On 09/28/22, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to implement their abuse policy by ensuring a thorough investigation was conducted, to include timely reporting, of an allegation of sexual abuse of a cognitively impaired resident. A progress note, dated 08/12/22, documented resident #7 reported to LPN #1 that she had been sexually abused by LPN #3. LPN #1 reported the allegation of sexual abuse to Administration and the DON at that time. LPN #1 was told the allegation would be investigated. Administration stated they did not report the sexual abuse allegation to state agencies, or conduct an investigation with other residents and staff, because LPN #3 was no longer working in the facility at the time the allegation was reported. Administration made a decision to move the resident from the current room to a private room on a hall without male staff and male residents. LPN #3 no longer worked in the facility but had continued to work for a sister facility. The facility failed to ensure the safety of resident #7, and all other residents, by not following their abuse policy for an allegation of sexual abuse. On 09/28/22 at 5:41 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 09/28/22 at 6:05 p.m., the Administrator and the corporate RN were notified of the IJ situation. On 09/29/22 at 11:55 a.m., an acceptable Plan of Removal was provided by the Administrator and the corporate RN. It documented the following: Plan of removal 09/28/22 1. The Administrator and Director of Nursing have been in-serviced on the abuse policy and investigation an allegation of sexual abuse as of 09/28/22 at 9:00 a.m. 2. All staff will be in-serviced on abuse policy. 3. All staff on duty and available have been in-serviced as of 09/28/22 at 5:00 p.m. 4. All other staff not on duty will be in-serviced prior to returning to work. 5. An investigation was initiated on 09/27/22 when incident was reported to corporate staff. 6. An initial state report was completed and submitted as well as notification to APS and local law enforcement, board of nursing, OSDH, family and physician on 09/27/22 at 6:40 p.m. 7. A PIP plan has been developed to audit all progress notes during stand up meeting to ensure that any and all incidents or unusual occurrence are immediately reported and investigated. 8. The nurse the allegation was made against had resigned on 07/24/22 and has not worked at this facility since. Said employee is currently working for a sister facility and has been placed on suspension once the corporate staff were made aware of the allegation and will remain suspended until investigation is complete. 9. The facility will interview all staff and alert and oriented residents by 11:00 a.m. on 09/29/22, and has interviewed a total of 6 staff members and 6 residents on 09/28/22 to determine if any forms of abuse are occurring in the facility. All staff and residents interviewed have denied any abuse or neglect at this time occurring in the facility. 10. Investigation is currently ongoing and will be completed within the timeline per state and federal regulation included in our policy. On 09/29/22, interviews were conducted with facility staff regarding education and in-service training pertaining to the immediate jeopardy plan of removal. Staff reported they had been in-serviced and were able to verbalize understanding of the information and training provided. The IJ was lifted, effective 09/29/22 at 2:57 p.m., when all elements of the plan of removal had been implemented. The deficient practice remained at a isolated level of no actual harm with a potential for more than minimal harm. Based on observations, record review, and interviews, it was determined the facility failed to ensure the abuse policy was implemented for one (#7) of six residents reviewed for abuse. The facility failed to implement their abuse policy by ensuring a thorough investigation was conducted, to include timely reporting, of an allegation of sexual abuse of a cognitively impaired resident. The administrative assistant reported nine allegations of abuse were reported in the last year. The Administrator reported 42 residents resided in the facility. Findings: The facility's Abuse and Neglect policy, dated 08/12/22, read in parts, .It is the policy of this facility to maintain an abuse free environment .The facility has developed and implements policies and procedures regarding abuse that include seven components including screening, training, prevention, identification, investigation, protection and reporting/response .Investigation: Any allegation of abuse will be investigated by the Administrator and the DON. The Administrator and the DON will, as a minimum: Review the resident medical record looking for events leading up to the incident .Interview the person(s) reporting the incident .Interview any witnesses to the incident .Interview the resident (if cognitive ability permits) .Interview staff members (on all shifts) who had contact with the resident during the period of the alleged incident if necessary .Interview the resident's roommate, family members, and visitors as able and necessary .Interview other residents to whom the accursed employee provides care or services .Review all events leading up to the incident .Residents who have been alleged to have been abused will be protected from harm during the investigation .Employees of this facility who have been accused of resident abuse will be suspended from duty until the investigation has been completed .Protection: Residents who have been alleged to have been abused will be protected from harm during the investigation. Employees of this 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 .Reporting: All incidents and allegations involving abuse is required to be reported within 2 hours .The Administrator will notify the Oklahoma State Department of Health and AP'S by faxing the Incident Report Form. Resident #7 had diagnoses which included dementia, Bipolar disorder, mood disturbance, anxiety, and Schizophrenia. A Care Plan, dated 04/28/22, read in parts .The resident has a behavior problem .On 04/28/22 resident extremely upset, using foul language, making derogatory remarks about the nurse, stating she was raped in the past and that is why she can not sleep at night, and declining her medications .Administer medications as ordered .Intervene as necessary to protect the rights and safety of others .Minimize potential for the resident's disruptive behaviors, by offering tasks which divert attention .Monitor behavior episodes and attempt to determine underlying cause. A Quarterly Assessment, dated 06/29/22, documented the resident's cognition was impaired and required extensive assistance with most ADLs. A Nurse Note, dated 08/12/22 at 9:44 a.m., documented, Reported by patient that nurse assaulted her rectally and now she is pregnant. She is requesting to see a specialist to prove that it happened. She continues to say male worker assaulted her. Resident then reported same information to CNA. At this time above information reported to administration and DON. Decision was made to move resident from her current room to private room on hall without male staff and patients. On 09/27/22 at 4:00 p.m., the corporate RN reported no incident report had been completed for resident #7 related to sexual abuse. On 09/28/22 at 11:30 a.m., the Administrator reported an incident report had not been initiated related to the sexual abuse allegation for resident #7 on 08/12/22. The Administrator stated the incident was not reported or investigated due to the alleged employee no longer working at the facility when the allegation was made. The Administrator reported the resident had been sick with a UTI and had been displaying many verbal and physical behaviors at the time the allegation was made. On 09/28/22 at 2:38 p.m., LPN #1 was interviewed and reported on 08/12/22, resident #7 had told her that LPN #3 had raped her. LPN #1 reported this was the first time sexual abuse had been reported to her from any resident. LPN #1 reported the resident did not tell her when the incident occurred but she knew the named employee, LPN #3, had not worked in the facility since the end of July 2022. The LPN stated she reported the allegation to the Administrator and the administrative assistant and they told her they would investigate it. The LPN reported an incident report should have been done when the allegation was made to her by the resident. On 09/28/22 at 2:45 p.m., the administrative assistant was interviewed and reported the sexual abuse allegation, reported by the resident on 08/12/22, was discussed with the Administrator and a decision was made not to investigate the allegation. The administrative assistant stated they were under the impression the incident had happened the previous night, the alleged nurse was no longer employed at the facility, and had not worked since July 2022. The administrative assistant reported the decision was made to move the resident to another hall with no male residents or male staff. The administrative assistant reported they received verbal report from LPN #1 of the sexual abuse allegation, and no other residents or staff were interviewed at the time of the allegation.

On 09/28/22, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure an allegation of sexual abuse was reported immediately after the allegation was reported to the Administrator. A progress note, dated 08/12/22, documented resident #7 reported to LPN #1 that she had been sexually abused by LPN #3. LPN #1 reported the allegation of sexual abuse to Administration and the DON at that time. LPN #1 was told the allegation would be investigated. Administration stated they did not report the sexual abuse allegation to state agencies, or conduct an investigation with other residents and staff, because LPN #3 was no longer working in the facility at the time the allegation was reported. Administration made a decision to move the resident from the current room to a private room on a hall without male staff and male residents. LPN #3 no longer worked in the facility but had continued to work for a sister facility. The facility failed to ensure timely reporting of an abuse allegation to maintain the safety of resident #7 and all other residents in the facility. On 09/28/22 at 5:41 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 09/28/22 at 6:05 p.m., the Administrator and the corporate RN were notified of the IJ situation. On 09/29/22 at 11:55 a.m., an acceptable Plan of Removal was provided by the Administrator and the corporate RN. It documented the following: Plan of removal 09/28/22 1. The Administrator and Director of Nursing have been in-serviced on the abuse policy and investigation an allegation of sexual abuse as of 09/28/22 at 9:00 a.m. 2. All staff will be in-serviced on abuse policy. 3. All staff on duty and available have been in-serviced as of 09/28/22 at 5:00 p.m. 4. All other staff not on duty will be in-serviced prior to returning to work. 5. An investigation was initiated on 09/27/22 when incident was reported to corporate staff. 6. An initial state report was completed and submitted as well as notification to APS and local law enforcement, board of nursing, OSDH, family and physician on 09/27/22 at 6:40 p.m. 7. A PIP plan has been developed to audit all progress notes during stand up meeting to ensure that any and all incidents or unusual occurrence are immediately reported and investigated. 8. The nurse the allegation was made against had resigned on 07/24/22 and has not worked at this facility since. Said employee is currently working for a sister facility and has been placed on suspension once the corporate staff were made aware of the allegation and will remain suspended until investigation is complete. 9. The facility will interview all staff and alert and oriented residents by 11:00 a.m. on 09/29/22, and has interviewed a total of 6 staff members and 6 residents on 09/28/22 to determine if any forms of abuse are occurring in the facility. All staff and residents interviewed have denied any abuse or neglect at this time occurring in the facility. 10. Investigation is currently ongoing and will be completed within the timeline per state and federal regulation included in our policy. On 09/29/22, interviews were conducted with facility staff regarding education and in-service training pertaining to the immediate jeopardy plan of removal. Staff reported they had been in-serviced and were able to verbalize understanding of the information and training provided. The IJ was lifted, effective 09/29/22 at 2:57 p.m., when all elements of the plan of removal had been implemented. The deficient practice remained at a isolated level of no actual harm with a potential for more than minimal harm. Based on observations, record review, and interviews, it was determined the facility failed to ensure an allegation of sexual abuse was reported immediately to the state agency for one (#7) of six residents reviewed for abuse. The facility failed to ensure the safety of all residents in the facility by not reporting an abuse allegation in a timely manner. The administrative assistant reported nine allegations of abuse were reported in the last year. The Administrator reported 42 residents resided in the facility. Findings: The facility Abuse and Neglect policy, dated 08/12/22, read in parts, .It is the policy of this facility to maintain an abuse free environment .The facility has developed and implements policies and procedures regarding abuse that include seven components including screening, training, prevention, identification, investigation, protection and reporting/response .Reporting: All incidents and allegations involving abuse is required to be reported within 2 hours .The Administrator will notify the Oklahoma State Department of Health and AP'S by faxing the Incident Report Form. Resident #7 had diagnoses which included dementia, Bipolar disorder, mood disturbance, anxiety, and Schizophrenia. A Care Plan, dated 04/28/22, read in parts .The resident has a behavior problem .On 04/28/22 resident extremely upset, using foul language, making derogatory remarks about the nurse, stating she was raped in the past and that is why she can not sleep at night, and declining her medications .Administer medications as ordered .Intervene as necessary to protect the rights and safety of others .Minimize potential for the resident's disruptive behaviors, by offering tasks which divert attention .Monitor behavior episodes and attempt to determine underlying cause. A Quarterly Assessment, dated 06/29/22, documented the resident's cognition was impaired and required extensive assistance with most ADLs. A Nurse Note, dated 08/12/22 at 9:44 a.m., documented, Reported by patient that nurse assaulted her rectally and now she is pregnant. She is requesting to see a specialist to prove that it happened. She continues to say male worker assaulted her. Resident then reported same information to CNA. At this time above information reported to administration and DON. Decision was made to move resident from her current room to private room on hall without male staff and patients. On 09/27/22 at 4:00 p.m., the corporate RN reported no incident report had been completed for resident #7 related to sexual abuse. On 09/28/22 at 11:30 a.m., the Administrator reported an incident report had not been initiated related to the sexual abuse allegation for resident #7 on 08/12/22. The Administrator stated the incident was not reported or investigated due to the alleged employee no longer working at the facility when the allegation was made. The Administrator reported the resident had been sick with a UTI and had been displaying many verbal and physical behaviors at the time the allegation was made. On 09/28/22 at 2:38 p.m., LPN #1 was interviewed and reported on 08/12/22, resident #7 had told her that LPN #3 had raped her. LPN #1 reported this was the first time sexual abuse had been reported to her from any resident. LPN #1 reported the resident did not tell her when the incident occurred but she knew the named employee, LPN #3, had not worked in the facility since the end of July 2022. The LPN stated she reported the allegation to the Administrator and the administrative assistant and they told her they would investigate it. The LPN reported an incident report should have been done when the allegation was made to her by the resident. On 09/28/22 at 2:45 p.m., the administrative assistant was interviewed and reported the sexual abuse allegation, reported by the resident on 08/12/22, was discussed with the Administrator and a decision was made not to investigate the allegation. The administrative assistant stated they were under the impression the incident had happened the previous night, the alleged nurse was no longer employed at the facility, and had not worked since July 2022. The administrative assistant reported the decision was made to move the resident to another hall with no male residents or male staff. The administrative assistant reported they received verbal report from LPN #1 of the sexual abuse allegation, and no other residents or staff were interviewed at the time of the allegation.

On 09/28/22, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure a thorough investigation was conducted for an allegation of sexual abuse to a cognitively impaired resident. A progress note, dated 08/12/22, documented resident #7 reported to LPN #1 that she had been sexually abused by LPN #3. LPN #1 reported the allegation of sexual abuse to Administration and the DON at that time. LPN #1 was told the allegation would be investigated. Administration stated they did not report the sexual abuse allegation to state agencies, or conduct an investigation with other residents and staff, because LPN #3 was no longer working in the facility at the time the allegation was reported. Administration made a decision to move the resident from the current room to a private room on a hall without male staff and male residents. LPN #3 no longer worked in the facility but had continued to work for a sister facility. The facility failed to ensure the safety of resident #7, and all other residents, by not conducting a thorough investigation for an allegation of sexual abuse. The facility failed to ensure the risk of sexual abuse to resident #7, and other residents, did not remain. On 09/28/22 at 5:41 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 09/28/22 at 6:05 p.m., the Administrator and the corporate RN were notified of the IJ situation. On 09/29/22 at 11:55 a.m., an acceptable Plan of Removal was provided by the Administrator and the corporate RN. It documented the following: Plan of removal 09/28/22 1. The Administrator and Director of Nursing have been in-serviced on the abuse policy and investigation an allegation of sexual abuse as of 09/28/22 at 9:00 a.m. 2. All staff will be in-serviced on abuse policy. 3. All staff on duty and available have been in-serviced as of 09/28/22 at 5:00 p.m. 4. All other staff not on duty will be in-serviced prior to returning to work. 5. An investigation was initiated on 09/27/22 when incident was reported to corporate staff. 6. An initial state report was completed and submitted as well as notification to APS and local law enforcement, board of nursing, OSDH, family and physician on 09/27/22 at 6:40 p.m. 7. A PIP plan has been developed to audit all progress notes during stand up meeting to ensure that any and all incidents or unusual occurrence are immediately reported and investigated. 8. The nurse the allegation was made against had resigned on 07/24/22 and has not worked at this facility since. Said employee is currently working for a sister facility and has been placed on suspension once the corporate staff were made aware of the allegation and will remain suspended until investigation is complete. 9. The facility will interview all staff and alert and oriented residents by 11:00 a.m. on 09/29/22, and has interviewed a total of 6 staff members and 6 residents on 09/28/22 to determine if any forms of abuse are occurring in the facility. All staff and residents interviewed have denied any abuse or neglect at this time occurring in the facility. 10. Investigation is currently ongoing and will be completed within the timeline per state and federal regulation included in our policy. On 09/29/22, interviews were conducted with facility staff regarding education and in-service training pertaining to the immediate jeopardy plan of removal. Staff reported they had been in-serviced and were able to verbalize understanding of the information and training provided. The IJ was lifted, effective 09/29/22 at 2:57 p.m., when all elements of the plan of removal had been implemented. The deficient practice remained at a isolated level of no actual harm with a potential for more than minimal harm. Based on observations, record review, and interviews, it was determined the facility failed to ensure an allegation of sexual abuse was thoroughly investigated for one (#7) of six residents reviewed for abuse. The facility failed to ensure the safety of all residents in the facility. The administrative assistant reported nine allegations of abuse were reported in the last year. The Administrator reported 42 residents resided in the facility. Findings: The facility's Abuse and Neglect policy, dated 08/12/22, read in parts, .It is the policy of this facility to maintain an abuse free environment .The facility has developed and implements policies and procedures regarding abuse that include seven components including screening, training, prevention, identification, investigation, protection and reporting/response .Investigation: Any allegation of abuse will be investigated by the Administrator and the DON. The Administrator and the DON will, as a minimum: Review the resident medical record looking for events leading up to the incident .Interview the person(s) reporting the incident .Interview any witnesses to the incident .Interview the resident (if cognitive ability permits) .Interview staff members (on all shifts) who had contact with the resident during the period of the alleged incident if necessary .Interview the resident's roommate, family members, and visitors as able and necessary .Interview other residents to whom the accursed employee provides care or services .Review all events leading up to the incident .Residents who have been alleged to have been abused will be protected from harm during the investigation .Employees of this facility who have been accused of resident abuse will be suspended from duty until the investigation has been completed .Protection: Residents who have been alleged to have been abused will be protected from harm during the investigation. Employees of this 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 .Reporting: All incidents and allegations involving abuse is required to be reported within 2 hours .The Administrator will notify the Oklahoma State Department of Health and AP'S by faxing the Incident Report Form. Resident #7 had diagnoses which included dementia, Bipolar disorder, mood disturbance, anxiety, and Schizophrenia. A Care Plan, dated 04/28/22, read in parts .The resident has a behavior problem .On 04/28/22 resident extremely upset, using foul language, making derogatory remarks about the nurse, stating she was raped in the past and that is why she can not sleep at night, and declining her medications .Administer medications as ordered .Intervene as necessary to protect the rights and safety of others .Minimize potential for the resident's disruptive behaviors, by offering tasks which divert attention .Monitor behavior episodes and attempt to determine underlying cause. A Quarterly Assessment, dated 06/29/22, documented the resident's cognition was impaired and required extensive assistance with most ADLs. A Nurse Note, dated 08/12/22 at 9:44 a.m., documented, Reported by patient that nurse assaulted her rectally and now she is pregnant. She is requesting to see a specialist to prove that it happened. She continues to say male worker assaulted her. Resident then reported same information to CNA. At this time above information reported to administration and DON. Decision was made to move resident from her current room to private room on hall without male staff and patients. On 09/27/22 at 4:00 p.m., the corporate RN reported no incident report had been completed for resident #7 related to sexual abuse. On 09/28/22 at 11:30 a.m., the Administrator reported an incident report had not been initiated related to the sexual abuse allegation for resident #7 on 08/12/22. The Administrator stated the incident was not reported or investigated due to the alleged employee no longer working at the facility when the allegation was made. The Administrator reported the resident had been sick with a UTI and had been displaying many verbal and physical behaviors at the time the allegation was made. On 09/28/22 at 2:38 p.m., LPN #1 was interviewed and reported on 08/12/22, resident #7 had told her that LPN #3 had raped her. LPN #1 reported this was the first time sexual abuse had been reported to her from any resident. LPN #1 reported the resident did not tell her when the incident occurred but she knew the named employee, LPN #3, had not worked in the facility since the end of July 2022. The LPN stated she reported the allegation to the Administrator and the administrative assistant and they told her they would investigate it. The LPN reported an incident report should have been done when the allegation was made to her by the resident. On 09/28/22 at 2:45 p.m., the administrative assistant was interviewed and reported the sexual abuse allegation, reported by the resident on 08/12/22, was discussed with the Administrator and a decision was made not to investigate the allegation. The administrative assistant stated they were under the impression the incident had happened the previous night, the alleged nurse was no longer employed at the facility, and had not worked since July 2022. The administrative assistant reported the decision was made to move the resident to another hall with no male residents or male staff. The administrative assistant reported they received verbal report from LPN #1 of the sexual abuse allegation, and no other residents or staff were interviewed at the time of the allegation.