On 07/27/23 at 4:14 p.m., the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy situation existed due to the facilities failure to ensure residents were free abuse and failed to protect from further abuse and neglect. Resident #7 reported on 07/13/23 that Resident #6 had touched her inappropriately on the breast and vaginal area. AN OSDH reportable incident dated 07/13/23 documented an investigation was initiated and Resident #6 would be placed on operation stand by. Operation stand by is 88 hours of close supervision after an incident. There is not consistent documentation this occurred. There is no documentation Resident #6 was interviewed. A SS note on 07/13/23 documented the police had been called, came out and interviewed five other residents along with Resident #7. Two other residents stated they witnessed the incident. Five days later, on 07/18/23, there were nine resident interviews conducted related to abuse. No staff interviews had been conducted. The incident was substantiated. There are not sufficient measures in place to protect residents from further abuse. Observations were made of Resident #6 wandering alone throughout the facility and out in the smoke area on 07/26 and 07/27/23. On two separate occasions, on 07/25/23, Resident #6 was verbally harassing a female resident and there was no documentation of interventions put in place or of investigations. The administrator and acting director of nursing stated the operational stand by was only for 88 hours but it should have continued until the district attorney determined if charges would be filled. 07/27/2023 at 4:25 p.m. the administrator and corporate nurse was informed of the immediate jeopardy situation. On 07/27/23 at 5:15 p.m., an acceptable plan of care was received. The plan of removal documented, Plan of removal for abuse, neglect, & exploitation. 1. On July 27, 2023 started Inservice to all staff on abuse, neglect, & exploitation will be completed on July 28th by 3pm. 2. Will identify residents that are requiring one-on one to ensure the safety of all residents. 3. Inservice staff on the residents that are requiring one-on-one and update care plans. 4. On July 27, 2023 will begin conducting safe surveys of all residents, guided by the regional team. 5. Root cause analysis will be conducted and completed July 28th, 2023 6. Regional Team will be responsible for POC, Plan of removal will be completed by July 28th, 2023 by 3pm. 07/31/23 after interviews with facility staff, review of resident safe surveys, and in-services on abuse, the immediacy was lifted, effective 07/31/23 at 5:00 p.m., when the last in-service was provided. The deficient practice remained at a pattern with the potential for more than minimal harm. Based on observation, record review and interview, the facility failed to ensure residents were free from abuse and neglect for two (#7 and #4) of six sampled residents reviewed for abuse and neglect. Resident #7 was inappositely touched by Resident #6 and the facility failed protect them and all residents from the abuse. Resident #4 was left on a metal bed frame when the air mattress malfunctioned causing the resident to be in pain and screaming until staff placed them in their chair. The Resident Census and Conditions of Residents form, dated 07/26/23, documented 84 residents resided in the facility. Findings: A facility policy titled Abuse, Neglect, Exploitation or Misappropriation Prevention Program, revised April 2021, read in part, . Residents have the right to be free from abuse, neglect .this included but is not limited to freedom from verbal, menatl, sexual or physicial abuse . 1. An initial report to the Oklahoma State Department of Health, dated 07/13/23, read in part, staff was notified by [Resident #7] had been in appropriately touched by [Resident #6] {Resident #7] stated that [Resident #6] approached .and placed hand down the front of [Resident #7] shirt while stating 'That's the best breast I have grabbed in a while .pushed [Resident #6] away from [them] .sat down on the floor facing [Resident #7] and reached up and grabbed [Resident #7] vaginal area aggressor on operation standby, visual monitoring for the safety of other residents .investigation concluded that the findings were substantiated. An incident note for Resident #7, dated 07/13/23 at 4:22 p.m., read in part, .Resident complained to Social Worker .that another resident had grabbed [Resident #7] left breast from behind. Psychiatrist in building and will exam male resident. Before dr was able to see either resident Midwest police arrived R/T this resident calling 911 from cell phone. Police officer .spoke with resident [Resident #7] and took copy of [their] daily journal on the event that [Resident #7] claims happened . A social service note for Resident #6, dated 07/13/23 at 8:33 p.m., read in part, .about 2:15 pm, another resident reported [Resident #6] allegedly touched [Resident #7] inappropriately and without consent. That resident's charge nurse and [Resident #6] charge nurse were made aware. PA .Law enforcement was involved. Administration is aware and taking appropriate precautions per state regulations. [Resident #6] was educated on boundaries and he was separated from resident. SSD observed nurses were redirecting [Resident #6] as needed. A late entry note, dated 07/13/23 at , read in part, Thursday resident touched a female resident inappropriately. DON .had psych see the resident same day . The note was entered by the Corporate nurse. A nurse's note for Resident #6, dated 07/14/23 at 1:59 p.m., read in part, .resident continues on monitoring for behaviors and for new orders. no s/s of adverse reaction noted thus far. no new behaviors noted .resident up walking around the facility in great spirits most of shift . An undated written statement from the social service director, read in part, .On Thursday, July 13. 2023 at approximately 2:15 p.m., [Resident #7] reported .[Resident #6] approached [Resident #7] and grabbed [Resident #7] breast and said something like 'this is the most beautiful thing I have ever seen .[Resident #6] .followed [Resident #7] to the smoking patio .sat on the floor directly in front of [Resident #7]. [Resident #6] proceeded to caress [Resident #7] leg. [Resident #7] told [Resident #6] to sop [sic] and [Resident #6] would not listen .stated [Resident #7] instructed [Resident #6] to stop touching [Resident #7] repeatedly. [Resident #6] then allegedly touched [Resident #7] crotch area over [their] pants .[Name deleted] stated she witnessed the situation .police arrived took a report . [Name deleted] stated that [Resident #6] was sitting in front of [Resident #7] and was 'touching on [them]' Sgt .stated that he would make a report and he would leave it up to the district attorney to make a decision . There was no documentation on the statement that Resident #6 was interviewed by the facility regarding the incident. The facility did not interview residents regarding the sexual abuse until 07/18/23, five days after the incident occurred. During the interviews, two residents stated Resident #6 always sits in front of you and begs for cigarettes and the second one stated Resident #6 sat too close to people and would spit on them. There was no documentation the facility had interviewed the aggressor and had documentation they were closely monitoring the resident to protect them from Resident #6. A social service note for Resident #6, dated 07/25/23 at 4:10 p.m. , read in part, .SSD witnessed resident verbally harassing another resident. [Resident #6] was raising .voice at her. The other resident stated, [Resident #6] has been getting in my face all day and cussing at me. DON aware of the situation. There was no documentation the facility had addressed Resident #6's aggressive behaviors towards other residents, protected them, and investigated the observation made by the social service director. On 07/26/23 at 3:30 p.m., Resident #6 was observed in the smoke area with five other residents with no staff present in the smoke area with them. Resident #6 was out in the smoke area until 3:50 p.m., then went back inside and wandered the facility up and down the halls and into the dining room. No staff was observed present in the dining room or within eye sight of the resident while inside the facility. On 07/26/23 from 5:30 p.m. through 6:20 p.m., Resident #6 was observed wandering through out the facility unsupervised going back and forth from their room to common area and out into the smoke area. On 07/27/3 at 9:40 a.m. Resident #6 was observed in the smoke area with other residents and no staff were around or in the the line of site of them. On 07/27/23 at 1:27 p.m., Resident #6 was observed aggressively walking down the hall cursing and yelling at other residents with vulgar threats. On 07/27/23 at 1:39 p.m., the social service director was asked about the incident between Resident #6 and Resident #7. The social service director stated Resdient #6 had grabbed and was being in appropriate with other residents. They than stated they were trying to find other placement for Resident #6. They were asked how other residents were being protected from Resident #6. The social service director stated they did not know what was being done, the administrator would decide on that. The social service director stated they did safe surveys, but could not recall when they were completed. On 07/27/23 at 2:12 p.m., the administrator was asked about the incident between Resident #6 and Resident #7. They stated Resident #6 had been placed on operation stand which meant staff was on stand by for assisting the resident for 88 hours. The administrator was asked to describe the investigation the facilty did and how they were protecting residents. The administrator stated the police came out and completed an investigation. The administrator stated the investigation should have been completed concurrently with the police investigation. The administrator stated Resident #6 should be one on one until we know if charges are being filed or a new placement was found. The administrator was made aware of Resident #6 wandering the facility without one on one supervison and being in the smoke area unattended. The administrator stated they thought the one on one was still being provided, but realized the operation stand by ended after 88 hours. The administrator was asked if Resident #6 was interviewed by anyone during the investigation. They stated the police completed an interview with the Resident and the social service director would have that information. On 07/27/23 at 2:38 p.m., the social service director stated neither they nor the police had interviewed Resident #6. 2. Resident #4 had diagnosis to include quadriplegic, major depression, anxiety, and post traumatic stress disorder. A nurse's progress note, dated 07/07/23 at 9:58 p.m., read in part, .The aide notified the nurse that resident bed is no [sic] working and air was coming out of the mattress .The writer noted a hole on the tube taking air into the air mattress .Resident was screaming a yelling the name of [name deleted] that [Resident #4] told her not to bring [Resident #4] bed right down and that is the reason [Resident #4] mattress leaking air. Resident continue to scream . A nurse's progress note, dated 07/07/23 at 11:11 p.m., read in part, .Res was removed from the bed and placed on the chair as [Resident #4] couldn't stop screaming and yelling . Resident #4's care plan meeting notes, dated 07/12/23, read in part, .staff attitudes with [Resident #4] .want this to stop .[Resident #4] endured mental/physical/emotional abuse .Resident left on a deleted air mattress for (35 min) .discussed .resident should not have been left on a deflated mattress for 30-35 min family and Resident is very disappointed in the lack of nursing care and treatment Resident has endured. Family wants formal abuse complaint filled .members present in meeting [Name deleted family] .[Resident #4] .[social service director] .[Administrator] .[DON] .[Name deleted family member] There was no documentation the facility had investigated a complaint of abuse filed during the care plan meeting on 07/12/23. On 07/26/23 at 1:25 p.m., Resident #4 stated they had been left on their bed without air for 35 minutes and no one would not get them out of the bed off the metal bed frame. Resident #4 stated the facility does nothing about the way they were treated and was told by the DON that only staff could be listened to. Resident #4 stated the facility does nothing complaints you have, they are treated badly by staff. Resident #4 stated they were hurting in pain when left in the bed on the metal frame. A nurse's note, dated 07/26/23 at 9:54 p.m., read in part, .Resident came in from the smoking area outside crying, requested to talk to the nurse and complained that a resident by [Name Deleted] had told him in [their] ears that she will cut him whispering. Resident noted that [they] was going to call and informed the [family memeber withheld]. The nurse asked [Name Deleted] and she said, 'I have not spoken a word to resident today'. There was no documentation the facility had investigated and protected residents from further abuse. On 07/27/23 at 8:15 a.m., Resident #4's POA stated they had a care plan meeting with the DON, Administrator that is no longer at the facility, and social service director. The POA stated they told them all the concerns of mistreatment and they did nothing about it. The POA stated that the DON told them they could not listen to what the resident had to say, or watch the videos, and would only listen to the staff. The POA stated they were afraid someone would die from the mistreatment they complained about and nothing had been done about their concerns. On 07/27/23 at 1:27 p.m., The social service director stated they were present in the care plan meeting on 07/12/123 and confirmed the DON told the family and Resident #4 that they would only believe staff and nothing the resident had to say. She further stated the DON would not take the videos the family had and view them. The social service director stated the family complained of abuse and mistreatment and the former administrator was in there and was not sure if anything was done about the concerns. The SSD stated Resident #4's, POA, complained of the resident being left on the metal frame for a long time and that would be neglect for failing to meet Resident #4 needs. The social service director stated they never followed up to make sure the allegations were being addressed. The social service director than stated without an investigation, the resident was not being protected from neglect. On 07/27/23 at 2:12 p.m., the administrator stated stated they would need to look into the allegations from Resident #4 and the family. They stated the former administrator resigned right after the meeting without notice, but it should have been looked into and reported. The administrator then stated nothing had happened and there was no investigation. On 07/31/23 at 2:23 p.m., the DON stated they did not investigate the complaint because the bed was fixed. The DON stated the resident had refused to get up out bed. The DON stated she did not look at the videos Resident #4 family offered. The DON was asked how long the Resident remained in bed with a defective air mattress. They stated they did not know what happened from the time it was found and the note where the resident was put in their chair. The DON stated the facility should have handled this as an abuse, but nothing was done. They were asked about the minutes from the care plan meeting and the formal abuse complaint being filled. The DON stated residents are not being protected. They were asked if there was an investigation and any protection to residents from the Resident #4 complaint on 07/26/23. The DON stated there was nothing that could be found. On 07/31/23 at 2:56 p.m., RN #1 stated they worked the night Resident #4 bed mattress leaked air. They were asked how long the Resident was in bed with the malfunctioning of the mattress. They stated the Resdient was yelling and yelling and they got them up in a chair. RN #1 stated they did not know how long it took staff to get the resident up out of bed. He stated Resident #4 continued to yell even when they placed duct tape on the tube, and they made a progress note when they were up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 08/02/23 at 3:37 p.m., the Oklahoma State Department of Health (OSDH) confirmed the existence an immediate jeopardy situation existed due to the facilities failure to have a system in place to ensure staff responded to a choking resident and provide the Heimlich maneuver according to standards. Resident #9 had diagnosis to include bipolar, dysphagia, protein calorie malnutrition, anxiety, reflux, and malignant neoplasm upper lobe left bronchus lung. On 07/29/23 a certified nurse aide provided assistance during the noon meal to Resident #9 after being asked. The resident was responding verbally throughout the meal until one bite when the resident took a deep breath and made attempts to cough. The certified nurse aide turned the resident on the side did thrust to back with no success and summoned the licensed practical nurse in charge of the hall of the emergency. During the response, the nurse did not instruct, and/or perform the Heimlich to assist the resident with choking. Staff was interviewed and confirmed the resident was choking, the nurse did not respond, and provide any assistance to Resident #9 such as suctioning and/or the Heimlich Maneuver. The certified nurse aide providing the meal assistance stated the resident struggled for 12 minutes and passed away. On 08/02/23 at 3:40 p.m., the administrator and Corporate nurse were informed of the immediate jeopardy. On 08/02/23 at 9:06 p.m., an acceptable plan of care was received. The plan of removal documented, Plan of Removal # 1 for Training on how to respond to choking. 1. On August 2nd, 2023 initiated education on the signs of choking for all staff. 2. On August 2nd, 2023 initiated education on how to respond to a resident choking for all staff. 3. If staff is not available for in-service, they will not be able to return to work until education done. 4. Will in-service returning (current) agency nurse on signs of choking and how to respond to a resident choking. 5. Will in-service Human resources on including training on signs of choking and resident choking as a mandatory training during orientation. Regional team will provide the in-services to Human resources on putting a system in place for orientation and every 6 months as an ongoing training. 6. Provided staff with policy and procedures for how to respond to choking and first-aide. 7. Root cause analysis will be conducted and completed by August 3rd, 2023 8. The Regional Operations Team will be responsible for the plan of correction, and plan of removal will be completed by August 4th, 2023, at 12pm. On 08/04/23 after interviews with facility staff, and review of in-service documentation the immediacy was lifted, effective 08/04/23 at 12:00 p.m., when the last in-service was provided. The deficient practice remained at an isolated harm to the resident. Based on record review, and interview, the facility failed to ensure staff responded to a choking resident and provide the Heimlich maneuver according to standards. Resident #9 was being assisted with their noon meal on 07/29/23 when they gasped for air and were choking on their food. LPN #1 did not respond to the choking, no one performed the Heimlich maneuver, and Resident #9 died. The Resident Census and Conditions of Residents form, dated 07/26/23, documented 84 residents resided in the facility. Findings: An undated facility policy titled, Emergency Procedure-Choking, read in part, .Trained staff will assist the resident who is choking by attempting to expel the forgiven body from the airway .if the resident can not cough .abdominal thrust be performed .report other information in accordance to facility policy and professional standards . Resident #9 was admitted to the facilty with diagnosis to included bipolar, chronic kidney disease, psychotic disorder with disillusions, anxiety, and malignant neoplasm of upper lobe, left lung. LPN #1's employee file documented they were hired on 07/17/23. There was no documentation on training and/or certifications for emergencies such as choking. A nurse's progress note, dated 07/29/23 at 2:32 p.m., read in part, .This nurse was summoned to room after reports from CNA of resident not responding to staff after eating lunch. Assessed resident, no breathing, pulse, or blood pressure registered. Also, no verbal or painful response noted. Sternal rub attempted along with vital signs. Pulse ox 64%. Finger sweep attempted in search of foreign objects, nothing visible or remarkable to show. Resident did not respond verbally or to painful stimuli . A nurse's progress note, dated 07/29/23 at 6:11 p.m., read in part, .Residents body picked up .Family at bedside obtaining resident's belongings . A discharge assessment, dated 07/29/23, documented the resident had died in the facility. There was no additional documentation located in the clinical record of what happened to the resident. Their was no documentation the incident had been reported to the Oklahoma State Department of Health. An anonymous written statement, dated 07/29/23, read in part, .Today during lunch I was helping feed [Resident #9] . [Resident #9] and I were talking about getting [Resident #9] up and into .chair after lunch when [Resident #9] took a breath and started choking .I ran to get the nurse who was in the hallway .[nurse] rolled [nurse] eyes and seemed annoyed when I told [nurse] that I needed her in [Resident #9] room and it was an emergency . When the nurse came into the room I told [nurse] that I was feeding [Resident #9] when [Resident #9] started choking .nurse told me to lay [Resident #9] flat and [nurse] put a pulse ox on her finger and left the room [Resident #9] was still choking and getting any air .face started turning blue while the nurse was away .trying to calm [Resident #9] down and put [Resident #9] head back up. The nurse came back into the room for about a minute then went out to tell the front desk to call the ambulance .The nurse wanted [Resident #9] lying flat on [Resident #9] back Three aids came into the room to assist .two more aids told the nurse [Resident #9] was choking .[Resident #9] turned completely blue and food started coming out of her nose .it was too late .[Resident #9] was fully alert the whole time [Resident #9] as choking and knew what was happening .The nurse moved slowly and with no urgency .was told several times that [Resident #9] was choking .[Resident #9] died a slow painful and panicked death . A written statement from CNA #10, dated 07/29/23, read in part, .saw the nurse coming out of [Resident #9] room stating that she was unresponsive and to call 911 .follow her back into the room .the nurse put a pulse ox on her finger and lays her flat .[CNA #6] is telling her .she is choking I say I think she is choking .I leave the room [ROOM NUMBER] to 3 mins later the nurse comes out to find who the hospice is and ask the other nurse to cancel EMT . A written statement from LPN #1, dated 07/29/23, read in part, .At approximately 1220 [12:20 p.m.] I was summoned to [Resident #9] room (201) by CNA's for an emergency. I got into her room and attempted to get her attention she did not reply to verbal stimula. I was told she had gotten choked on her lunch. Her appearance was discolored .performed a sternal rub .attempted a finger sweep down her throat On 08/02/23 at 10:10 a.m., CNA #8 stated they were the lead nurse aide and assisted with staffing. The CNA stated LPN #1 no longer was employed at the facility and they could not tell why they were no longer employed. On 08/02/23 at 10:29 a.m., same time as above CNA #6 stated they were agency staff that worked on 07/29/23 and had assisted Resident #9 with their noon meal. CNA #6 stated Resident #9 usually did not need asssistance with their meal, but they had asked because they had a lot of pain in their arms and hands. CNA #6 stated the resident was talking throughout the meal about getting up in their wheelchair after the meal to go out to the common area. I gave her a bite of mashed potatoes and gravy and Resident #9 took a deep breath and was trying to cough. The CNA stated they made sure Resident #9's head was up and placed the resident on their side after she could not say anything and Resident #9 face was turning red. CNA #6 stated the resident lipped for her to get the nurse and immediately told LPN #1 what was going on. The aide stated LPN #1 was slow to come to the room and placed a pulse ox on, lowered the bed, and left the room. CNA #6 stated there were other aides in the room after the incident started. The CNA identified CNA #7, CNA #9, and CNA #4 as being in the room after the resident started to choke. CNA #6 stated CNA #7 and the other aides raised the head of bed so the Resident was not flat and food started coming out the mouth and noise as well as flem. CNA #6 stated Resident #9 died a very painful death and was conscious looking at us with her eyes. The CNA stated the resident had a scared look on her face and LPN #1 did not do anything. The aide stated they thought when the nurse was in the room they would have provided guidance and assisted the resident with the choking. CNA #6 stated they were in shock and wished they had done more, but really thought the nurse would do the right thing once in the room. CNA #6 stated Resident #9 was trying to get something up and when Resident took a deep breath you could see Resident #6 was terrified by the look on their face. On 08/02/23 at 11:03 a.m., CNA #7 stated they were an agency aide working at the facility on 07/29/23 on the 7:00 a.m. through 3:00 p.m. shift. CNA #7 stated they went into Resident #9's room and saw the nurse in there taking her pulse and the Resident was lying flat. The CNA stated they and the other aides raised the head of the bed up and he tapped the back of the resident. CNA #7 stated once the head of bed was up and Resident #9 was not lying flat, food come of the nose and mouth. CNA #7 stated they did not nor did anyone perform the Heimlich or provide suctioning. CNA #7 stated the resident's eyes were open, they were in distress, and it appeared they were choking. CNA #7 stated the nurse left the room and Resident #9 passed away. CNA #7 stated he was provided the option of writing a statement on what happened, but they choose not to because they came in the room after the even started. On 08/02/23 at 11:21 a.m., the MDS Coordinator #1, stated they were management on duty the day the incident occurred. They stated Resident #9 had passed away and they were not actively dying even though they were on hospice services. The MDS coordinator stated Resident #9 was a DNR, but that did not apply to someone that was choking. The MDS Coordinator stated they asked LPN #1 if they had performed the Heimlich to Resident #9. The MDS Coordinator stated LPN #1 stated Resident #9 was choking and the only tried a finger sweep, toook vital signs and the resident was gone. They stated LPN #1 told them she did not perform the Heimlich on the Resident. The MDS Coordinator then stated she informed LPN #1 they should have known to perform the Heimlich even though Resident #9 was a DNR. The MDS Coordinator #1 then stated the aides felt as though the nurse did not respond to the resident in distress and only took the vital signs and left the room and were asked to write a statement of what happened. On 08/02/23 at 11:40 a.m., the Hospice RN, stated they received a call from the facility at 12:27 p.m., that Resident #9 was unresponsive. The nurse than stated she was never told Resident #9 had choked. They stated they had received a call from medical examiner asking questions around the choking, but knew nothing about Resident #9 choking. The Hospice RN stated if Resident #9 was choking, they should get help to see if the airway can be cleared. On 08/02/23 attempts were made to reach LPN #1 for an interview and no calls were returned. On 08/02/23 at 3:40 p.m., the Corporate RN stated they asked CNA #6 if the resident grabbed her throat and they said no and the resident was not choking since that was a universal sign. On 08/04/23 at 11:31 a.m., CNA #9 stated they were agency staff working at the facility on 07/29/23, when they entered the room of Resident #9 and the resident was in distress. They stated CNA #6, #7 and themselves raised the head of bed because the resident was lying flat and they were choking and the nurse kept requesting they keep the resident lying flat. The CNA stated they tried to get a blood pressure and the blood pressure cuff read error. The CNA stated the nurse had left the room when she was trying to take the blood pressure. CNA #9 stated once the resident head of bed was up the resident had food coming from their mouth and nose. CNA #9 stated no one in the room preformed the Heimlich and she did not see the nurse do anything except leave the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 07//27/23 at 11:45 a.m., the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy situation existed due to the facilities failure to have a system in place to ensure residents were not missing from the facility and had procedures in place to account for all residents during the shift. Resident #2 had diagnoses which included Schizophrenia, Chronic Obstructive Pulmonary Disease, Senile Degeneration of brain, major depression, and anxiety. The Residents cognition was moderately impaired and they wandered the facilty. The resident had an elopement risk assessment completed on 07/02/23 and the Resdient was at risk for elopement. The care plan did not address wandering or elopement risk for Resident #2. Resident #2 was interviewed and stated they had left the facility by going over the fence because the fire department told them. Resident #2 stated they had walked a long and did not remember who brought them back to the facility. Video surveillance was observed with the maintance supervisor and Resident #2 was last seen on the camera in any part of the facility and/or property at 3:46 p.m. on 07/20/23. On 07/21/23 Resident #2 was found approximately 15 miles from the facility at a hospital and was returned to the facility. The resident was found to have blisters on their feet. Interviews with the staff working on 07/21/23 when the resident eloped were conducted and they had no knowledge the resident was gone from the facility. The staff also stated they knew the resident was at risk for elopement from his history at another facility of leaving the facility. On 07/27/23 at 12:00 p.m., the administrator and Corporate nurse were informed of the immediate jeopardy. On 07/27/23 at 3:40 p.m., an acceptable plan of care was received. The plan of removal documented, Plan of Removal for Cross Timbers Senior Mental Health July 27, 2023 Oklahoma State department of health, we are saddened by the allegation of failure to have a proper system in place to protect residents from an elopement. 1. On July 27, 2023 identified all residents who are at an elopement risk in Cross Timbers nursing and rehabilitation. 2. in-serviced all staff on who is an elopement risk at Cross Timbers Nursing and rehabilitation services. 3. Will place a binder with resident's name and face sheet identifying an elopement risk at nurse's station. 4. Will Inservice all staff on protocol for elopement drill for the safety of the residents and update care plans. 5. Current agency staff will be in serviced on #1 and #3 prior to returning to work shift. 6. Residents who are out in the smoking area will have line of sight during smoke breaks 7. Root cause analysis will be conducted and completed today 7/27/2023. Plan of removal done by 6pm 7.27.23 8. Regional managers will be responsible for the POC. 07/31/23 after interviews with facility staff, review of wandering assessments for all residents, care plans for moderate to high risk residents, and in-services the immediacy was lifted effective 07/31/23 at 5:00 p.m., when the last in-service was provided. The deficient practice remained at an isolated harm to the resident. Based on observation, record review, and interview, the facility failed to have a system in place to account for residents that wandered and at risk for elopement for one (#2) of three sampled residents who were at risk for elopement and wandered the facility. Resident #2 left the faciity on [DATE] at approximately 3:46 p.m., and was gone for over seven hours without staff knowing he was missing. Resident #2 returned to the facility on [DATE] at 12:40 p.m., and was found to have blisters on his feet. The MDS Coordinator identified 72 residents that were at risk for elopement and wandered the facility. Findings: Resident #2 was admitted to the facility on [DATE] with diagnosis of Schizophrenia, Chronic Obstructive Pulmonary Disease, Senile Degeneration of brain, major depression, and anxiety. An elopement risk assessment, dated 07/03/23 documented Resident #2 was at risk for elopement. A review of the clinical record contained no documentation the facility had completed a base-line care plan on admission to address the elopement risk of Resident #2. An admission assessment, dated 07/11/23, documented Resident #2 wandered the facility and was moderately impaired with their cognition. A review of the comprehensive admission care plan, dated 07/06/23, read in part, I have forgetfulness and poor memory. I have trouble making decisions and remembering to do daily care needs. I need verbal direction and reminders and supervision of staff . The care plan did not address Resident #2's wandering and risk for elopement. A police report, dated 07/20/23, read in part, .description missing person .incident status active synopsis .Resident with severe dementia left facility. Entered NCIC and Silver Alert issued .On 7/20/2023 at approximately 2329 hours [11:29 p.m.] , I responded to the area of [Facility] in reference to a missing person. The RP, [LPN #2], told me that a residence, [Resident #2], had possibly left the facility and could not be found . [Resident #2] is a [AGE] year old white male who was last seen wearing a white shirt, black sweat pants and red tennis shoes. He was also wearing a ball cap that was possibly blue in color and adorning a full beard .[LPN #2] explained to me that [Resident #2] has severe dementia and has been in a nursing facility for the last fourteen years .almost non verbal and mumbles lowly .gets extremely confused said [Resident #2] has done this in the past at prior facilities and left the grounds . 07/21/2023 .I watched the surveillance footage with [mainteance supervisor] I saw [Resident 32] go to the smoking area atb1537 [3:37 p.m.] hours and not return While I was at the nursing home other officers were canvassing the area in vehicles and with a drone. Once I finished at the nursing home I started to canvass the area. I stopped by 1300 Buena Vista Ave and spoke to the resident .residence is just north of the nursing home. I told her why I was speaking with her and she asked me for a description of [Resident #2] [Name deleted] told me she saw a man matching [Resident #2] description climb over the north fence. She told me this was yesterday (07/20/2023), sometime in the afternoon. I asked .if it could have been around 1530 to 1600 hours. [Name deleted] stated yes . Zt approx 1152 hours [Resident #2] was located by Oklahoma City Police Dept, at [Name deleted] .on S [NAME] Ave . A nurse's note, dated 07/21/023 at 1:21 a.m., read in part . This nurse was informed by on coming aide that [Resident #2] in his bed. At that time all staff began searching the building and surrounding property. After 20 minutes of searching [Name deleted] police notified. Contacted CMA [CMA #1] who stated she had last seen resident on smoke porch around 2200. Staff continued searching supervisors where notified and police searched building. Contacted residents previous facility who said resident was typically found on main roads and at gas stations. This information was relayed to police. A nurse's progress note, dated 07/21/23 at 12:45 p.m., read in part, .Resident came back to the facility at 1245 ambulating accompanied with one staff .Skin assessment done, resident had little blisters on feet, shoes removed and non-skid socks given to resident to put on .Resident put on 1:1 observation . On 07/26/23 at 3:30 p.m., Resident #2 was observed in the smoke area with five other residents with no staff present in the smoke area with them. Resident #2 was out in the smoke area until 3:50 p.m. went back inside and wandered the facility and into the dining room. No staff was observed present in the dining room or within eye sight of the resident while inside the facility. On 07/26/23 from 5:30 p.m. through 6:20 p.m., Resident #2 was observed wandering through out the facility unsupervised going back and forth from room to dining room and out into the smoke area. On 07/26/23 at 4:45 p.m., CNA #1 stated they worked on hall 200 on the 3:00 p.m. through 11:00 p.m. shift. She stated hall 200 had no resident that were at risk for elopement, but Resident #2 had jumped the fence and escaped and was placed on one on one for a short time. CNA #1 confirmed the worked on the on the 3:00 p.m. through 11:00 p.m. shift on 07/20/23 and did not know of anyone having left the facility. They stated residents are to be checked on every two hours and independent residents, like Resident #2 only when the call light comes on. CNA #1 stated Resident #2 was not in his bed or room each time they checked on him, but he would normally go outside to smoke. CNA #1 stated they did not look for the Resident because he was normally in bed or outside in the smoke area. CNA #1 than stated they do not remember seeing Resident #2 and they did not know when they had escaped over the fence. CNA #1 stated they still do not check on the Resdient unless they used the call light. On 07/26/23 at 5:03 p.m., CNA #2 stated they worked on hall 200 on the 3:00 p.m. through 11:00 p.m. shift and worked a double shift on hall 200 on 07/20/23. When asked to identify any resident on hall 200 that was at risk for elopement, CNA #2 no one on the hall was at risk for elopement. CNA #2 stated they did not see the resident at all on the 3:00 p.m. through 11:00 p.m. shift when they checked the room. They stated they will check every resident every two hours and if not in the room they do not look for them because residents move around so much. CNA #2 than stated she did not find out the resident was missing until the next day when they came in for their shift. On 07/26/23 at 5:16 p.m., CNA #3 they worked 07/20/23 on the 3:00 p.m. through 11:00 p.m. shift. She stated all residents were at risk for elopement because they all walk around the facility. CNA #3 was asked to identify any resident that had left the building on 07/20/23, they stated no one left the building on that night. On 07/26/23 at 5:23 p.m., CNA #4 stated they were not aware of anyone leaving the facility on the evening of 07/20/23. They stated they did work that and worked on hall 200. CNA #4 stated they had worked with Resident #2 as an agency staff and they were a high risk for elopement got away from the other facilities. CNA #4 stated they did not see Resident #2 on the 3:00 p.m. through 11:00 p.m. shift on 07/20/23 and the last time they saw them was in the morning because they worked a double shift. CNA #4 stated they checked on residents every two hours and did not find out until the next day Resident #2 had been missing. On 07/26/23 at 6:00 p.m., RN #1 stated they had worked her for five months. The RN stated they worked on the on the 3:00 p.m. through 11:00 p.m. on 07/20/23 and no one left the facility grounds on that night. They were asked about Resident #2 and their elopement risk and if they have ever left the facility grounds. RN #1 stated they knew nothing about Resident #2 and their elopement risk. On 07/26/23 at 6:10 p.m., CMA #2 stated they were working on the 3:00 p.m. through 11:00 p.m., on 07/20/23. They were asked to identify any resident on hall 200 at risk for elopement. The CMA #2 stated there was a new resident on the hall that wanders all the time and was always by the nurses station and to the smoke area. She was not able to identify the resident and identify Resident #2 at risk for elopement. They were asked to identify any resident who had eloped from the facility on the evening shift of 07/20/23, they stated no one had eloped from the facility that night. The CMA than stated there are a lot of agency staff working on hall 200 and they do not know the residents like staff who work at the facility full time. On 07/27/23 at 9:13 a.m., LPN #1, stated they have worked at the facility for one week and worked on the 3:00 p.m. through 11:00 p.m. on 07/20/23 on the hall Resident #2 resided on. LPN #1 stated Resident #2 did not leave the facility grounds on 07/20/23. The LPN was asked to identify residents that were at risk for elopement and they could not identify any resident including Resident #2 as an elopement risk. The LPN stated on 07/20/23, they did not know any of the residents let a long who would be an elopement risk. LPN #1 stated the night started out hectic because someone had to be sent to the hospital and stated Resident #2 was not one on one and they did not know of them being one on one at any time. On 07/27/23 at 9:39 a.m., CNA #5 was asked where Resident #2 was. The CNA stated they did not know but was out in the smoke area the last time they saw them. On 07/27/3 at 9:40 a.m. Resident #2 was observed in the smoke other residents and no staff were around or in the the line of site of them. On 07/27/23 at 9:50 a.m., the coordinator states someone brought Resident #2 back to the facility the next day and they did not know the exact time. The staffing coordinator stated they did not know when the resident left but they had left and was gone until the next day. They stated they were called in to help look for the resident once staff realized they were missing. On 07/27/23 at 9:57 a.m., MDS Coordinator #1 reviewed the care plan and stated the care plan did not address Resident #2 being at risk for elopement as the facility identified on admission. On 07/27/23 at 10:04 a.m., the administrator stated the resident returned to the facilty the next day in the afternoon. They further stated the Resdient was found several miles from the facility. The administrator stated they did not watch the surveillance video but the police and the maintenance supervisor looked at them. They than stated the medication aide did five the 9:00 p.m. medications to the resident. On 07/27/23 at 10:08 a.m., the BOM stated the police notified the facility the resident was found several miles a way at a hospital. The BOM stated she took the call informing them he had been found and the agency nurse had already picked Resident #2 up and brought him back to the facility. 07/27/2023 from 10:33 a.m. through 11:15 a.m., video surveillance camera footage was observed with maintenance supervisor was observed for the hours of 2:000 p.m. through 12:00 a m., The maintance supervisor stated the video footage was watched and provided to the police department and the last time he had been seen in the facility was around 3:37 p.m. On 07/20/23 the resident was observed in the halls of the facility until 3:467 p.m., when he exited hall 100 to the smoke area. From 3:47 p.m. through 11:30 p.m., the resident was not observed in the halls, or dining room. On 07/31/2023 at 3:23 p.m., LPN #2 stated they were an agency nurse that worked at the facility on 07/20/23 on the 3:00 p.m. to 11:00 p.m. shift. They stated CMA #1 came to here and asked where Resident #2 was located and never came back so I thought they found the resident to give them medications. The LPN stated all the aides had left for the night when someone said Resident #2 was not in his room. LPN #2 stated their was a chair against the fence and the police were called. LPN #2 stated the Resdient was located approximately 15 miles from the facility. LPN #2 stated they did not realize the Resident #2 was missing the night before because they always would ask for cigarettes and they are kept on the cart. LPN #2 stated they knew the resident from another facility and he was a high risk for elopement and was able to get away from the facility more than once. The LPN stated when they took Resident #2 shoes and socks off his feet were red and they had blisters on his toes. When asked about the surveillance camera inside the facility and the resident not being observed on the camera since 3:46 p.m., LPN #2 stated it was hard to believe that she did not notice the resident was gone and that there was another nurse on the hall that was being trained also.

On 08/02/23 at 3:37 p.m., the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy situation existed due to the facilities failure to have a system in place to ensure staff were trained on and responded to a choking resident. Resident #9 had diagnosis to include bipolar, dysphagia, protein calorie malnutrition, anxiety, reflux, and malignant neoplasm upper lobe left bronchus lung. On 07/29/23 a certified nurse aide provided assistance during the noon meal to Resident #9 after being asked. The resident was responding verbally throughout the meal until one bite when the resident took a deep breath and made attempts to cough. The certified nurse aide turned the resident on the side, did thrust to back with no success, and summoned the licensed practical nurse in charge of the hall of the emergency. During the response, the nurse did not instruct and/or perform the Heimlich to assist the resident with choking. Staff was interviewed and confirmed the resident was choking, the nurse did not respond, and provide any assistance to Resident #9 such as suctioning and/or the Heimlich Maneuver. The Certified nurse aide providing the meal assistance stated the resident struggled for 12 minutes and passed away. They also confirmed no one performed the Heimlich. Facility confirmed there was no system in place for agency staff and facility staff to ensure they were trained and had the skills necessary to respond to a resident that was choking. A review of the LPN employee file contained no documentation they had current certification and training in CPR to include the Heimlich maneuver. The corporate nurse, stated they do not have anything that shows the nurse was certified and/or trained for the Heimlich. On 08/02/23 at 3:40 p.m., the administrator and Corporate nurse were informed of the immediate jeopardy. On 08/02/23 at 9:06 p.m., an acceptable plan of care was received. The plan of removal documented, Plan of Removal # 2 for Training and competency in CPR 1. On August 2nd, initiated education and instruction on first aide and choking for all staff inclusive of agency staff ( current returning). 2. To ensure all staff are inserviced, staff cannot work until they have been in-serviced. 3. Will have a post test for Heimlich maneuver and return demonstration. 4. Root cause analysis will be conducted and completed by 8.3.23. 5. Will inservice Human resources and provide a check off list of in-services needed to new hires prior to starting in their department. Will begin on 8.3.23 and complete by 5pm on August 3rd, 2023. 6. Regional Operations team will be responsible for Plan of correction, and plan of removal will be done and completed by August 4th, 23 @ 12pm. On 08/04/23 after interviews with facility staff, and review of in-service documentation the immediacy was lifted, effective 08/04/23 at 12:00 p.m., when the last in-service was provided. The deficient practice remained at an isolated harm to the resident. Based on record review and interview, the facility failed to have a system in place to ensure staff were trained on and responded to a choking resident. Resident #9 was being assisted with her noon meal on 07/29/23 when they gasped for air and was choking on their food. LPN #1 did not respond to the choking and no one performed the Heimlich maneuver and Resident #9 died. The Resident Census and Conditions of Residents form, dated 07/26/23, documented 84 residents resided in the facility. Findings: Resident #9 was admitted to the facilty with diagnosis to include bipolar, chronic kidney disease, psychotic disorder with disillusions, anxiety, and malignant neoplasm of upper lobe, left lung. LPN #1's employee file documented they were hired on 07/17/23. There was no documentation of training and/or certifications for emergencies such as CPR and choking. A nurse's progress note, dated 07/29/23 at 2:32 p.m., read in part, .This nurse was summoned to room after reports from CNA of resident not responding to staff after eating lunch. Assessed resident, no breathing, pulse, or blood pressure registered. Also, no verbal or painful response noted. Sternal rub attempted along with vital signs. Pulse ox 64%. Finger sweep attempted in search of foreign objects, nothing visible or remarkable to show. Resident did not respond verbally or to painful stimuli . A nurse's progress note, dated 07/29/23 at 6:11 p.m., read in part, .Residents body picked up .Family at bedside obtaining resident's belongings . On 08/02/23 at 10:10 a.m., CNA #8 stated they were the lead nurse aide and assisted with staffing. The CNA stated LPN #1 was no longer was employed at the facility and they could not tell why they were no longer employed. On 08/02/23 at 10:10 a.m., CNA #6 stated they were agency staff that worked on 07/29/23 and was the one assisting Resident #9 with their noon meal. CNA #6 stated the resident was talking throughout the meal about getting up in their wheelchair after the meal to go out to the common area. They stated they gave Resident #9 a bite of mashed potatoes and gravy and Resident #9 took a deep breath and was trying to cough. The CNA stated they made sure Resident #9's head was up and placed the resident on their side after she could not say anything and Resident #9 face was turning red. CNA #6 stated the resident lipped for her to get the nurse and immediately told LPN #1 what was going on. The aide stated LPN #1 was slow to come to the room and placed a pulse ox on, lowered the bed, and left the room. CNA #6 stated there were other aides in the room after the incident started. The CNA identified CNA #7, CNA #9, and CNA #4 as being in the room after the resident started to choke. CNA #6 stated CNA #7 and the other aides raised the had of bed so the Resident was not flat and food started coming out the mouth and noise as well as flem. CNA #6 stated Resident #9 died in a very painful death and was conscious looking at us with her eyes. The CNA stated the resident had a scared look on her face and LPN #1 did not do anything. The aide stated they thought when the nurse was in the room they would have provided guidance and assisted the resident with the choking. CNA #6 stated they were in shock and wished they had done more but really thought the nurse would do the right thing once in the room. CNA #6 stated Resident #9 was trying to get something up and when Resident took a deep breath you could see Resident #6 was terrified by the look on their face. On 08/02/23 at 11:03 a.m., CNA #7 stated they were an agency aide working at the facility on 07/29/23 on the 7:00 a.m. through 3:00 p.m. shift. CNA #7 stated they went into Resident #9 room and saw the nurse in there taking her pulse and the Resident was lying flat. The CNA stated they and the other aides raised the head of the bed up and he tapped the back of the resident. CNA #7 stated once the head of bed was up and Resident #9 was not lying flat food come of the nose and mouth. CNA #7 stated they did not nor did anyone perform the Heimlich or provide suctioning. CNA #7 stated the residents eyes were open and they were in distress and it appeared they were choking. CNA #7 stated the nurse left the room and Resident #9 passed away. On 08/02/23 at 1:37 p.m., the BOM stated they complete orientation for new hires and set them up to get trained. The BOM stated she will complete the orientation of the new employee on standard practices that are basic and nursing would be responsible for training them on nursing procedures. The BOM office manager stated they do not provide any orientation or training to agency staff and the staffing coordinator would be responsible for making sure they are trained and oriented to the facility. They stated the DON would be responsible to make sure all direct staff are trained on emergency procedures such a resident that was choking. On 08/02/23 at 1:45 p.m., CNA #8 stated they were the lead certified nurse aide and help with scheduling and getting agency staff when needed. They were asked how they ensured agency staff were proficient in skills such as assistant residents when they were choking. CNA #8 stated they go room to room and talk about the residents but do not make sure they are proficient in any skills and did no formal training or check of skills. On 08/02/23 at 1:51 p.m., the MDS Coordinator #1 stated the facility will do orientation and go over procedures only and the CPR and procedures for choking are expected all nurses are to have current training on the standards of practice. They stated there should be a process in place to make sure agency staff have the training and skills necessary to perform their duties, but was not sure if the facility was doing that. On 08/02/23 at 2:05 p.m., the Corporate RN stated there were competency check off for full time staff and would check for them. The Corporate RN then stated the agency staff would send their competency checks off when they come in, and she would provide them. She stated the nurse's should have current CPR certifications and we would have them in the employee file. A request was made for the training and certifications for LPN #1 and competency skills for CNA #6, CNA #7, and CNA #9. On 08/02/2023 at 3:38 pm., the Corporate RN stated they did not have any certification in the employee file for LPN #1 and there was nothing to show the training and competency of the agency aide, CNA #6, CNA #7, CNA #9. On 08/02/23 at 3:40 p.m., the Corporate RN stated they asked CNA #6 if the resident grabbed her throat and they said no and the resident was not choking since that was a universal sign. She than stated they called the Hospice nurse who said the resident may have choked. On 08/04/23 at 11:31 a.m., CNA #9 stated they were agency staff working at the facility on 07/29/23, when they entered the room of Resident #9 and the resident was in distress. They stated CNA #6, #7, and themselves raised the head of bed because the resident was lying flat and they were choking and the nurse kept requesting they keep the resident lying flat. The CNA stated they tried to get a blood pressure and the blood pressure cuff read error. The CNA stated the nurse had left the room when she was trying to take the blood pressure. CNA #9 stated once the resident head of bed was up the resident had food coming from their mouth and nose. CNA #9 stated no one in the room preformed the Heimlich and she did not see the nurse do anything except leave the room.

On 03/07/23, an IJ situation was determined to exist due to the facility failing to ensure: a. Resident #2 was not exploited by being asked to partake in illegal drug activity, and b. Resident #8 was not exploited by being given $15 to purchase illegal drugs from Resident #1. Resident #2 stated they were threatened with a 30 day eviction notice if they did not participate. Resident #8 stated the Administrator told them they would get kicked out of the facility if they did not participate. On 03/07/23 at 3:57 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 03/07/23 at 4:06 p.m., the administrator was notified of the IJ situation. On 03/08/23 at 3:49 p.m., an acceptable plan of removal was provided. The plan of removal documented: Plan of removal for CrossTimbers Senior Mental Health March 7, 2023 Oklahoma State department of health, we are saddened by the allegation of exploitation of our residents by our administrator. We take all allegations of abuse, neglect, and exploitation seriously our plan to remove the Immediate Jeopardy based on new information and findings by the state surveyor today we have: 1. On March 7, 2023 suspended administrator pending investigation. 2. Regional operations manager will conduct onsite investigation on allegation of exploitation March 8, 2023. 3. Investigation will include speaking with all parties involved: family, residents, APS, surveyors, and administrator. 4. On March 7th, nursing team-initiated in-services for all staff on abuse, neglect, and exploitation Human Resources and designee will complete in-services Completion date of in-services March 8, 2023. 5. Will conduct safe surveys of all residents. Completion date March 8, 2023, guided by regional operations manager. 6. Root cause analysis will be conducted and completed by March 8, 2023 7. Regional operations manager will be responsible for POC. 8. Completion date 3/8/2023 at 8pm. On 03/09/23, interviews were conducted with staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. The staff stated they had been in-serviced and were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. On 03/09/23 at 12:15 p.m., the IJ was removed when all components of the plan of removal had been completed. This was effective as of 03/09/23 at 11:01 a.m. The deficiency remained at a level of potential harm at a pattern. Based on record review and interview, the facility failed to ensure residents weren't exploited for two (#2 and #8) of three sampled residents reviewed for abuse. The Resident Census and Conditions of Residents report, dated 03/06/23, documented 91 residents resided in the facility. Findings: A 2022 Abuse, Neglect and Exploitation policy, read in part, .'Exploitation' means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion .The facility will develop and implement written policies and procedures that .Prohibit and prevent abuse, neglect, and exploitation of residents . 1. Resident #8 had diagnoses which include bipolar disorder. A Resident Grievance form, dated 02/27/23, read in part, .Resident #1 states Resident #8 was in Resident #1's room and Resident #8 asked Resident #1 to buy weed for Resident #8. Resident #8 gave Resident #1 $10 for it. Resident #1's roommate noticed the administrator was standing outside the door when this happened .Resident #8 stated to Resident #1 that Resident #8 was given money by the administrator to buy weed. Resident #8 was caught with weed and was trying to get out of it by helping locate others with weed . On 03/06/23 at 8:35 a.m., Resident #1 stated the Administrator sent a resident with $10 dollars to buy weed from them. Resident #1 stated, I don't even sell weed. On 03/07/23 at 11:40 a.m., the DON was asked how the grievance, dated 02/27/23, had been resolved. She stated, I think we are still working on that because it became an APS issue. She stated they were trying to figure out who was bringing drugs into the building. The DON stated part of the investigation was Resident #8 was to take money to Resident #1 to see if Resident #1 would sell them drugs. On 03/07/23 at 12:03 p.m., the Administrator was asked to explain the grievance made by Resident #1. She stated they were in the process of investigating how drugs were getting in the building. She stated she had given Resident #8 $15 dollars of her own money to see if Resident #1 would sell them weed. The Administrator stated she followed Resident #8 to Resident #1's room and tried to listen to the interaction outside the door. On 03/07/23 at 2:38 p.m., Resident #8 was asked if staff had ever asked them to help set up another resident related to drugs. Resident #8 stated, Yes. Resident #8 stated the Administrator gave them $15 dollars to try to buy weed from Resident #1 about two weeks ago. Resident #8 stated Resident #1 was giving them a hard time now and everyone was calling them a snitch. On 03/07/23 at 3:00 p.m., Resident #8 was asked how they felt being called a snitch. They stated, It is what it is. Resident #8 stated, She told me if I didn't do that, I'd get kicked out. Resident #8 stated, She basically bullied me to do it. Resident #8 stated, I felt like it was my only option. 2. Resident #2 had diagnoses which included quadriplegia, major depressive disorder, anxiety disorder, and post traumatic brain injury. A Quarterly Resident Assessment, dated 12/09/22, documented Resident #2 had moderate cognitive impairment, no behaviors, required total dependence of two-person physical assist for the task of bed mobility, transfer, dressing, toilet use, and bathing. It documented the resident required extensive assistance two-person physical assist for the task of locomotion on unit, locomotion off unit, and personal hygiene. It documented the resident had range of motion impairment on both sides in the upper and lower extremities. A Resident Education form, dated 01/17/23, documented Resident #2 was at risk of a 30-day notice due to smoking inside the facility. A State Reportable incident for Resident #2, incident date 02/17/23, documented a combined initial and final investigation on allegations of abuse/mistreatment and allegations of neglect was sent to OSDH on 02/22/23. Part B documented on 02/22/23, a State Agency worker reported to the Administrator the resident or resident representative made a complaint stating they were given an inappropriate 30-day notice. It documented the resident was asked to set up staff and residents to get them to smoke so they could get fired or kicked out of the facility. The State reportable documented a resident tried to coerce them into smoking weed. It documented the Administrator stated they would try to make it go away. The incident report read in parts, .If [Resident #2] did a sting operation. [They] has [sic] been threatened with a 30 day notice .when everyone else was given a warning .Investigation initiated immediately. Administrator suspended pending investigation . There was no documentation 30 day notices had been given to Resident #2. A final State Reportable to the 02/17/23 incident, documented the facility completed an initial investigation by interviewing the resident and other residents in the area. A safe survey was completed with 10 residents along with staff abuse questionnaire with 13 staff members. Physician, Local Law Enforcement, and Family were notified. The Administrator was suspended pending the investigation. It documented upon completion of the investigation; the facility was unable to substantiate the allegation of abuse. It documented interviews and focused assessments with yielded no clear signs for the substantiation of the allegation. The facility educated all staff on the signs and symptoms of abuse, policies and procedures for reporting allegations of abuse, neglect, and misappropriation. An updated policy and procedure on illegal drug use in the facility was completed. The resident and staff questionnaires, completed for the abuse allegation, did not document residents or staff were asked about threats of 30-day notices. The questionnaires did not document residents or staff were asked if anyone had ever asked them to set up residents or staff members to get them to smoke so they could get fired or kicked out of the facility. There was no documentation of a completed investigation related to the Administrator's involvement in the above abuse allegation provided to the survey team. A Police Call Sheet report, dated 02/22/23, documented the Administrator believed seven residents were smoking marijuana at the facility. It documented staff was unable to find any marijuana in the rooms at this time. On 03/01/23 at 2:34 p.m., Family Member #1 stated last week the Administrator had police come into the facility because she thought Resident #2 was the THC supplier. Family Member #1 stated Resident #2 was not physically capable of putting anything in their own mouth. They stated the Administrator searched the resident's room and bag without the Resident's permission. They stated after the Administrator searched Resident #2's room without consent, the Administrator asked Resident #2 to be an informant to find out who was providing marijuana in the facility. Family member #1 stated because of the above incident, Resident #2 was afraid to leave their room. On 03/01/23 at 3:46 p.m., Resident #2 stated the Administrator and the SSD had come into their room. Resident #2 stopped mid conversation and started to get upset with facial grimacing. The resident then continued stating they came into the room and asked them to set up an employee with a sting operation a couple weeks ago. They stated they wanted them to have a kitchen employee, whose real name they did not know, come into their room which had a video camera in it, and hit some weed. They stated they had told the Administrator and the SSD that they would do it. Resident #2 stated after the conversation, Resident #2 told the kitchen employee about the above conversation. They stated since then, the staff started telling Resident #2 30-day eviction. Resident #2 stated they hadn't done anything wrong, they stated someone else had the marijuana. Resident #2 stated the Administrator and SSD said if they didn't do the sting operation, they would be kicked out of the facility. They stated the staff members kept saying it over and over every day. Resident #2 began getting upset and crying. They stated the kitchen staff member they wanted them to set up was their friend. Resident #2 stated the Administrator and SSD had asked them to get the kitchen staff member to bring Resident #2 weed and get them high. Resident #2 stated the Administrator told them to only hit the weed two times when they bought it. They stated the Administrator wanted them to set up a resident also and as a result, they would Knock off my 30-day notice. On 03/01/23 at 4:00 p.m. Resident #2 stated the Administrator kept saying 30-day notice hanging it over their head. The resident began crying again. Resident #2 stated the 30-day notice was verbal, not written. They stated the Administrator and SSD searched their room multiple times since the above event without their consent. On 03/07/23 at 1:50 p.m., the DON was asked the policy for investigating allegations of abuse. The DON stated an investigation would be completed which included interviewing residents and staff members to see if they had any concerns. The DON stated if a resident made an allegation against a staff member, the staff member would be suspended pending the investigation. The DON stated the physician and family would be notified, and the investigation would continue until a conclusion was reached. The DON was asked to explain the incident, dated 02/17/23, involving Resident #2. The DON stated they were not made aware of the abuse allegation from the State Agency worker until 02/22/23. The DON stated Resident #2 made an allegation of abuse and neglect. The DON stated Resident #2 had been in trouble with drugs multiple times and they were notified of a 30-day notice related to drugs. The DON stated the notice was given verbally by the Administrator. The DON stated the resident admitted to using drugs but refused a drug test. The DON was asked if residents or staff were interviewed regarding a 30-day notice. They stated, No. They were asked what investigation was completed for the 30-day inappropriate notice allegation. The DON stated the wording on the State Reportable came directly from the State Agency worker's report. The DON stated the facility did not investigate the 30-day notice because they were not officially given one. The DON was asked to explain Resident #2 being asked to set up staff/residents to have him smoke so they could get fired in a sting operation which was documented on the State Reportable. The DON stated the Administrator wanted to find out who was bringing in marijuana. The DON stated the Administrator and Resident #2 had a conversation if the resident would smoke with a particular person, they could identify who the person was that was bringing in the drugs. The DON stated it was just asked by the Administrator, but it was never set up. They stated the Administrator had been suspended on the 23rd and returned on the 28th due to the February Abuse allegation involving Resident #2. They were asked how the facility determined it was safe for the Administrator to return to work. The DON stated, I didn't determine that, Corporate determined that. The DON was asked to explain Part C on the combined initial and final report for Resident #2. She stated they were supposed to mark it out. They stated it was a separate incident, and the Final report was the corrected one. The DON was asked if during the investigation, were residents asked if the Administrator had asked them to purchase or use drugs. They stated, I don't believe so. They were asked how the allegation was thoroughly investigated. They stated, I don't know. The DON stated she knew the Administrator had asked specific residents, but as for if she asked other residents, We don't know. The DON was asked if they had any involvement with the setting up or asking any residents to use drugs in the facility. They stated, No. On 03/07/23 at 2:43 p.m., the Administrator was asked to explain the above State Reportable involving Resident #2. She stated, prior to the State Agency worker notifying the facility of the above abuse allegation, the facility was already investigating drugs in the facility. They stated residents were blaming each other. The Administrator stated she had come to Resident #2 because they had audio and video present in their room. They stated Resident #2's family member was present. They stated Resident #2 confessed to smoking weed. The Administrator stated they told Resident #2 they needed to find out who was bringing it in. The Administrator stated the resident stated they didn't want to be a snitch. The Administrator asked Resident #2 to act as they normally would. The Administrator was asked to explain what that meant. They stated whether it was get it [marijuana] or participate, or whatever Resident #2 normally did related to drugs in-front of the camera. The Administrator stated they were trying to catch who was bringing marijuana into the facility/selling it on camera. The Administrator stated they asked to have access to Resident #2's camera to help them catch who was bringing in drugs to the facility. The Administrator stated if Resident #2 was unwilling to tell them who was bringing in the drugs, they still had to proceed with the 30-day notice. They stated, Possible 30-day notice. The Administrator stated Resident #2 was notified they were going to get a 30-day notice via a phone call made by the Administrator to the resident's family members related to drug use. The Administrator stated the family was upset. She stated they hadn't actually issued a 30-day notice, they were just notifying the family which stage of their policy they were in. The Administrator stated she had not seen Resident #2 using drugs in the facility. The Administrator reported they believed the resident had tested positive for drugs. The Administrator was asked to provide this documentation. No documentation of the resident testing positive for drugs was provided during the survey. On 03/07/23 at 3:12 p.m., the DON informed the Administrator the survey team had the Safe Surveys which were completed with residents. They were made aware, upon review of the surveys, there was no documentation residents were asked about 30-day notices or being asked to buy drugs in the Safe Survey. They were informed the survey did not address the specific concerns on the Abuse allegation involving Resident #2.