complications, including movement disorder, discomfort, [MEDICAL CONDITION], gait disturbance,constipation/impaction or cognitive/behavioral impairment through review date. Intervention: ...Report to charge nurse negative behavior, refusal of meals, ADL care, medication or etc." No combative behaviors were documented as a problem or update on the care plan. On 05/22/12 at 4:30 p.m., the DON was interviewed about an incident which occurred on 04/28/12. The DON reported CNA #1 told her resident #3 had reported a CNA had been mean to him. The DON reported she and the social services personnel went to the resident's room to interview him about the incident. The DON reported the resident denied he had said a CNA was mean to him. The DON was asked if she had any information on the incident. She stated, "Yes." The DON gave the surveyor a Customer First Concern/Grievance Report, dated 04/30/12, in regard to the resident. The report documented: Resident's name: (name deleted) Date received 4/30/12 Individual initiating concern: (name deleted) Concern reported to: DNS Staff member (name deleted) Describe concern using factual terms: was reported by CNA that Res. stated CNA from last night was combative with him. Individual(s) designated to take action on this concern: DNS/Administrator/SS Date assigned 4/30/12, Date to be resolved by 4/30/12 Was a group meeting held? (yes and no boxes were both blank) Spoke with Res. with social services present. Resident denied that he had said this and stated he wanted Administrator (name deleted) to get him more money. What other action was taken to resolve concern (be specific)? Spoke with the Administrator (name deleted) about res. money and SS about res. behavior. Call placed to (another facility name deleted). Was grievance/concern resolved? Yes. described resolution Denied he made statement. Identify the methods used to notify resident and/or resident representative of the resolution: x one-to-one discussion date of notification 4/30/12 This form was completed by DON (name deleted). On 05/23/12 at 10:25 a.m., CNA #1 was interviewed about the alleged abuse concerning resident #3 on April 28, 2012. She reported the resident told her, "They were being really mean to me. The girl that worked last night tried to throw me out of this chair. She tried to hurt me." The resident reported that girl could lose her job for that. The resident reported the girl ripped my shirt. CNA #1 reported she asked the resident where his shirt was and the resident pointed to the foot of his bed. The CNA picked the shirt up. She reported the shirt was torn at the chest area. The CNA reported she then went and looked at the schedule to see who worked that particular night. At that time, the CNA went back to the residents room and called the Administrator/Operational Manager from her cell phone. The CNA reported to the Administrator/Operational Manager what the resident had told her about the incident. The CNA reported the Administration/Operational Manager reported the staff called her last night and told her the resident was being combative and didn't want to be changed. The Administrator/Operational Manager told CNA #1 she would take care of it Monday. CNA #1 reported she went to the DON's office on Monday because she had felt the Administrator/Operational Manager "had blown her off." The CNA reported she told the DON what the resident had told her about the incident. On 05/23/12 at 11:20 a.m., the Administrator/Operational Manager was asked if CNA #1 had called her the weekend of the incident. The Administrator/Operational Manager reported the CNA did call her, but she did not recall the CNA saying anything about the incident. The Administrator/Operational Manager reported resident #3 had become combative on April 28, 2012 and scratched CNA #4 on her arms. She also reported that the resident was upset because he did not want to be changed and his money was missing. The surveyor attempted to contact CNA #4 by telephone three different times and was unable to reach the CNA. The Administrator/Operational Manager was asked if she had completed an investigation concerning the incident and the alleged abuse. She reported, no. She was then asked if she had reported the allegation of abuse to the OSDH. She reported, no. An incident report, concerning the above incident, could not be located in the incident report log book or in the state reportable book. On 05/23/12 at 1:30 p.m., the DON was asked if an incident report had been completed on the alleged abuse. She reported, no. She was asked if the alleged abuse had been reported to the OSDH. She reported she had not completed an incident report or reported the incident to the OSDH because the resident denied it happened. The DON was asked if she had completed interviews with other staff members who cared for the resident or other residents on that hall. She reported she had not. The DON was asked if she had received statements from the CNA who had reported this for the resident. She stated, "No." On 05/23/12 at 3:55 p.m., resident # 3 was asked if anyone was rough with him. The resident stated "Yes. They tore my shirt trying to get me in bed." The resident was asked if he reported it to anyone. The resident reported he told the ADM/Operational Manager, which he mentioned by name. The facility failed to follow their policy on abuse and conduct an investigation of the alleged abuse. No steps were taken to protect the resident. No reports were filed to the appropriate state agencies. On 05/24/2012 at 5:00 p.m., the Immediate Jeopardy was removed after all staff had been inserviced on the abuse policy and procedures and after staff were interviewed and showed current knowledge of the abuse policy and procedures. The deficient practice remained at no actual harm with potential for more than minimal harm at a pattern.

On 05/23/12, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to follow their abuse policy and ensure an allegation of abuse was investigated and residents were protected. At 4:00 p.m., the Oklahoma State Department of Health was notified. The immediate jeopardy situation was verified. At 4:15 p.m., the ADM and the DON were notified of the IJ situation. At 5:00 p.m. an acceptable plan of removal was presented to the survey team. The facility's plan of removal was as follows: "1. Upon receiving any allegation of abuse/neglect said employee will be immediately suspended pending and complete and thorough investigation and will not be allowed to return to the facility until the investigation has been completed and that any risk of harm to the resident can be removed. The resident will be assessed/evaluated for any signs of abuse/neglect. 2. A thorough investigation will be completed and include the review of the resident's medical record, interview of any person's reporting the incident, interviews of any witnesses to the incident, interview of the resident( if cognitive ability permits), interview with staff members ( on all shift) who have had contact with the resident during the period of the allegation, interview the resident's roommate if applicable, family members, and visitors as applicable, interviews of other residents to whom the accused employee provides care or services to, and review all events leading up to the incident. 3. All resident's whom have been alleged to have been abused will be protected from harm during the investigation. 4. All alleged violations of abuse/neglect will be reported to the OSDH and any CNA who has been found unfit for services will be reported to the State Nurse Aide Registry. Any licensed nurse found unfit for services will bee reported to the OBN. 5. All allegations of abuse/neglect will be reviewed in QA during the next scheduled meeting to determine changes that are needed, if any in facility practices and policies and procedures will be amended of developed to prevent further occurrences. 6. This facility will also provide training and education in regards to identification of abuse/neglect and reporting process from staff to administration and will include. how to identify potential signs of abuse and to report to charge nurse and that all staff are to report to the abuse coordinator (i.e.. the Administrator) and Director of Nursing of any allegations of abuse/neglect." Based on record review, observation, resident and staff interviews, it was determined the facility failed to follow their policy for reporting an allegation of abuse to the appropriate personnel and to investigate an allegation of abuse for one (#3) of one sampled resident. This had the potential to affect all 56 residents who resided in the facility. The facility policy on resident abuse, under investigation documented, "Any allegation of abuse will be investigated by the Administrator and the Director of Nursing. The Administrator and the Director of Nursing will, as a minimum: a. Review the resident's medical record looking for events leading up to the incident. b. Interview the person(s) reporting the incident. c. Interview any witnesses to the incident; d. Interview the resident ( if cognitive ability permits); e. Interview staff members ( on all shifts) who have had contact with the residents during the period of the alleged incident if necessary; f. Interview the resident's roommate, family members, and visitor as able and necessary; g. Interview other residents to whom the accused employee provides care or services; and h. Review all events leading up to the incident." The resident abuse policy, under protection, documented, "Residents who have been alleged to have been abused will be protected from harm during the investigation. Employees of the facility who have been accused of resident abuse will be suspended from duty. This action will remain in effect until the investigation has been completed." The resident abuse policy, under reporting/response, documented, "All alleged violations and all substantial incident will be reported to the Oklahoma State Department of Health as described in number 5 above. Any C.N.A. who had been found unfit service by a court of law will be reported to the State Nurse Aide Registry. Any licensed nurse found unfit for service by a court of law will be reported to the Oklahoma Board of Nursing." Resident #3 had [DIAGNOSES REDACTED]. An admission assessment, dated 04/03/12, documented the resident was severely impaired with cognition, required extensive assistance of one person with transfers, dressing, personal hygiene and was always incontinent of bowel and bladder. Mood or behavior symptoms were not exhibited. A care plan, dated 4/13/12, documented, "Focus (resident's name deleted) uses [MEDICAL CONDITION] medications r/t Dx of [MEDICAL CONDITION] and receives Risperadol, Trazadone for Depression,[MEDICATION NAME] and [MEDICATION NAME] for [MEDICAL CONDITION] disorder. ( name deleted) has refused evening meal since Admission. "Goals (resident's name deleted) will be free of drug related complications, including movement disorder, discomfort, [MEDICAL CONDITION], gait disturbance,constipation/impaction or cognitive/behavioral impairment through review date. Intervention: ...Report to charge nurse negative behavior, refusal of meals, ADL care, medication or etc." No combative behaviors were documented as a problem or update on the care plan. On 05/22/12 at 4:30 p.m., the DON was interviewed about an incident which occurred on 04/28/12. The DON reported CNA #1 told her resident #3 had reported a CNA had been mean to him. The DON reported she and the social services personnel went to the resident's room to interview him about the incident. The DON reported the resident denied he had said a CNA was mean to him. The DON was asked if she had any information on the incident. She stated, "Yes." The DON gave the surveyor a Customer First Concern/Grievance Report, dated 04/30/12, in regard to the resident. The report documented: Resident's name: (name deleted) Date received 4/30/12 Individual initiating concern: (name deleted) Concern reported to: DNS Staff member (name deleted) Describe concern using factual terms: was reported by CNA that Res. stated CNA from last night was combative with him. Individual(s) designated to take action on this concern: DNS/Administrator/SS Date assigned 4/30/12, Date to be resolved by 4/30/12 Was a group meeting held? (yes and no boxes were both blank) Spoke with Res. with social services present. Resident denied that he had said this and stated he wanted Administrator (name deleted) to get him more money. What other action was taken to resolve concern (be specific)? Spoke with the Administrator (name deleted) about res. money and SS about res. behavior. Call placed to (another facility name deleted). Was grievance/concern resolved? Yes. described resolution Denied he made statement. Identify the methods used to notify resident and/or resident representative of the resolution: x one-to-one discussion date of notification 4/30/12 This form was completed by DON (name deleted). On 05/23/12 at 10:25 a.m., CNA #1 was interviewed about the alleged abuse concerning resident #3 on April 28, 2012. She reported the resident told her, "They were being really mean to me. The girl that worked last night tried to throw me out of this chair. She tried to hurt me." The resident reported that girl could lose her job for that. The resident reported the girl ripped my shirt. CNA #1 reported she asked the resident where his shirt was and the resident pointed to the foot of his bed. The CNA picked the shirt up. She reported the shirt was torn at the chest area. The CNA reported she then went and looked at the schedule to see who worked that particular night. At that time, the CNA went back to the residents room and called the Administrator/Operational Manager from her cell phone. The CNA reported to the Administrator/Operational Manager what the resident had told her about the incident. The CNA reported the Administration/Operational Manager reported the staff called her last night and told her the resident was being combative and didn't want to be changed. The Administrator/Operational Manager told CNA #1 she would take care of it Monday. CNA #1 reported she went to the DON's office on Monday because she had felt the Administrator/Operational Manager "had blown her off." The CNA reported she told the DON what the resident had told her about the incident. On 05/23/12 at 11:20 a.m., the Administrator/Operational Manager was asked if CNA #1 had called her the weekend of the incident. The Administrator/Operational Manager reported the CNA did call her, but she did not recall the CNA saying anything about the incident. The Administrator/Operational Manager reported resident #3 had become combative on April 28, 2012 and scratched CNA #4 on her arms. She also reported that the resident was upset because he did not want to be changed and his money was missing. The surveyor attempted to contact CNA #4 by telephone three different times and was unable to reach the CNA. The Administrator/Operational Manager was asked if she had completed an investigation concerning the incident and the alleged abuse. She reported, no. She was then asked if she had reported the allegation of abuse to the OSDH. She reported, no. An incident report, concerning the above incident, could not be located in the incident report log book or in the state reportable book. On 05/23/12 at 1:30 p.m., the DON was asked if an incident report had been completed on the alleged abuse. She reported, no. She was asked if the alleged abuse had been reported to the OSDH. She reported she had not completed an incident report or reported the incident to the OSDH because the resident denied it happened. The DON was asked if she had completed interviews with other staff members who cared for the resident or other residents on that hall. She reported she had not. The DON was asked if she had received statements from the CNA who had reported this for the resident. She stated, "No." On 05/23/12 at 3:55 p.m., resident # 3 was asked if anyone was rough with him. The resident stated "Yes. They tore my shirt trying to get me in bed." The resident was asked if he reported it to anyone. The resident reported he told the ADM/Operational Manager, which he mentioned by name. The facility failed to follow their policy on abuse and conduct an investigation of the alleged abuse. No steps were taken to protect the resident. No reports were filed to the appropriate state agencies. On 05/24/2012 at 5:00 p.m., the Immediate Jeopardy was removed after all staff had been inserviced on the abuse policy and procedures and after staff were interviewed and showed current knowledge of the abuse policy and procedures. The deficient practice remained at no actual harm with potential for more than minimal harm at a pattern.