On 04/17/25, a past noncompliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Res #35 was not verbally abused. On 04/17/25 at 1:30 p.m. the OSDH was notified and verified the existence of the past noncompliance IJ related to the facility's failure to ensure residents were not verbally abused. On 05/06/25 at 12:48 p.m. the administrator was notified of the immediate jeopardy situation. The administrator was provided the IJ template. Documentation showed the facility completed staff in-service regarding abuse on 03/03/25. Employee #1 was suspended, then terminated on 03/04/25. A quality assurance meeting was held on 03/05/25 regarding abuse. Based on observation, record review, and interview, the facility failed to ensure a resident was not verbally abused for 1 (#35) of 3 sampled residents reviewed for abuse. The DON identified six allegations of abuse were reported to the OSDH within the past year. Findings: On 04/15/25 at 2:08 p.m., Res #35 was observed walking in a common area on the memory unit. The resident was speaking loudly in a tearful voice saying could someone help they did not know how to get out. A policy titled Abuse Investigation and Reporting, revised July 2017, read in part, If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual . The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation An undated facesheet for Res #35 had diagnoses which included neurocognitive disorder with Lewy body, diabetes, and major depressive disorder. Res #35's annual assessment, dated 02/19/25, showed the resident was severely impaired for daily decision making and had a BIMS score of 4. The assessment showed the resident received antipsychotic, antianxiety, and antidepressant medications. An OSDH incident form, dated 02/28/25, showed an allegation of abuse. The form showed per written statements by witnesses, the raised tone of voice by certified medication aide #1 caused Res #35 to become upset and cry. On 04/16/25 at 3:04 p.m., Res #35's family stated they were made aware of the verbal abuse allegation the same evening. On 04/17/25 at 2:57 p.m., the director of nursing stated upon completion of the investigation the facility decided to terminate the staff member. On 04/17/25 at 3:00 p.m., the administrator stated a video was viewed regarding the incident. The administrator stated they could not understand what was said, but by facial expressions and gestures they determined verbal abuse did occur.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective [DATE] related to the facility's failure to ensure cardio-pulmonary resuscitation was provided according to standards of care for Res #1 who was a full code status and implement all components of the facility's CPR policy On [DATE] at 4:20 p.m., the Oklahoma State Department of Health was notified and verified the existence of the past noncompliance IJ related to the facility's failure to implement their CPR policy and provide CPR to Res #1 who was a full code. The past noncompliance IJ was removed effective [DATE] after the facility put measure in place to prevent recurrence. On [DATE] staff were in-serviced on CPR status, DNR code status policy and procedures were reviewed, code status identification policy and procedures were included in all new hire packets, with in-person training upon hire. On [DATE] at 10:35 a.m., code status identification was observed at each room/name plates on the memory care unit. On [DATE] at 10:42 a.m., the Activity Director reported having been in-serviced regarding code status and CPR and reported knowledge of how to locate the code status of a resident and when CPR should be done. On [DATE] at 10:45 a.m., LPN #3 reported having been in-serviced regarding code status and CPR and reported examples of a change in condition for a resident, when to notify the physician, where a resident's code status is posted, when to do CPR. On [DATE] at 10:53 a.m., code status identification was observed at room/name plates in the long term care halls. On [DATE] at 10:55 a.m., RN #2 reported they were not able to attend the in-service, but did review the in-service documentation. RN #2 reported examples of a change in condition for a resident, when to notify the physician, where a resident's code status is posted and when to do CPR. Based on observation, record review, and interview, the facility failed to provide CPR to a resident who was full code status and implement their CPR policy for one (#1) of four sampled residents reviewed for code status. The DON identified 15 residents who were a full code status. The administrator identified 55 residents who resided in the facility. Findings: An Emergency Procedure - Cardiopulmonary Resuscitation policy, revised February 2018, read in part, Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest .Preparation for Cardiopulmonary Resuscitation 1. Obtain and/or maintain American Red Cross or American Heart Association certification in Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) for key clinical staff members who will direct resuscitation efforts, including non-licensed personnel .7. Provide information on CPR/BLS and advance directives to each resident/representative upon admission. Res #1 had diagnoses which included congestive heart failure, pneumonia and dyspnea. A physician order, dated [DATE] documented Res #1 was a full code. A care plan focus, dated [DATE], documented Res #1 was full code status. There was no advance directive acknowledgement in Res #1's medical record. A progress note, dated [DATE] at 2:17 a.m., documented LPN #1 observed Res #1's oxygen saturation was 55% on 3 liters of oxygen and their respiratory rate was 20. The note documented the nurse increased the resident's oxygen to four liters per minute and placed their nasal cannula into their mouth which raised their oxygen saturation to 82%. The note documented upon recheck of the resident's oxygen saturation it had dropped back down to 54%. The nurse documented they removed the supplemental oxygen and placed Res #1 on their CPaP machine which did not raise the resident's oxygen saturation beyond 55%. The note documented the resident remained with this oxygen saturation until 11:00 p.m. at which time LPN #1 reassessed Res #1's vital signs. The note documented the resident's oxygen saturation had dropped to 35%. The note did not document EMS or a physician was contacted at this time. The note documented LPN #1 continued to reassess the resident and the oxygen saturation did not rise beyond 34%. The note documented at 12:00 a.m., a CNA notified LPN #1 Res #1 was gone. The nurse documented upon their assessment of Res #1 no vital signs were detected and the provider was notified of their passing. The note documented the provider called a time of death of 12:15 a.m. The note did not document CPR was initiated, or emergency services were contacted. A written statement from CNA #1, dated [DATE], documented around 9:00 p.m. or 10:00 p.m. on the night of [DATE], LPN #1 noted Res #1's oxygen saturation was dropping and stated to CNA #1 it appeared the resident was going to die. CNA #1 documented they asked LPN #1 and LPN #2 what the resident's code status was more than one time and the response received was Res #1 was a DNR. The CNA documented they notified LPN #1 the resident was breathing but non-responsive during peri-care. CNA #1 documented when they returned to Res #1's room Res #1 was not breathing but was still warm. They documented they notified LPN #1 at which time the LPN went to the resident's room to assess the resident. The statement documented the LPN checked the resident for breath sounds and pulse, which were not observed. CNA #1 documented they observed LPN #1 calling LPN #2. The statement documented CNA #1 went to the other hall to provide care and upon their return LPN #1 stated the resident was a full code. CNA #1 documented they asked LPN #1 if CPR should be initiated to which the nurse stated its too late now. A facility interview with LPN #1, dated [DATE], documented the nurse was not aware of the process to check a resident's code status or the process to verify code status. The interview documented LPN #1 was told by another nurse during report Res #1 was a DNR and was not to be sent to the hospital but did not verify the resident's code status. The interview documented upon notification from the aide that Res #1 was gone, LPN #1 took about five minutes to determine Res #1 was full code status. The interview documented LPN #1 was unaware of the nursing standard requirement to start CPR on residents with unknown code status until EMS or a provider stopped CPR. A written statement from CNA #2, dated [DATE], documented at 10:30 p.m. on [DATE], CNA #2 was instructed by LPN #2 to go assist LPN #1 because Res #1's vital signs wasn't looking very great. CNA #2 observed LPN #1 obtaining vital signs. The CNA documented LPN #1 retrieved LPN #2 for assistance. The CNA documented they observed LPN #2 recheck[ed] what LPN #1 had done. The CNA documented they observed LPN #1 notify LPN #2 the resident had passed. They documented they discovered the resident was a full code while attempting to find contact information for the resident's family. The CNA documented they were upset because they were told the resident was a DNR and felt they could have done CPR. An undated written statement from CNA #3, documented LPN #1 notified them around 11:00 p.m. Res #1 had passed. They documented while waiting for instruction from the nurse they were informed by LPN #2 the resident was a DNR. They documented the nurses discovered the resident was a full code while attempting to contact the resident's spouse. An employee disciplinary action form for LPN #2, dated [DATE], documented LPN #2 had received disciplinary action due to failure to provide life saving measures. The form documented LPN #2 declined to give a written statement of events. An employee termination form, dated [DATE], documented LPN #1 was terminated due to the failure to provide life saving measures for Res #1 on [DATE]. On [DATE] at 2:40 p.m., the DON reported they were unable to locate an advance directive acknowledgement for Res #1. On [DATE] at 4:40 p.m., RN #1 reported LPN #1 should have provided CPR to Res #1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** An IJ situation was determined to be in existence related to the facility failing to ensure foot pedals were used during a wheelchair transfer which resulted in Resident #1 sustaining a fracture on 04/09/23. An x-ray, dated 04/09/23, documented Resident #1 sustained a displaced fracture of the medial malleolus of the left ankle. Resident #1 had been transported to an orthopedic appointment on 04/11/23 and wheel chair foot pedals were not in use during that transfer. On 04/21/23 at 1:01 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 04/21/242 at 1:08 p.m., the Administrator and DON were notified of the IJ situation. On 04/21/23 at 3:03 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: April 21, 2023 1. Identify all residents that need foot pedals. 2. Foot pedals will be placed on residents' wheelchairs that need foot pedals. 3. In-service all staff on proper wheelchair safety and use of foot pedals. In-service staff that cannot be present in person by telephone and education witnessed by DON and/or ADON. No staff will work before having appropriate in-service related to wheelchair safety and foot pedal usage. In-services are to be completed by DON and /or ADON. 4. Update care plan on residents that need foot pedals. 5. A policy will be formulated proper wheelchair use. All staff will be given the policy prior to working their next shift. 6. The above will be completed by 1700 [5:00 p.m.] today. On 04/21/23, facility staff were interviewed and were able to state they had been educated on wheelchair safety and foot pedal use. Care plans had been updated to reflect residents' need for foot pedals. On 04/21/23 at 6:45 p.m., the Administrator and DON were notified the immediacy was lifted effective 04/21/23 at 5:00 p.m. and the deficiency remained at a harm level. Based on observation, record review, and interview, the facility failed to ensure foot pedals were used during wheelchair transports for two (#1 and #2) of three sampled residents reviewed for accident hazards. The DON identified 12 residents required wheelchairs with foot pedals. Findings: 1. Resident #1 had diagnoses which included displaced bimalleolar fracture of the left leg and osteopenia. A Resident Assessment, dated 02/09/23, documented Resident #1's cognition was intact and they used a wheelchair for mobility. A Progress Note, dated 04/09/23 at 12:04 p.m., read in part, .Pt up in wheelchair being pushed per staff member when pt let foot drop and foot twisted under wheelchair with c/o pain to left ankle with edema and outward deformity, tender to touch. Elevated and ice pack applies. Dr .notified with order to send pt to ER for [NAME] [sic] of left ankle. Notified [family member name deleted] and sending [Resident #1] to ER. An Orthopedics and Sports Medicine note, dated 04/11/23, documented Resident #1 reported they were being pushed in a wheelchair without foot pedals, their left foot got caught under the wheelchair, and they experienced immediate pain to the left leg. On 04/18/23 at 4:03 p.m., Resident #1 was asked if staff transported them safely in their wheelchair and used foot pedals. Resident #1 stated, You know it's not safe. They stated staff did not use foot pedals. Resident #1 was asked if they had ever sustained an injury while being pushed in the wheelchair. They replied they sustained a leg fracture in two places. Resident #1 was observed sitting in a gerichair with feet elevated. A wheelchair without foot pedals was observed in the room. Resident #1 was asked if they had been in the wheelchair without foot pedals since the incident on 04/09/23. They stated they were taken to an orthopedic appointment on 04/11/23 in that wheelchair. On 04/21/23 at 9:27 a.m., CMA #1 was asked what the policy was for pushing residents in a wheelchair. They stated to make sure if they had foot pedals, to put them on. On 04/21/23 at 9:30 a.m., CNA #2 was asked what the policy was for pushing residents in a wheelchair. They stated they had not been informed. On 04/21/23 at 9:32 a.m., LPN #1 was asked what the policy was for pushing residents in a wheelchair. LPN #1 stated they would push residents slowly and watch for obstacles. On 04/21/23 at 10:54 a.m., the ACT/SSD was asked about the incident with Resident #1 on 04/09/23. They stated they were pushing Resident #1 in their wheelchair to the dining room. The ACT/SSD stated they told Resident #1 they needed to raise their feet and hold them up. The ACT/SSD stated they were barely outside the Resident's door when Resident #1 hollered out, and they stopped pushing the wheelchair. The ACT/SSD stated Resident #1 told them they couldn't hold their foot up and let it drop. The ACT/SSD stated they backed the wheelchair up and pulled it back to Resident #1's room. The ACT/SSD stated Resident #1 stated they were in pain, thought their leg was broken and needed to go to the hospital. The ACT/SSD was asked if Resident #1 had foot pedals in use at the time. They stated, No. The ACT/SSD was asked if Resident #1 had been transported to an outside appointment since the accident on 04/09/23. They stated, Yes. The ACT/SSD stated the activity aide and maintenance man had taken the resident in their wheelchair. The ACT/SSD was asked if foot pedals had been in use for that transport. They stated, No. On 04/21/23 at 11:10 a.m., the ACT assistant was asked about Resident #1's transport to the orthopedic appointment on 04/11/23. They were asked if Resident #1 had foot pedals in use for the wheelchair during that transport. The ACT assistant stated they honestly did not remember them having foot pedals in use. On 04/21/23 at 11:36 a.m., the DON stated Resident #1 was being transported down the hall in a wheelchair on 04/09/23 and did not think foot pedals were in use. They stated the resident sustained a fracture. The DON was asked if foot pedals were in use for the transport to the orthopedic appointment on 04/11/23. They stated the Administrator informed them they were not. 2. Resident #2 had diagnoses which included Alzheimer's disease, muscle weakness, lack of coordination, difficulty ambulating, and communication deficit. A Resident Assessment, dated 01/19/23, documented Resident #2 had severe cognitive deficits and had impaired range of motion to bilateral lower extremities. On 04/21/23 at 7:45 a.m., Resident #2 was observed in a wheelchair in the dining room. Dietary aid #1 was observed to push Resident #2 from the dining room to hall 100. There were no foot pedals observed on the wheelchair. Resident #2 was observed to hold their feet up during the transport. Resident #2 then propelled themselves part way up the hall. On 04/21/23 at 7:48 a.m., LPN #1 was observed to push Resident #2 to the nurses' station, LPN #1 answered the telephone, then pushed Resident #2 to their room on hall 200. Resident #2 kept their feet elevated during the transport. On 04/21/23 at 9:13 a.m., CMA #1 was observed pushing Resident #2 in a wheelchair from hall 100 to their room on hall 200. There were no foot pedals observed on the wheelchair. Resident #2 was observed holding their feet up off the floor. On 04/21/23 at 12:23 p.m., the DON was asked for a wheelchair and foot pedal policy. On 04/21/23 at 12:37 p.m., the DON stated there was not a policy for wheelchairs and foot pedals.