On 08/13/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure supervision was provided to a resident who smoked and used oxygen that resulted in Resident #20 igniting themselves and received second degree burns to their face.On 08/13/25 at 5:09 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On 08/13/25 at 5:23 p.m., the administrator and the DON were notified of the IJ situation and the IJ template was provided.On 08/14/25 at 11:40 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Incident: Resident was smoking while wearing oxygen and accidentally ignited [themself], resulting in burn injuries and immediate life-threatening risk.1. Immediate Action Taken- Oxygen was removed from the resident's vicinity and turned off to eliminate fuel source. Staff responded immediately, extinguishing the fire, and activated emergency medical response, first aid was provided at the facility prior to transport. Resident transferred to the emergency department for burn evaluation/treatment.2. Identification of All Residents at Risk- Facility wide audit within 2 hours to identify all residents who use oxygen and smoke. Each identified resident immediately educated on fire risks and safe practices. Residents using oxygen prohibited from smoking without staff present; oxygen removed at least 10 feet for 10 minutes from ignition source before lighting any smoking material.3. Education- 07/17/2025: All staff and residents were in-serviced on the smoking policy, confiscating smoking materials, lighting equipment and vapes. Fire drills were carried out per CMS and NFPA regulations. Competency verified through verbalization of hazard recognition. 08/13/2025 at 6:50 p.m.: All staff educated on the importance of communications of hazard identification related to smoking and oxygen supervision. Staff is to immediately communicate if a resident is placing themselves in danger.4. Systemic Changes to Prevent Recurrence- Smoking Policy revised to mandate staff removal of oxygen and confirmation of safe distance and time frame before resident smokes. Care plan updated for all residents who smoke. Maintenance to inspect and ensure No Smoking Oxygen in Use is posted and visible in all relevant areas.If a resident is observed attempting to smoke with oxygen in place- Staff will immediately notify licensed nurse on duty- staff will 1:1 resident until licensed nurse arrives.- Licensed nurse will assess respiratory status prior to oxygen removal.- Licensed nurse will remove the oxygen tubing/tank from the resident before smoking in accordance with the facility smoking policy.- Licensed nurse will notify Administrator, Director of Nursing, or designee immediately.Any staff member who observes a resident not following the smoking policy will immediately:- Immediately notify the nurse on duty.- Remain with the resident until the nurse arrives to prevent unsafe action.- Licensed nurse will:Intervene to stop unsafe behavior and secure any smoking materialsNotify the Admin/DON or designee immediatelyDocument the incident and interventions in the resident's medical record.5. Monitoring & QASupervised smoking will continue for all residents.Any non-compliance will be clearly documented with results reported to QAPI: corrective action taken immediately if deviation noted.6. Completion Date for Immediate Jeopardy RemovalAll immediate corrective actions completed by 08/14/25 at 2:00 p.m.The IJ was lifted, effective 08/14/25 at 2:00 p.m., when all components of the plan of removal had been completed. Multiple staff on different shifts were interviewed regarding the in-service they received; and audits were reviewed. In-services and fire drills were reviewed. The revised smoking policy was reviewed. Care plans were reviewed, and no smoking signs were observed in designated areas. The deficiency remained at an isolated level with the potential for more than minimal harm.Based on record review and interview, the facility failed to ensure supervision was provided to a resident who smoked and used oxygen for 1 (#20) of 4 sampled residents reviewed for accidents.The administrator identified 53 residents resided in the facility, 6 residents smoked and wore oxygen frequently/routinely, and 14 residents smoked and had as needed orders for oxygen.Findings:An undated Smoking and Oxygen Use Policy-Long-Term Care Facility, read in part, Residents have the right to smoke if medically cleared; however, safety must be prioritized when oxygen therapy is involved. The facility may limit or revoke smoking privileges for residents who are noncompliant with safety protocols . Residents must be removed from oxygen for at least 10 minutes before smoking. Smoking is only permitted in the designated outdoor smoking areas under staff supervision. Oxygen equipment must be stored away from the smoking area. Staff must verify that the resident has complied with the disconnection time before allowing smoking.An undated order summary showed Resident #20 had diagnoses which include hypoxemia, congestive heart failure, and chronic obstructive pulmonary disease.An evaluation Smoking and Safety, dated 12/14/24, showed Resident #20 had balance problems while sitting or standing. The evaluation did not have any clinical suggestions marked.A physician's order, dated 12/16/24, showed oxygen at 4 liters per minute via nasal cannula three times a day.A care plan, initiated 02/14/25, showed Resident #20 required supervision while smoking and to ensure residents' oxygen was removed and turned off before smoking.A care plan, revised, 05/18/25, showed Resident #20 smoked independently and required supervision while smoking.A care plan, initiated, 07/17/25 and revised on 07/21/25, showed Resident #20 was noncompliant with smoking while oxygen in use, with goal for resident to be free from complications related to noncompliance. The care plan showed only one intervention of the resident placed on 1:1 related to smoking with the use of oxygen, educate resident on importance of not smoking while oxygen in use related to safety. An Initial INCIDENT REPORT FORM, dated 07/17/25, showed serious harm. The report showed the resident went to the front of the building and told the receptionist they were going outside for fresh air. The report showed once resident was outside, they lit a cigarette while they were wearing their oxygen cannula. The report showed the oxygen caught on fire and they were sent to the emergency room for evaluation and treatment.A behavior note, dated 07/17/25 at 12:52 p.m., read in part, Resident observed preparing to go outside to smoke with nasal canula in place. Informed resident of the risk associated with smoking while using oxygen, including fire hazard. Resident was advised not to smoke while on oxygen therapy. Will continue to reinforce safety precautions. Supervisor notified.A facility incident report, dated 07/17/25 at 2:45 p.m., read in part, Resident [#28] came wheeling to the nurses station fast, stated [Resident #20] set [themselves] on fire. [They] were smoking cigarette with [Their] oxygen on. Went to front door found [Resident #20] sitting in wheel chair. Face burn along nose and lips, and neck area. Awake and alert, non-compliant, explained to resident earlier no smoking because of oxygen.An incident note, dated 07/17/25 at 3:56 p.m., read in part, Resident outside smoking with oxygen on and caught face on fire. Noted blackened areas to face and nose. Bottom lip is swollen and small amount of red substance noted. EMSA [emergency medical services authority] here resident transported to [hospital] burn center via stretcher.An After Visit Summary, dated 07/17/25 - 07/19/25, showed Resident #20 had second degree burn of face.A Smoking and Safety, evaluation, dated 07/18/25, showed Resident #20 had poor vision or blindness. It did not have any clinical suggestions or interventions marked.A Smoking and Oxygen use, in-service, dated 07/18/25 showed 8 staff signatures. Resident #20's discharge return anticipated resident assessment, dated 07/30/25, showed the resident's cognition had modified independence with decision making, required supervision to substantial assistance with mobility. The assessment did not show the resident smoked.There was no documentation of staff supervision while resident smoked outside.On 08/12/25 at 8:15 a.m., Resident #20 was asked what happened to their face. They stated, I got burned smoking with oxygen on. They stated there were not any nurses outside when the incident occurred. Resident #20 stated they were outside without any supervision for about 30 minutes. They stated there was somebody outside but they were on their phone. Resident #20 stated a lot of the time people would be out there smoking and no ones with them. They stated they get the code to the door so they go out there and smoke without the staff out there. They stated they get their smoking material from the nurse. On 08/12/25 at 1:38 p.m., the activity assistant stated there were seven designated times for residents to smoke and the residents had to wait at the nurse's station for the designated staff to pass out the cigarettes to them one at a time and the staff has the lighter. The stated they were supervised by either staff staying outside or watching through the window. The activity assistant stated they were aware of the smoking incident with Resident #20 but had no knowledge if they were supervised at the time of the incident. The activity assistant stated there was only one resident to their knowledge that was an independent smoker, and it was not Resident #20. On 08/12/25 at 2:03 p.m., CNA #1 stated the whole building watches for smokers. They stated the residents had a lock box the materials were kept in and it was separated by each resident. CNA #1 stated Resident #20 required encouragement to not smoke due to breathing problems and oxygen. CNA #1 stated the resident was upset the day of the incident. CNA #1 stated the last time they saw Resident #20 that day, they were sitting up front by the tv at the table. CNA #1 stated the resident was always moving around. CNA #1 stated they heard the RN on duty (whom did not return phone calls for interview) state they were sending Resident #20 out because they set themselves on fire. CNA #1 stated it occurred around lunch time, and they had signed themselves out and went out the front and no staff was with them. Unable to speak to the RN that sent resident out to the hospital as they did not answer the phone, and the nurse that made the note of the resident preparing to go outside with oxygen was no longer employed at the facility since the date of the incident. On 08/13/25 at 11:54 a.m., Resident #20's family member #1 stated they did not provide the resident with a lighter and that the last time they had visited Resident #20 was on Saturday the 2nd and had brought snacks only. On 08/13/25 at 12:19 p.m., Resident #20's family member #2 stated they did not provide the resident with any smoking material and they do not purchase the cigarettes for them. They stated they last visited the resident two weeks ago. On 08/13/25 at 12:37 p.m., LPN #2 stated Resident #20 did not normally leave the facility and if they did, it was with their family member. They stated Resident #20 were normally in their room or the tv room and would sit outside for fresh air. LPN #2 stated they were aware of the recent smoking incident, and the resident was currently out of cigarettes and had tried to be sneaky to get from another resident. LPN #2 reviewed the sign out books, dated for 07/11/25 - 07/22/25, for Resident #20's name. LPN #2 stated the resident didn't typically sign out and were always on the back smoking area. The resident sign out book showed the resident had signed out on 07/14/25 at unknown time and another with an unknown date with a time frame of 8:45 a.m., and for 07/14/25 with a family member. LPN #2 stated no resident went out with their cigarettes without staff during smoking time. On 08/13/25 at 1:24 p.m., the administrator and DON were interviewed. The administrator stated after reviewing the nurse note from 07/17/25, their expectation regarding interventions to prevent hazard from smoking while on oxygen was the residents don't have lighters, and the tanks were to be turned completely off on the wheel chair before they were allowed to go smoke. The DON interjected and stated 90% of the time they were the one to remove the tank and put it in the dining room until the resident came back in. The administrator stated the implemented interventions when the resident was observed preparing to go outside to smoke while wearing oxygen was they talked to the resident about the dangers. The administrator stated nothing showed the resident attempted at that moment with that staff member to go outside. The administrator stated Resident #20 was very evasive to staff members and if they said no, the resident would roll around the building until someone that doesn't know. They stated the resident did not say they were going out to smoke, and they did not see any smoking material on them.On 08/13/25 at 1:30 p.m., both the administrator and the DON stated a resident should not be allowed to smoke with the intent they will still be on their oxygen.On 08/13/25 at 1:32 p.m., the administrator stated they did not do any resident safe surveys at the time of the incident on 07/17/25. They stated the incident could have affected other residents. They were unaware of how the resident obtained the smoking material. The administrator stated residents that were mentally capable could check themselves out as they could not keep them trapped in the property and they had the right to leave and had a right to their property and do their due diligence to get them upon their return. The administrator stated no resident was allowed to smoke independently, even independent smokers, and if they sign out it was off property, all had been educated, and Resident #20 had been educated multiple times.On 08/13/25 at 1:34 p.m., the administrator stated Resident #20 could sign themselves out. The administrator stated they did not see where the resident was signed out for 07/17/25. They stated the residents were not required to sign out to get fresh air or while on the property.On 08/13/25 at 3:03 p.m., the administrator stated they ensure resident safety while outside on premises by frequent observations and frequent checks, I can't keep them locked in.On 08/13/25 at 3:07 p.m., CNA #5 stated the last time they were in-serviced regarding the smoking protocol and safety was when they first started in May.The hire date for CNA #5 was 05/05/25 per the employee list with hire dates provided by the administrator.

On 05/28/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents were free from verbal abuse and failure to implement interventions to protect residents from physical abuse. An admission resident assessment, dated 12/18/24, showed Resident #3's cognition was intact (BIMS 15). A quarterly resident assessment, dated 01/15/25, showed Resident #5's cognition was intact (BIMS 15). A quarterly resident assessment, dated 01/25/25, showed Resident #4's cognition was intact (BIMS 13). A facility reported incident, dated 02/28/25, showed an allegation of abuse/mistreatment involving Resident #3, Resident #4, and Resident #5. The reported incident showed at approximately 6:00 p.m., the residents were outside smoking when an alleged altercation involving threats of physical harm occurred between residents. The reported incident showed Resident #3 made verbal threats of physical harm to Resident #5. Resident #4 became upset and allegedly made threats of physical harm to Resident #3. Residents #3 and #4 were immediately separated and placed on 1:1 for the protection of all residents. The reported incident showed residents were placed on 1:1 for the duration of the investigation. The reported incident showed care plans were updated as appropriate. The reported incident showed Resident #3 was sent out for a geri-psych evaluation and their care plan would be revised as needed upon return. The reported incident showed staff were re-educated on the signs and symptoms of abuse, and the policies and procedures for reporting abuse, neglect, and misappropriation. The final facility reported incident was faxed to OSDH on 03/05/25 at 3:50 p.m. There were no updates to Resident #3 or Resident #4's care plan regarding the above incident. The facility did not provide documentation of 1:1 provided for each shift for the duration of the investigation. The facility did not provide documentation of staff having been in-serviced related to abuse, neglect, and misappropriation as documented in the facility reported incident. An incident note, effective 02/28/25 at 7:30 p.m. showed it was reported to LPN #1 Resident #4 verbally threatened another resident with bodily harm. The resident stated, I will kick your [explicit]. Resident #4 separated from other residents until they went to bed. A behavior note, dated 02/28/25 at 8:44 p.m., showed Resident #3 was being observed 1:1 by the previous DON due to an alleged incident of verbal threats of physical harm to another resident. While sitting in this nurse's office, Resident #3 went into their purse and retrieved a small 1 ½ inch knife. The previous DON asked Resident #3 for the knife and the resident refused. The previous DON then informed the resident that it was illegal to posses a knife on the property. Resident #3 then attempted to jab knife at this nurse while simultaneously handing the knife to the previous DON. An incident note, effective 02/28/25 at 9:50 p.m., showed it was reported to LPN #2 Resident #3 was threatening another resident with bodily harm. They stated, ILL [SIC] WILL SET YOU ON FIRE AND HAVE SOMEONE SHOOT YOU IN THE HEAD. The note showed the resident was separated and placed on 1:1 until EMSA arrived. A behavior note, dated 03/01/25 at 8:47 p.m., showed Resident #3 continued to display verbal outbursts including yelling directed towards staff and other residents. A behavior note, dated 03/03/25 at 9:53 a.m., showed staff spoke with Resident #3 regarding their aggressive behaviors and them pulling a knife on the nurse. The resident admitted they did it and agreed to go to the hospital for treatment. On 05/28/25 at 2:02 p.m., LPN #2 stated at the time of the incident on 02/28/25, Resident #3 was very verbally aggressive with other residents and making threats. LPN #2 stated at the time of the incident, Resident #3 stated to Resident #5, I'll beat your [explicit] and burn you up. LPN #2 stated Resident #3 stated they would call a family member to kill Resident #5. They stated Resident #3 was placed on one on one and had additional incidents. LPN #2 stated on one incident Resident #3 pulled a knife on the former DON and the wound care nurse. They stated staff were able to get the knife away and sent the resident out for a psychiatric evaluation. LPN #2 stated Resident #3 had the knife hidden in their purse. On 05/28/25 at 2:07 p.m., LPN #1 stated on 02/28/25 Resident #3 was yelling at Resident #5 and Resident #4 was taking up for Resident #5. They stated the residents were separated and Resident #3 was in the former DONs office when the resident pulled out a knife and acted like they were going to stab the former DON. They stated the facility tried to get Resident #3 sent out for evaluation. On 05/28/25 at 3:51 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 05/28/25 at 4:00 p.m., the administrator and DON were notified of the IJ situation and provided the IJ template. On 05/30/25 at 5:01 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Deficiency Summary: Resident #3 made verbal threats of physical harm to Resident #5. Resident #4 became upset at Resident #3 and allegedly made verbal threats of physical harm to Resident #3 which had the potential to put Resident #3 and Resident #5 at risk of serious harm or death. This continues to be a hazard for all residents in the facility. 1. Immediate Action Taken: a. Resident #3 and Resident #4 were immediately separated from other residents at the time of incident. b. Resident #3 was immediately placed on 'One on One' with Protection of Resident until [they] was transferred to Geri-Psych for evaluation and treatment. c. Resident #4 was immediately placed on 'One on One' with Protection of Resident until he was evaluated and treated by Geri-Psych. d. Resident #3 and Resident #4 care plans were reviewed and updated. 2. Systemic Changes Implemented: a. Change in Director of Nursing on 4/28/2025. b. QA - The following Performance Improvement Plan (PIPs) were developed through QA: i. Documentation/Charting on 5/9/2025 ii. Care Plans on 5/9/2025 iii. Employee Orientation on 5/9/2025 iv. Grievances on 5/14/2025 v. Clinical concerns on 5/28/2025 c. Staff were educated on 'One on One' with Protection of Resident on 05/28/2025. d. Staff were educated on 'One on One' with Protection of Resident documentation on 05/28/2025. e. Firearm and Weapon Prohibition Policy updated to specifically include knives 3. Education and Training a. In-service of all staff on the following: Completed on 5/28/2025 i. Abuse, Neglect, and Exploitation Policy. - inclusive of threatening behaviors and no weapons including knives. ii. Firearm and Weapon Prohibition Policy Update for residents - includes knives iii. Firearm and Weapon Prohibition Policy Update for staff - includes knives iv. 'One on One' with Protection of Resident. v. 'One on One' with Protection of Resident documentation [sic]. b. In-service of all members of nurse management on the following: Completed on 5/28/2025 i. Care Plan Development. Facility will be in compliance on 5-30-2025 at 8:00 am. On 06/02/25 at 9:46 a.m., CNA #5 stated they had not received any recent training or in-services. They stated they were new and their second day of work was Thursday 05/29/25. They stated they had not received any information regarding 1:1 or weapons. On 06/02/25 at 11:36 a.m., the DON stated CNA #5 was brand new. The DON stated CNA #5 was not on the list of who completed the training for the plan of removal because they were new. On 06/02/25 at 11:38 a.m., the DON stated CNA #5 trained with CNA #3 on 05/28/25 and on 05/29/25. The DON stated CNA #5 would receive the training related to the POR today 06/02/25. On 06/02/25 at 11:58 a.m., the administrator provided documentation of CNA #5 completing abuse training on 05/16/25. The administrator stated CNA #5's hire date was 05/16/25 and they had not been on the floor since Thursday, 05/29/25. In-service sheets for abuse and neglect, no knives, guns, ammunition, explosives, on the premises, and supervising a resident who was on 1:1, were all dated 06/02/25 at 12:30 p.m., and were signed as completed by CNA #5. The IJ was lifted, effective 06/02/25 at 12:30 p.m., when all components of the plan of removal had been verified as completed. This was verified by staff interviews, review of in-service information, and a review of resident records to ensure interventions were in place for residents who exhibited threatening behaviors and what the facility was to do when there was a knife concern. The deficient practice remained at an isolated level with the potential for more than minimal harm. Based on observation, record review, and interview, the facility failed to: a. ensure residents were free from verbal abuse for 3 (#3, 4 and #5) of 5 sampled residents reviewed for abuse; b. implement interventions to protect residents from potential physical abuse for 1 (#3) of 5 sampled residents reviewed for abuse; and c. ensure residents were free from neglect for 1 (#1) of 5 sampled residents reviewed for abuse. The DON and the regional clinical director identified 51 residents resided in the facility. Findings: A firearm and weapon prohibition policy, dated 2024, read in part, A safe and secure environment is fundamental for fulfilling our company's mission of providing medical care and related health care services. Our company is committed to maintaining a safe workplace that is free of violence.To prevent the unauthorized possession of weapon(s) while on company premises .Any employee who becomes aware of a violation of this policy is required to immediately notify his/her supervisor of such violation .Violation of this policy is considered a serious offense that endangers the safety of our patients, staff, and visitors. Therefore, this offense may result in termination of employment (Staff), discharge from facility (Resident), and criminal prosecution. An abuse, neglect, and exploitation policy, dated 2025, read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Establish policies and procedures to investigate any such allegation .Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures .Establish coordination with the QAPI [Quality Assessment and Performance Improvement] program .Employee Training .Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as .Aggressive and/or catastrophic reactions of residents .Outbursts or yelling out .The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect.Possible indicators of abuse include, but are not limited to .Verbal abuse of a resident overheard .Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning [and] repositioning.Protection of Resident .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation.Responding immediately to protect the alleged victim .Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed .Increased supervision of the alleged victim and residents .Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator .Providing emotional support and counseling to the resident during and after the investigation, as needed .Revision of the resident's care plan if the resident's medical, nursing, physical, mental or psychosocial needs or preferences change as a result of an incident of abuse .This coordinated effort results in the QAA [Quality Assessment and Assurance] Committee determining .If a thorough investigation is completed .Whether the resident is protected .Whether an analysis was conducted as to why the situation occurred .Risk factors that contributed to the abuse (e.g., history of aggressive behaviors, environmental factors). A facility reported incident, dated 02/28/25, showed an allegation of abuse/mistreatment involving Resident #3, Resident #4, and Resident #5. The reported incident showed at approximately 6:00 p.m., the residents were outside smoking when an alleged altercation involving threats of physical harm occurred between residents. The reported incident showed Resident #3 made verbal threats of physical harm to Resident #5. Resident #4 became upset and allegedly made threats of physical harm to Resident #3. Residents #3 and #4 were immediately separated and placed on 1:1 for the protection of all residents. The reported incident showed residents were placed on 1:1 for the duration of the investigation. The reported incident showed care plans were updated as appropriate. The reported incident showed Resident #3 was sent out for a geri-psych evaluation and their care plan would be revised as needed upon return. The reported incident showed staff were re-educated on the signs and symptoms of abuse, and the policies and procedures for reporting abuse, neglect, and misappropriation. The final facility reported incident was faxed to OSDH on 03/05/25 at 3:50 p.m. The facility did not provide documentation of staff having been in-serviced related to abuse, neglect, and misappropriation as documented in the facility reported incident. The facility did not provide documentation of 1:1 provided for each shift for the duration of the investigation. The daily staffing sheets showed: a. on 03/01/25 1:1 was assigned for Resident #3 and Resident #4 for the 3:00 p.m. to 11:00 p.m. shift. There was no documentation 1:1 was assigned for the 7:00 a.m. to 3:00 p.m. or the 11:00 p.m. to 7:00 a.m. shift; b. on 03/02/25 1:1 was assigned Resident #3 and Resident #4 for the 3:00 p.m. to 11:00 p.m. shift. One staff member was assigned 1:1 for the 7:00 a.m. to 3:00 p.m. shift but it did not document what resident they were assigned to. There was no documentation 1:1 was assigned for the 11:00 p.m. to 7:00 a.m. shift; and c. on 03/03/25 there was no documentation 1:1 was assigned for Resident #4 for the 3:00 p.m. to 11:00 p.m. shift or the 11:00 p.m. to 7:00 a.m. shift. Resident #4 was still in the facility and had not yet been evaluated by mental health services. There were no updates to Resident #3 or Resident #4's care plan regarding the above incident. 1. On 05/28/25 at 2:20 p.m., Resident #3 was observed lying in their bed in their room watching television. The resident began voicing concerns with wanting to get out of the facility. An admission resident assessment, dated 12/18/24, showed Resident #3's cognition was intact (BIMS 15). The assessment showed Resident #3 had diagnoses which included depression, anxiety disorder, and schizophrenia. A behavior note, dated 02/28/25 at 8:44 p.m., showed Resident #3 was being observed 1:1 by the previous DON due to an alleged incident of verbal threats of physical harm to another resident. While sitting in this nurse's office, Resident #3 went into their purse and retrieved a small 1 ½ inch knife. The previous DON asked Resident #3 for the knife and the resident refused. The previous DON then informed the resident that it was illegal to posses a knife on the property. Resident #3 then attempted to jab knife at this nurse while simultaneously handing the knife to the previous DON. An incident note, effective 02/28/25 at 9:50 p.m., showed it was reported to LPN #2 Resident #3 was threatening another resident with bodily harm. They stated, ILL [SIC] WILL SET YOU ON FIRE AND HAVE SOMEONE SHOOT YOU IN THE HEAD. The note showed the resident was separated and placed on 1:1 until EMSA arrived. A behavior note, dated 03/01/25 at 8:47 p.m., showed Resident #3 continued to display verbal outbursts including yelling directed towards staff and other residents. A behavior note, dated 03/03/25 at 9:53 a.m., showed staff spoke with Resident #3 regarding their aggressive behaviors and them pulling a knife on the nurse. The resident admitted they did it and agreed to go to the hospital for treatment. Behavioral health hospital records, dated 03/03/25 through 03/14/25, showed Resident #3's presenting problem was they threatened a staff member with a knife. The records showed the reason for Resident #3's admission was they were a danger to others and had severe mood symptoms. The record showed key factors contributing to admission were increased aggression and violent behavior. 2. A quarterly resident assessment, dated 01/15/25, showed Resident #5's cognition was intact (BIMS 15). The assessment showed Resident #5 had diagnoses which included heart failure and hypertension. An order note, dated 02/28/25 at 9:58 p.m., showed LPN #2 was informed Resident #5 was threatened bodily harm by another resident. The note showed another resident told Resident #5 they would set the resident on fire and have someone shoot them in the head. The note showed the resident was checked for bodily harm. 3. A quarterly resident assessment, dated 01/25/25, showed Resident #4's cognition was intact (BIMS 13). The assessment showed Resident #4 had diagnoses which included hypertension, aphasia following cerebral infarction, parkinsonism, and history of traumatic brain injury. An incident note, effective 02/28/25 at 7:30 p.m., showed it was reported to LPN #1 Resident #4 verbally threatened another resident with bodily harm. The resident stated, I will kick your [explicit]. Resident #4 was separated from other residents until they went to bed. A mental health provider note for Resident #4, dated 03/04/25, read in part, resident reportedly threatened another resident (per another resident) with bodily harm saying 'I will kick your [explicit]'. This was after [they] heard the resident threatening another resident with bodily harm including having someone shoot them. [Resident #4] reports today that [they] would never hurt a woman and [they] has no feeling of wanting to hurt anyone. What [they] was doing, [they] relates, was trying to get this [resident] to hit [them] to show that [they] is violent. [They] reports that this resident often verbally abuses one particular resident and [they] were tired of it.today reports [they] is 'over' the situation that prompted [their] 1:1, and that [they] never intended to hurt anyone and does not want to hurt anyone or end their life.[They] does voice understanding of [their] behaviors and that words have certain outcomes in a tightly ran facility that has to follow many guidelines per state.I do not see the need for 1:1 to continue at this time. The note was signed on 03/04/25 by PA #1. On 05/23/25 at 1:01 p.m., CNA #4 stated they had received abuse education about a month ago. They stated they watched for verbal abuse, physical abuse, and neglect of patient care. They stated they would notify the administrator if abuse/neglect was observed or reported to them. On 05/23/25 at 1:07 p.m., CNA #2 stated they had received education on abuse and neglect. They stated they watched for every form of abuse including yelling, facial expressions, hand motions, anything that made a resident feel uncomfortable. They stated they would notify their charge nurse and DON if abuse/neglect was observed or reported to them. On 05/23/25 at 1:15 p.m., CNA #3 stated they were unsure of the last education they received regarding abuse/neglect. They stated they believed it was around January 2025. They stated they had not observed any signs or symptoms of abuse or neglect in the facility. They stated if abuse was observed or reported to them, they would contact the charge nurse immediately. On 05/23/25 at 1:19 p.m., ACMA #1 stated they had received education on abuse/neglect a couple Fridays ago. They stated they observed for financial, verbal, physical abuse, and misappropriation. They stated they would report any concerns with abuse/neglect to their nurse, DON, and administrator. On 05/23/25 at 1:22 p.m., LPN # 3 stated they had received education related to abuse/neglect multiple times. They stated they observed for emotional, spiritual, and physical abuse. They stated if abuse/neglect was observed or reported to them, they would notify their supervisor, complete an incident report, and ensure everything was documented. On 05/23/25 at 1:24 p.m., LPN #4 stated they had received an in-service last Friday on abuse/neglect. They stated they monitored for resident to resident abuse, staff to resident abuse, and resident to staff abuse. They stated if they observed abuse or it was reported to them, they would first remove the stressor, then report it to the DON and administrator who was the abuse coordinator. On 05/28/25 at 11:22 a.m., Resident #4 stated they had previously had an incident with Resident #3. They stated Resident #3 was cussing at Resident #5 and Resident #4 stated they told Resident #3 to quit. On 05/28/25 at 11:49 a.m., ACMA #1 stated they remembered Resident #3 talking smack on the day of the incident. They stated it was Resident #3 and Resident #5. They stated Resident #4 stepped in and they were talking about viscous stuff, setting people on fire, and killing them. They stated Resident #3 said it to Resident #5. ACMA #1 stated they heard them yelling initially. ACMA #1 stated Resident #3 said [explicit], shut the [explicit] up, I will set your [explicit] on fire. They stated Resident #5 said Don't nobody like your ugly [explicit]. ACMA #1 stated Resident #4 said they would beat Resident #3 up. They stated nobody touched anyone, it was all verbal and heated. ACMA #1 stated they tried to separate them and hollered for the nurse. They stated Resident #3 and #4 were placed on 1:1. ACMA #1 stated the only other staff present at the time no longer worked at the facility. On 05/28/25 at 12:23 p.m., the administrator stated when they were made aware of an allegation of abuse or neglect, they would immediately make sure the residents were safe. They stated staff would notify the abuse coordinator who was the administrator, and they would ensure statements were obtained and the resident was assessed. On 05/28/25 at 12:24 p.m., the administrator stated the responsible party, DON, physician, and depending on what happened, psych services would be notified of an allegation of abuse or neglect. On 05/28/25 at 12:26 p.m., the administrator stated in the abuse allegation involving Residents #3, #4, and #5, the residents were outside smoking and got into a verbal altercation. They stated Resident #4 thought Resident #3 was calling them names. They stated Resident #3 started yelling at Resident #5. The administrator stated Resident #4 approached Resident #3 and told them they were tired of the name calling. The administrator stated staff were present and immediately separated the residents. They stated the physician was notified and Resident #3 and #4 were put on 1:1 observations. On 05/28/25 at 12:29 p.m., the administrator stated they completed an initial reportable incident form and interviewed residents and staff. They stated assessments were completed and the records were reviewed. They stated senior psych services were contacted for an evaluation and medication review. They stated Residents #3, #4, and #5 showed no signs or symptoms of abuse or distress. The administrator stated Resident #3 was admitted for psych services. They stated Resident #3 remained on 1:1 until they were admitted and there were no other incidents. On 05/28/25 at 12:37 p.m., the administrator and the DON were asked to review the behavior note dated 02/28/25 which discussed Resident #3 taking a knife out of their purse and attempting to jab at the former DON. They were asked what the facility did in response to Resident #3's knife incident. The DON stated staff got the knife from the resident. On 05/28/25 at 1:48 p.m., the DON and administrator were asked how the facility was ensuring Resident #3 did not obtain a knife and attempt to use it again. The administrator stated Resident #3 had no family or friends and did not go anywhere. The DON stated staff should not be carrying anything like that on their person or in their purse. The administrator stated they did not know how Resident #3 got a knife. The DON stated they were not at the facility at the time of the incident and did not know how the resident got a knife. On 05/28/25 at 1:51 p.m. the administrator stated they were not in the building at the time of the knife incident. They stated they did not know about the knife incident at the time. They stated they did not recall when they were made aware of the knife incident. On 05/28/25 at 1:52 p.m., the administrator stated they could not answer for who was providing 1:1 for the 7:00 a.m. to 3:00 p.m. or the 11:00 p.m. to 7:00 a.m. shift on 03/01/25. They stated they would look for additional documentation of who was assigned 1:1 for the other dates and to see if the resident had a roommate for the 11:00 p.m. to 7:00 a.m. shift. On 05/28/25 at 2:02 p.m., LPN #2 stated at the time of the incident on 02/28/25, Resident #3 was very verbally aggressive with other residents and making threats. LPN #2 stated at the time of the incident, Resident #3 stated to Resident #5, I'll beat your [explicit] and burn you up. LPN #2 stated Resident #3 stated they would call a family member to kill Resident #5. They stated Resident #3 was placed on one on one and had additional incidents. LPN #2 stated on one incident Resident #3 pulled a knife on the former DON and the wound care nurse. They stated staff were able to get the knife away and sent the resident out for a psychiatric evaluation. LPN #2 stated Resident #3 had the knife hidden in their purse. On 05/28/25 at 2:07 p.m., LPN #1 stated on 02/28/25 Resident #3 was yelling at Resident #5 and Resident #4 was taking up for Resident #5. They stated the residents were separated and Resident #3 was in the former DON's office when the resident pulled out a knife and acted like they were going to stab the former DON. They stated the facility tried to get Resident #3 sent out for evaluation. 4. An admission resident assessment, dated 04/07/25, showed Resident #1 was dependent on staff for toileting hygiene and lower body dressing and required substantial/maximum assistance for oral hygiene, upper body dressing, and personal hygiene. The cognition part of the assessment was incomplete. A facility reported incident, dated 05/16/25, showed an allegation of abuse/mistreatment and an allegation of neglect involving Resident #1 and CNA #6. The reported incident showed Resident #1 stated CNA #6 was mean to them. They stated, When I push my call light the CNA comes in and says what do you want with a mean tone. The reported incident showed Resident #1 told CNA #6 they needed to be changed and CNA #6 stated, I only have to change you every [two] hours and you have to urinate more before I change you. The reported incident showed Resident #1 could only separate their legs partially and stated CNA #6 forcefully pulled their legs apart which caused a great deal of pain. The reported incident showed Resident #1 reported it was not the first time CNA #6 was mean to them and they did not feel safe with CNA #6 in the building. The reported incident showed CNA #6 was terminated effective immediately. The report was completed by the DON. A BIMS evaluation, dated 05/26/25, showed Resident #1's cognition was intact (BIMS score 15). On 05/23/25 at 10:18 a.m., Resident #1 stated they had asked CNA #6 to change them. They stated the CNA informed them We only change you every two hours. Resident #1 stated CNA #6 reported, So I'm not going to change you until five o'clock. Resident #1 stated five o'clock passed so they pushed their call light. They stated CNA #6 came in huffing and puffing and said just because they said they would change them at five did not mean they would be in right at five. CNA #6 stated, I'll change you when I get the chance. Resident #1 stated CNA #6 started hollering and pointing their finger in their face. They stated CNA #6 told them they were not the only resident they had to take care of. Resident #1 stated they left the room and slammed the door. On 05/23/25 at 10:23 a.m., Resident #1 stated CNA #6 came back shortly after and was extremely rough when they changed them. They stated the CNA held their leg down with what felt like Extreme pressure. Resident #1 stated they received a lot of fluid through a feeding tube and urinated frequently. On 05/23/25 at 10:26 a.m., Resident #1 stated the DON had spoken to them again today and asked if they were comfortable with CNA #6 returning to work. Resident #1 stated if CNA #6 did that to them, who else would they do it to. They stated they would hate to find out they mistreated a resident who was unable to speak up for themselves. On 05/23/25 at 1:15 p.m., CNA #3 stated they had been at the facility about four months and were not sure of any abuse/neglect allegations involving Resident #1. On 05/23/25 at 1:19 p.m., ACMA #1 stated they were not aware of any abuse/neglect allegations involving Resident #1. On 05/23/25 at 1:24 p.m., LPN #4 stated Resident #1 was talking with them in their room while they were completing a treatment. They stated the resident reported one of the CNAs only changed them every two hours and would fuss when they had to go in the resident's room. They stated it was a night shift aide. LPN #4 stated they reported it to the DON and were unsure of the findings of the investigation. On 05/23/25 at 1:33 p.m., the DON stated if abuse or neglect was reported to them, they would immediately suspend the staff member involved. They stated they would start the initial state reportable and if applicable notify the nurse aide registry. The DON stated they would have social services go in with a form to at least 50 percent of the residents on the hall and survey them without coaxing them. The DON stated they would then speak with staff and gather all their information before completing the final report. They stated based on the investigation findings, they determined what action to take. The DON stated in regards to the abuse allegation involving Resident #1, they went back and spoke to the resident. The DON stated based on their discussion, they did not feel it would not happen again to another resident if CNA #6 returned to work. The DON stated they terminated CNA #6. The DON stated it was their first time to complete an abuse allegation. On 05/23/25 at 1:36 p.m., the DON stated they monitored for signs of abuse such as missing money, how a resident was spoken to, the way they were cared for, and the way staff were treating residents overall. They stated if a resident stated they needed to be changed, staff were to change them. The DON stated they did not care if the resident was changed two minutes ago, even if the brief was bone dry, they stated it didn't matter because this is the resident's home not theirs. On 05/23/25 at 1:38 p.m., the DON[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 02/24/23, the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy situation related to the facility neglecting to provide Resident #110's medications for the treatment of schizophrenia and anxiety. Resident #110 was admitted to the facility on [DATE] with diagnoses of schizophrenia and anxiety. The facility did not complete a baseline care plan that addressed the mental health diagnoses. The admission orders documented the resident was to receive Risperidone 1 milligram two times a day for schizophrenia and Buspirone 10 milligrams three times a day for anxiety. A review of the progress notes documented the medication was on order and not received from 01/11/23 through 01/15/23. The medication administration record documented Risperidone was not provided as ordered in the morning with notes to indicate the medication was on order. The Buspirone was not administered as ordered. There were notes indicating the medication was on order. A review of the pharmacy manifest documented the facility had received 60 tablets of the Risperidone and 42 tablets of Buspirone on 01/11/23 at 11:58 p.m. On 01/15/23, Resident #110 attacked another resident, pulled their hair, gouged their eyes and choked them. Resident #110 was arrested when police were called and the victim pressed charges. On 02/24/23 at 1:40 p.m., the Administrator #1, and Administrator #2 was notified of the existence of the immediate jeopardy. On 02/27/23 at 5:50 p.m., the facility provided an acceptable plan of removal for the immediacy. The plan documented the following: Plan of Removal 2/26/2023 1. All resident's medications that are not administered will be properly documented in the progress note and will be documented when the doctor is notified to ensure continuity of care and to prevent harm, abuse, or neglect. 2. All residents in the facility with mental health diagnosis will be audited to ensure proper medication management by ensuring medications are in the building and available to resident according physician order, if medications are not available, the pharmacy and Dr. [Name deleted] will be notified. 3. All resident's medications and orders were audited to ensure residents are receiving the care based off the physician's orders. 4. In-services will be initiated immediately for all licensed staff concerning the process of medication orders and re-ordering and medication unavailable process. 5. In-services will be initiated immediately for all licensed agency staff concerning the process of medication orders, re-ordering, medication unavailable process and missed/refused medication dosages including how to contact the pharmacy and physician of record which was posted in medication room. 6. In-services will be initiated immediately for all licensed staff concerning the process of refilling medication carts, checking in medication upon arrival, checking to see if medications are on hand and notifying pharmacy when medication needs to be refilled. 7. All staff that are not working (i.e. on leave or vacation) currently will be in serviced via phone conversation. If we are unable to be reached by phone, an email or text will be sent to the employee with a return reply to ensure it was received and understood. 8. An audit was initiated immediately and finished within 24 hours concerning medication availability, all medication carts were audited to ensure the physician orders matched the medication available and any discrepancy in medication orders were flagged, corrected and/or a licensed staff notified the physician immediately. 9.The policy on receiving medications has been updated and it is required to have ordered psychotropic medications available to residents within 4 hours. If medications are unavailable, the physician and pharmacy must be notified immediately for a medication order change from the physician or the use of emergency local pharmacy. The pharmacy will now receive a call from the admitting nurse ensuring that the medication orders have been received. 10.The pharmacy consultants will conduct MAR/ Cart audits. Initiation Date: 2/24/2023 Completion Date: 11:59 PM on 2/28/2023 1. All residents in the facility shall receive a baseline care plan within 48 hours of admission to address the resident's POC. 2. In-services will be initiated immediately for all licensed staff concerning the baseline care plan and comprehensive care plan policy and procedure. 3. An audit will be initiated immediately and finished within 24 hours concerning new admits, readmits, new orders and the baseline care plan completion to ensure all basic care needs are being met. Initiation Date: 2/24/2023 Completion Date: 11:59 PM on 2/28/2023 On 03/01/23 after interviews, review of all in services, and documentation, all components of the plan of removal had been completed and the immediacy was lifted effective 03/01/23 at 4:45 p.m. The deficient practice remained at a level of isolated harm. Based on record review, observation, and interview, the facility neglected to provide antipsychotic medication to a resident for one (#110) of seven residents reviewed for medications. Resident #110 did not receive their antipsychotic medications for schizophrenia and anxiety. On 01/15/23, Resident #110 attacked Resident #34, pulled their hair, gouged their eyes, and chocked them four days after admission. The Resident Census and Conditions of Resident's, form, dated 02/22/23 documented 23 residents received psychoactive medications. Findings: An Abuse, Neglect and Exploitation, policy, dated 01/01/23, read in parts, .It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written polices and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Resident #110 was admitted to the facility on [DATE] with diagnoses which included schizophrenia and anxiety. The hospital discharge order summary dated 01/11/23 documented the resident had orders for Risperidone for schizophrenia and Buspirone for anxiety. The medication manifest dated 01/11/23, for Resident #110 documented the facility received 60 tablets of 1 mg Risperidone and 42 tablets of 10 mg Buspirone on 01/11/23 at 11:58 p.m. Resident #110's medication order summary documented the resident was to receive: Risperidone 1 mg one tablet by mouth two times a day for schizophrenia, and Buspirone 10 mg three times a day for anxiety. Both orders were first written on 01/11/23, the day of admission. A review of the clinical record contained no baseline care plan for the resident to address his diagnoses of schizophrenia and anxiety and the use of Risperidone and Buspirone. The MAR for January 2023 documented Resident #110 was to receive risperdone in the morning between 9:00 a.m. and 11:00 a.m.; and again between 7:00 p.m. and 11:00 p.m. Resident #110 did not receive their Risperidone in the morning on 01/12/23, 01/13/23, 01/14/23. The reason the medication was not provided indicated to see the progress notes. The MAR documented the Resident #110 had received their evening medications on 01/12/23, 01/13/23, and 01/14/23. A review of the progress notes, dated 01/12/23, 01/13/23, 01/14/23, documented Resident #110 Risperidone was on order. The MAR for January 2023 documented Resident #110 was to receive Buspirone at 8:00 a.m., 2:00 p.m., and 8:00 p.m. Resident #110 did not receive their Buspirone on 01/11/23 at 8:00 p.m., 01/12/23 at 8:00 a.m. and 2:00 p.m.; 01/13/23 at 8:00 a.m. and 2:00 p.m., and 01/14/23 at 8:00 a.m. and 2:00 p.m. The reason the medication was not provided indicated to see the progress notes. The MAR documented the Resident #110 had received their 8:00 p.m. dose of Buspirone on 01/12/23, 01/13/23, and 01/14/23. A review of the progress notes, dated 01/12/23, 01/13/23, 01/14/23, documented Resident #110 Buspirone was on order. The MAR documented the residents' medications were not provided on 01/15/23 due to being out of the facility. A report to the Oklahoma State Department of Health, dated 01/15/23, read in parts, .location facility grounds-dining area .suspected criminal act local law enforcement 01/15 .time 8:13am received report [Resident #110] arguing with [Resident #34], which led to [Resident #110] chocking [Resident #34] police arrived [Resident #110] aggressively charged the policy officers .was arrested for assault and battery . There was no documentation in Resident #110 clinical record how the resident medications was disposed of after their arrest on 01/15/23. On 02/16/23 at 3:15 p.m., the family of Resident #110 stated the facility had spoken with them after discharge and told them the medications were not provided because they were not in the facility. The family member further stated when Resident #110 was on their medications they were stable, and added the resident currently was in the process of being admitted to a psychiatric hospital due to being unstable and being suicidal. When asked how long Resident #110 had these mental health diagnoses, they stated since Resident #110 had been young. On 02/17/2023 at 12:10 p.m., Resident #34 stated they were in the dining room and they asked Resident #110 if they had come from prison. Resident #34 then stated, [ Resident #110] had grabbed their hair, gouged their eyes and chocked them. Resident #34 also stated Resident #110 had not even been at the facility for even a week. There had been no problems until that day. On 02/23/23 at 1:30 p.m., the medication destruction area was observed with DON #1 and no medications or destruction records were located for Resident #110. DON #1 stated they could not find anything remaining medication for destruction. On 02/24/23 at 9:51 a.m., DON #1 stated she did not know if the medications were in the building or not. She stated she can only go by the documentation which stated the medications were on order. DON #1 then stated that If the manifest said they were here they should have been provided and I cannot provide any documentation if the medications were sent with him to jail or he ever received them. DON #1 was asked about possible adverse effects to Resident #110 without receiving antipsychotic medication for schizophrenia and anxiety. DON #1 stated they could not answer that. DON #1 had no comment when asked if not providing the psychoactive medications fits the definition of neglect. On 02/24/23 at 11:10 a.m., the medical director stated Resident #110 would have been kept on his Risperidone and Buspirone when admitted due to them not knowing the resident. The medical director stated that If a resident is not receiving his antipsychotic medication, they could have no effect or become more aggressive. He was asked if he was aware Resident #110 had not been receiving the medications for schizophrenia and anxiety. The medical director stated they did not know and had they known changes would have been looked at. The medical director was made aware of the 01/15/23 incident and they stated, That was a significant occurrence and had I known I would have made changes. On 02/23/23 at 12:32 p.m., the pharmacist was asked what effects on residents not having psychoactive medications provided as ordered. The pharmacist stated, they could have more behaviors. They then stated Resident #110 would also have more anxiety without medications. The pharmacist then stated they were not aware they did not receive the medications and why it stated the medications were on order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 03/02/23, an Immediate Jeopardy (IJ) situation was determined to exist related to the facilities failure to implement interventions to prevent PU/PI development for Resident #21 who was admitted without PU/PIs, but who had multiple co-morbidities and was totally dependent on staff, placing Resident #21 at increased risk for PU/PI development; and failed to provide ongoing skin assessments for the same resident. Resident #21 developed an avoidable unstageable PU/PI on their right heel. Resident # 21 admitted on [DATE] to the facility with hospice care. admission skin assessment documented no skin concerns to heels. Resident had a Physician's order, revised on 09/05/22 for weekly skin assessments every Sunday. Residents record documented weekly skin assessments were conducted on 10/02/22, 10/23/22, 11/13/22, 12/25, 01/08, 01/29, 02/19, and 02/26. The facility missed a total of 17 Physician's ordered skin assessments since admission. No concerns to right heel were documented in these assessments. No other documentation of PU/PI in residents record documented concerns with right heel. On 03/01/23 during observation surveyor observed a golf ball sized, dark colored area to Resident #21's right heel. On 03/02/23, LPN #1 stated Resident #21 had no skin issues other than a few scattered bruises to his abdomen. Surveyor accompanied LPN #1 into Resident #21's room to conduct a skin assessment. LPN #1 assessed Resident #21's right heel and stated He has a black spot on his right heel, I just found it. Wound care consultant verified it was an unstageable PU/PI, measuring 2 cm. by 3.1 cm. Resident #21 with co-morbidities which included diabetes type 2 and heart disease this puts the resident at a higher risk for infection, increased pain, and loss of limb. The lack of assessing, monitoring, and intervening places dependent residents at risk for avoidable PU/PI. On 03/02/23 at 4:22 p.m., The Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 03/02/23 at 4:44 p.m., the Administrator were notified of the IJ situation. On 03/03/23 at 3:36 p.m., a plan of removal was submitted to The Oklahoma State Department of Health. The plan of removal was reviewed and given acceptance to move forward with the plan of removal date of 03/03/23 at 4:00 p.m. The plan of removal sent via email documented: 1. All residents in the facility shall receive a skin sweep immediately to assess and determine a baseline for pressure injury. If a resident refuses a skin assessment it will be documented in PCC, the doctor will be notified, and the nursing staff will follow physician's order for further evaluation or treatment. 2. All residents will have an order for skin assessments upon admission, readmission and weekly thereafter. 3. In-services will be initiated by clinical staff immediately for all licensed staff including but not limited to CNAs, CMAs, LPNs and RNs regarding skin assessments and resident shower policies. 4. In-services were added to the agency in-service book located at the front reception area and all agency employees must read and sign stating they understand both policies and procedures related to resident showers and skin assessments prior to working their shift on the floor. 5. Formal Letter written and sent to Hospice Agencies informing the agency that a book of in- services and education is located in front of their hospice notebook and all licensed hospice employees must read and sign stating they understand policy and procedures related to skin assessments and resident showers prior to providing care. 6. All staff that are not working currently will be in-serviced via phone conversation. If they are unable to be reached by phone, an email or text will be sent to the employee regarding the in-service. Employees who were unable to be reached will need to complete both in-services regarding resident showers and skin assessments prior to beginning their next shift. 7. An audit was initiated immediately and finished within 2 hours concerning the current skin integrity of each resident (who allowed skin sweeps). Any findings and/or concerns were documented in PCC, the physician was notified, and the resident was added to the wound team's list for further assessment and treatment. Initiation Date: 3/2/2023 Completion Date: 4:00 PM on 03/03/2023 On 03/03/23, staff were interviewed regarding training/updates in regard to the Skin assessment policy and protocol. Staff stated they had received in person and/or phone calls from various members of administrative nursing employees and verbalized understanding of the information provided in the in-service pertaining to the plan of removal. On 03/03/23 at 4:21 p.m., the IJ was removed when all components of the plan of removal had been completed. This was effective as of 03/03/23 at 4:00 p.m. The deficiency remained at a isolated level of actual harm. Based on record review, observation and interview, the facility failed to ensure: a. Weekly skin monitoring and/or weekly wound assessments were conducted and b. Adequate wound care/treatment was initiated timely for one (#21) of one sampled resident reviewed for pressure ulcers. This resulted in actual harm to Resident #21 who developed a pressure injury which worsened to an avoidable deep tissue injury. The Resident Census and Conditions of Residents form, dated 02/22/23, documented 55 residents resided in the facility. Findings: A Skin Audits by Nursing Assistants policy, revised on 03/08/23, read in parts, .It is our policy to communicate changes in skin condition to appropriate personnel as part of our systematic approach for pressure injury prevention and management. This policy establishes responsibilities of nursing assistants in communicating changes in skin condition .Nursing assistants shall inspect the skin surface during bath/shower and report to the resident's nurse immediately .Nursing assistants shall also report changes in skin condition that are noted during any care procedure . A Skin Integrity - Foot Care policy, revised on 03/08/23, read in parts, .It is the policy of this facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice,, as applicable, to maintain mobility and good foot health. This policy pertains to maintaining the skin integrity of the foot .The facility will provide foot care and treatment in accordance with professional standards of practice, including the prevention of complications from resident's medical conditions . A Skin Assessment policy, revised on 03/08/23, read in parts, .It is our policy to perform full body skin assessment as part of our systematic approach to pressure injury prevention and management .A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury .Documentation of skin assessment date and time of assessment .observations .type of wound .describe wound .resident refused and why .other information as indicated or appropriate . Resident #21 had diagnoses which included diabetes mellitus type 2 without complications and heart disease. A Physician's Order dated 09/05/22, documented, Perform weekly skin assessment every SUNDAY on 3-11 shift - CHART UNDER SKIN OBSERVATION TOOL. An admission Assessment dated, 09/09/22 documented Resident #21's cognition was fully intact, and they required extensive assistance with bed mobility and bathing. The assessment also documented Resident #21 had no pressure ulcers. An undated Care Plan, read in parts, .I am at risk for potential .pressure ulcer development .Follow facility policies/protocols for the prevention/treatment of skin breakdown .I need extensive assistance to turn/reposition at least every 2 hours and as needed . A Skin Observation Tool, dated 02/26/23, read in parts, .Res with scattered bruising to bilateral abd, insulin site. Bilat feet pitting, 2+ edema to BLE . On 03/02/23 at 8:01 a.m., LPN #2, was asked if Resident #21 had any skin issues. They stated he had no skin issues, only a few scattered bruises to his abdomen, heels were red and very dry skin. On 03/02/23 at 8:08 a.m., LPN #2 was asked if they could assess Resident #21's skin. LPN # stated Resident #21 had a black spot on their right heel, I just found it. LPN #2 stated I haven't done a skin assessment on him since my three days here. On 03/02/23 at 8:14 a.m., LPN #2 states they will notify wound care. They stated the only treatment was for Cetaphil to Resident #21's legs. They stated they knew his feet were red but hadn't seen a black area. On 03/02/23 at 11:22 a.m., the Wound Care Consultant observed the area, they stated it was a deep tissue injury measuring 2.0 cm by 3.1 cm. On 03/03/23 at 10:28 a.m., the DON #1 stated shower sheets were used to document the skin assessments. They stated skin assessments were ordered to be done weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 02/24/23 at the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy situation related mental health services and treatment for Resident #110 who had a diagnosis of schizophrenia and anxiety and received psychoactive medications. Resident #110 was admitted to the facility on [DATE] with diagnoses of schizophrenia and anxiety. The facility did not complete a baseline care plan that addressed the mental health diagnoses. The admission orders documented the resident was to receive Risperidone 1 milligram two times a day for schizophrenia and Buspirone 10 milligrams three times a day for anxiety. A review of the progress notes documented the medication was on order and not received from 01/11/23 through 01/15/23. The medication administration record documented Risperidone was not provided as ordered in the morning with notes to indicate the medication was on order. The Buspirone was not administered as ordered also with notes indicating the medication was on order. A review of the pharmacy manifest documented the facility had received 60 tablets of the Risperidone and 42 tablets of Buspirone on 01/11/23 at 11:58 p.m. On 01/15/23 Resident #110 attacked another resident pulling their hair, gouging their eyes and choking them. Resident #110 was arrested when police was called and the victim pressed charges. On 02/24/23 at 1:40 p.m., the Administrator, and Administrator #1 was notified of the existence of the immediate jeopardy. On 02/27/23 at 5:50 p.m., the facility provided an acceptable plan of removal for the immediacy. The plan documented the following: Plan of Removal 2/26/2023 1. All resident's medications that are not administered will be properly documented in the progress note and will be documented when the doctor is notified to ensure continuity of care and to prevent harm, abuse, or neglect. 2. All residents in the facility with mental health diagnosis will be audited to ensure proper medication management by ensuring medications are in the building and available to resident according physician order, if medications are not available, the pharmacy and Dr. [Name deleted] will be notified. 3. All resident's medications and orders were audited to ensure residents are receiving the care based off the physician's orders. 4. In-services will be initiated immediately for all licensed staff concerning the process of medication orders and re-ordering and medication unavailable process. 5. In-services will be initiated immediately for all licensed agency staff concerning the process of medication orders, re-ordering, medication unavailable process and missed/refused medication dosages including how to contact the pharmacy and physician of record which was posted in medication room. 6. In-services will be initiated immediately for all licensed staff concerning the process of refilling medication carts, checking in medication upon arrival, checking to see if medications are on hand and notifying pharmacy when medication needs to be refilled. 7. All staff that are not working (i.e. on leave or vacation) currently will be in serviced via phone conversation. If we are unable to be reached by phone, an email or text will be sent to the employee with a return reply to ensure it was received and understood. 8. An audit was initiated immediately and finished within 24 hours concerning medication availability, all medication carts were audited to ensure the physician orders matched the medication available and any discrepancy in medication orders were flagged, corrected and/or a licensed staff notified the physician immediately. 9.The policy on receiving medications has been updated and it is required to have ordered psychotropic medications available to residents within 4 hours. If medications are unavailable, the physician and pharmacy must be notified immediately for a medication order change from the physician or the use of emergency local pharmacy. The pharmacy will now receive a call from the admitting nurse ensuring that the medication orders have been received. 10.The pharmacy consultants will conduct MAR/ Cart audits. Initiation Date: 2/24/2023 Completion Date: 5:00 PM on 2/28/2023 1. All residents in the facility shall receive a baseline care plan within 48 hours of admission to address the resident's POC. 2. In-services will be initiated immediately for all licensed staff concerning the baseline care plan and comprehensive care plan policy and procedure. 3. An audit will be initiated immediately and finished within 24 hours concerning new admits, readmits, new orders and the baseline care plan completion to ensure all basic care needs are being met. Initiation Date: 2/24/2023 Completion Date: 5:00 PM on 2/28/2023 On 03/01/23 after interviews, review of all in services and documentation all components of the plan of removal had been completed and the immediacy was lifted effective 03/01/23 at 4:45 p.m. The deficient practice remained at a level of harm. Based on record review, observation and interview, the facility failed to provide antipsychotic medication to a resident for one (#110) of seven residents reviewed for medications. Resident #110 did not receive his psychoactive medications for schizophrenia and anxiety. On 01/15/23 Resident #110 attacked Resident #34 pulling their hair, gouging their eyes and chocking them. The resident census and conditions of resident's form dated 02/22/23 documented 23 residents received psychoactive medications. Findings: Resident #110 was admitted to the facility on [DATE] with diagnoses which included schizophrenia and anxiety. The hospital discharge order summary dated 01/11/23 documented the resident had orders for Risperidone for schizophrenia and Buspirone for anxiety. The medication manifest dated 01/11/23, for Resident #110 documented the facility received 60 tablets of 1 mg Risperidone and 42 tablets of 10 mg Buspirone on 01/11/23 at 11:58 p.m. Resident #110 medication order summery documented the resident was to receive Risperidone 1 mg one tablet by mouth two times a day for schizophrenia, order was first written on 01/11/23; and Buspirone 10 mg three times a day for anxiety. Both orders were first written on 01/11/23, the day of admission. A review of the clinical record contained no base line care plan for the resident to address his diagnoses of schizophrenia and anxiety and the use of Risperidone and Buspirone. The MAR for January 2023 documented Resident #110 was to receive Risperidone in the morning between 9:00 a.m. and 11:00 a.m.; and again between 7:00 p.m. and 11:00 p.m. Resident #110 did not receive their Risperidone in the morning on 01/12/23, 01/13/23, 01/14/23. The reason the medication was not provided indicated to see the progress notes. The MAR documented the Resident #110 had received their evening medications on 01/12/23; 01/13/23, and 01/14/15. A review of the progress notes, dated 01/12/23, 01/13/23, 01/14/23, documented Resident #110 Risperidone was on order. The MAR for January 2023 documented Resident #110 was to receive Buspirone at 8:00 a.m., 2:00 p.m., and 8:00 p.m. Resident #110 did not receive their Buspirone on 01/11/23 and 8:00 p.m.; 01/12/23 at 8:00 a.m. and 2:00 p.m.; 01/13/23 at 8:00 a.m. and 2:00 p.m., and 01/14/23 at 8:00 a.m. and 2:00 p.m. The reason the medication was not provided indicated to see the progress notes. The MAR documented the Resident #110 had received their 8:00 p.m. dose of Buspirone on 01/12/23, 01/13/23, and 01/14/23. A review of the progress notes, dated 01/12/23, 01/13/23, 01/14/23, documented Resident #110 Buspirone was on order. The MAR documented the residents' medications were not provided on 01/15/23 due to being out of the facility. A report to the Oklahoma State Department of Health, dated 01/15/23, read in parts, .location facility grounds-dining area .suspected criminal act local law enforcement 01/15 .time 8:13am received report [Resident #110] arguing with [Resident #34], which led to [Resident #110] chocking [Resident #34] police arrived [Resident #110] aggressively charged the policy officers .was arrested for assault and battery . There was no documentation in Resident #110 clinical record how the resident medications were disposed of after their arrest on 01/15/23. On 02/16/23 at 3:15 p.m., the family of Resident #110 stated the facility had spoken with her after discharge and told her the medications were not provided because they were not in the facility. The family member further stated when Resident #110 was on their medications they were stable, and added the resident currently was in the process of being admitted to a psychiatric hospital due to being unstable and being suicidal. When asked how long Resident #110 had these mental health diagnoses, they stated since Resident #110 had been young. On 02/17/2023 at 12:10 p.m., Resident #34 stated they were in the dining room and they asked Resident #110 if they had come from prison. Resident #34 then stated, [ Resident #110] had grabbed their hair, gauged the eyes and chocked them. Resident #34 also stated Resident #110 had not been at the facility not even a week there had been no problems until that day. On 02/23/23 at 1:30 p.m., the medication destruction area was observed with the DON and no medications or destruction records were located for Resident #110. The DON stated they could not find anything when observing with the surveyor. On 02/24/23 at 9:51 a.m., the DON stated she did not know if the medications were in the building or not. She stated she can only go by the documentation which stated the medications were on order. The DON then stated if the manifest said they were here they should have been provided and I cannot provide any documentation if the medications were sent with him to jail or he ever received them. The DON was asked about effects to Resident #110 without receiving psychoactive medication for schizophrenia and anxiety. The DON stated they could not answer that. On 02/24/23 at 11:10 a.m., the Medical director, who was also the attending physician, stated Resident #110 would have been kept on his Risperidone and Buspirone when admitted due to them not knowing the resident. They stated if a resident is not receiving his antipsychotic medication, they could have no effect or become more aggressive. The Medical Director was asked if he was aware Resident #110 had not been receiving the medications for schizophrenia and anxiety. The physician stated they did not know and had they known changes would have been looked at. The physician was made aware of the 01/15/23 incident and they stated, That was a significant occurrence and had I known I would have made changes. On 02/23/23 at 12:32 p.m., the pharmacist was asked what effects on residents not having antipsychotic medications provided as ordered. The pharmacist stated, they could have more behaviors. They then stated Resident #110 would also have more anxiety without medications. The pharmacist then stated they were no aware they did not receive the psychoactive medications and why it stated they were on order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #10 had diagnoses which included diabetes mellitus due to underlying condition with diabetic amyotrophy, hepatitis C, and unspecified convulsions. A Physician's order for Resident #10, dated 01/26/23, read in parts, .metformin HCI oral tablet 1000 mg .Give 1000 tablet by mouth two times a day for diabetic amyotrophy . A January 2023 TAR documented six of six doses of metformin 1000 mg were not administered. A February 2023 TAR documented 56 of 56 doses of metformin 1000 mg were not administered. On 02/28/23 at 9:32 a.m., ACMA #1 was asked if Resident #10 had metformin on the cart. They stated no. On 02/28/23 at 2:35 p.m., the DON as asked if there was a physician's order for Resident #10 for metformin 1000 mg. She stated yes. She stated the order was placed on 01/26/23 and was to be given twice a day. The DON was asked if the medication had been given in January and February, she stated no it had not been given. On 02/24/23 at the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy situation related to medication acquisition and storage. Resident #110 who had a diagnosis of schizophrenia and anxiety had psychoactive medications not provided and documented as on order. The MAR documented the resident did not receive some doses due to medication being on order and then documented other doses were provided. The facility did not have an accurate accounting of the psychoactive medications and what happened to them after Resident #110 was discharged from the facility. Resident #110 was admitted to the facility on [DATE] with diagnoses of schizophrenia and anxiety. The facility did not complete a baseline care plan that addressed the mental health diagnoses. The admission orders documented the resident was to receive Risperidone 1 milligram two times a day for schizophrenia and Buspirone 10 milligrams three times a day for anxiety. A review of the progress notes documented the medication was on order and not received from 01/11/23 through 01/15/23. The medication administration record documented Risperidone was not provided as ordered in the morning with notes to indicate the medication was on order. The Buspirone was not administered as ordered also with notes indicating the medication was on order. A review of the pharmacy manifest documented the facility had received 60 tablets of the Risperidone and 42 tablets of Buspirone on 01/11/23 at 11:58 p.m. On 01/15/23 Resident #110 attacked another resident pulling their hair, gouging their eyes and choking them. Resident #110 was arrested when police was called and the victim pressed charges. On 02/24/23 at 1:40 p.m., the Administrator, and Administrator #1 was notified of the existence of the immediate jeopardy. On 02/27/23 at 5:50 p.m., the facility provided an acceptable plan of removal for the immediacy. The plan documented the following: Plan of Removal 2/26/2023 1. All resident's medications that are not administered will be properly documented in the progress note and will be documented when the doctor is notified to ensure continuity of care and to prevent harm, abuse, or neglect. 2. All residents in the facility with mental health diagnosis will be audited to ensure proper medication management by ensuring medications are in the building and available to resident according physician order, if medications are not available, the pharmacy and Dr. [Name deleted] will be notified. 3. All resident's medications and orders were audited to ensure residents are receiving the care based off the physician's orders. 4. In-services will be initiated immediately for all licensed staff concerning the process of medication orders and re-ordering and medication unavailable process. 5. In-services will be initiated immediately for all licensed agency staff concerning the process of medication orders, re-ordering, medication unavailable process and missed/refused medication dosages including how to contact the pharmacy and physician of record which was posted in medication room. 6. In-services will be initiated immediately for all licensed staff concerning the process of refilling medication carts, checking in medication upon arrival, checking to see if medications are on hand and notifying pharmacy when medication needs to be refilled. 7. All staff that are not working (i.e. on leave or vacation) currently will be in serviced via phone conversation. If we are unable to be reached by phone, an email or text will be sent to the employee with a return reply to ensure it was received and understood. 8. An audit was initiated immediately and finished within 24 hours concerning medication availability, all medication carts were audited to ensure the physician orders matched the medication available and any discrepancy in medication orders were flagged, corrected and/or a licensed staff notified the physician immediately. 9.The policy on receiving medications has been updated and it is required to have ordered psychotropic medications available to residents within 4 hours. If medications are unavailable, the physician and pharmacy must be notified immediately for a medication order change from the physician or the use of emergency local pharmacy. The pharmacy will now receive a call from the admitting nurse ensuring that the medication orders have been received. 10.The pharmacy consultants will conduct MAR/ Cart audits. Initiation Date: 2/24/2023 Completion Date: 5:00 PM on 2/28/2023 1. All residents in the facility shall receive a baseline care plan within 48 hours of admission to address the resident's POC. 2. In-services will be initiated immediately for all licensed staff concerning the baseline care plan and comprehensive care plan policy and procedure. 3. An audit will be initiated immediately and finished within 24 hours concerning new admits, readmits, new orders and the baseline care plan completion to ensure all basic care needs are being met. Initiation Date: 2/24/2023 Completion Date: 5:00 PM on 2/28/2023 On 03/01/23 after interviews, review of all in services and documentation all components of the plan of removal had been completed and the immediacy was lifted effective 03/01/23 at 4:45 p.m. The deficient practice remained at a level of harm. Based on record review, observation and interview, the facility failed to have a system in place for ordering and accounting of medications for three (#110, #39, and #10) of 24 residents reviewed for medications. Resident #110 did not have an accurate accounting of their psychoactive medications for schizophrenia and anxiety and the facility was not able to account for the medications upon discharge from the facility. On 01/15/23 Resident #110 attacked Resident #34 pulling their hair, gouging their eyes and chocking them and was arrested. The resident census and conditions of resident's form dated 02/23/23 documented 23 residents received psychoactive medications. Findings: 1. Resident #110 was admitted to the facility on [DATE] with diagnoses which included schizophrenia and anxiety. The hospital discharge order summary dated 01/11/23 documented the resident had orders for Risperidone for schizophrenia and Buspirone for anxiety. The medication manifest dated 01/11/23, for Resident #110 documented the facility received 60 tablets of 1 mg Risperidone and 42 tablets of 10 mg Buspirone on 01/11/23 at 11:58 p.m. Resident #110 medication order summery documented the resident was to receive Risperidone 1 mg one tablet by mouth two times a day for schizophrenia, order was first written on 01/11/23; and Buspirone 10 mg three times a day for anxiety. Both orders were first written on 01/11/23, the day of admission. A review of the clinical record contained no base line care plan for the resident to address his diagnoses of schizophrenia and anxiety and the use of Risperidone and Buspirone. The MAR for January 2023 documented Resident #110 was to receive Risperidone in the morning between 9:00 a.m. and 11:00 a.m.; and again between 7:00 p.m. and 11:00 p.m. Resident #110 did not receive their Risperidone in the morning on 01/12/23, 01/13/23, 01/14/23. The reason the medication was not provided indicated to see the progress notes. The MAR documented the Resident #110 had received their evening medication of Risperidone on 01/12/23; 01/13/23, and 01/14/15. A review of the progress notes, dated 01/12/23, 01/13/23, 01/14/23, documented Resident #110 Risperidone was on order. The MAR for January 2023 documented Resident #110 was to receive Buspirone at 8:00 a.m., 2:00 p.m., and 8:00 p.m. Resident #110 did not receive their Buspirone on 01/11/23 and 8:00 p.m.; 01/12/23 at 8:00 a.m. and 2:00 p.m.; 01/13/23 at 8:00 a.m. and 2:00 p.m., and 01/14/23 at 8:00 a.m. and 2:00 p.m. The reason the medication was not provided indicated to see the progress notes. The MAR documented the Resident #110 had received their 8:00 p.m. dose of Buspirone on 01/12/23, 01/13/23, and 01/14/23. A review of the progress notes, dated 01/12/23, 01/13/23, 01/14/23, documented Resident #110 Buspirone was on order. The MAR documented the residents' medications were not provided on 01/15/23 due to being out of the facility. A report to the Oklahoma State Department of Health, dated 01/15/23, read in parts, .location facility grounds-dining area .suspected criminal act local law enforcement 01/15 .time 8:13am received report [Resident #110] arguing with [Resident #34], which led to [Resident #110] chocking [Resident #34] police arrived [Resident #110] aggressively charged the policy officers .was arrested for assault and battery . There was no documentation in Resident #110 clinical record how the resident medications were disposed of after their arrest on 01/15/23. On 02/16/23 at 3:15 p.m., the family of Resident #110 stated the facility had spoken with her after discharge and told her the medications were not provided because they were not in the facility. The family member further stated when Resident #110 was on their medications they were stable, and added the resident currently was in the process of being admitted to a psychiatric hospital due to being unstable and being suicidal. When asked how long Resident #110 had these mental health diagnoses, they stated since Resident #110 had been young. On 02/17/23 at 8:42 a.m., CMA #2 stated the facility was out of a lot of medication and they did not have them. CMA #2 then stated there was a huge problem with medications not being in the facility to provide to residents. On 02/17/2023 at 12:10 p.m., Resident #34 stated they were in the dining room and they asked Resident #110 if they had come from prison. Resident #34 then stated, [ Resident #110] had grabbed their hair, gauged the eyes and chocked them. Resident #34 also stated Resident #110 had not been at the facility not even a week there had been no problems until that day. On 02/23/23 at 1:30 p.m., the medication destruction area was observed with the DON and no medications or destruction records were located for Resident #110. The DON stated they could not find anything when observing with the surveyor. On 02/24/23 at 9:51 a.m., the DON stated they did not know if the medications were in the building or not. She stated she can only go by the documentation which stated the medications were on order. The DON then stated if the manifest said they were here they should have been provided and I cannot provide any documentation if the medications were sent with Resident #110 to jail or if they ever received them. The DON was asked about effects to Resident #110 without receiving psychoactive medication for schizophrenia and anxiety. The DON stated they could not answer that. On 02/24/23 at 11:10 a.m., the Medical Director, who was also the attending physician, stated Resident #110 would have been kept on his Risperidone and Buspirone when admitted due to them not knowing the resident. Physician #1 Stated if a resident is not receiving his psychoactive medication, they could have no effect or become more aggressive. They were asked if he was aware Resident #110 had not been receiving the medications for schizophrenia and anxiety. The Medical Director stated they did not know and had they known changes would have been looked at. The physician was made aware of the 01/15/23 incident and they stated, That was a significant occurrence and had I known I would have made changes. On 02/23/23 at 12:32 p.m., the pharmacist was asked what effects on residents not having psychoactive medications provided as ordered. The pharmacist stated, they could have more behaviors. They then stated Resident #110 would also have more anxiety without medications. The pharmacist then stated they were not aware they did not receive the medications and why it stated they were on order. The pharmacist further stated the medications had been delivered to the facility, but was not sure what happened to them afterwards. 2. Resident #39 had diagnoses which included conversion disorder with seizures. A review of the current physician's orders documented the resident had the following medications ordered for seizures: Iagabine HCL 4 mg three times a day first started 12/15/21. A review of the MAR's dated January 2023, and February 2023 contained no documentation to indicate the Iagabine had been administered since 01/29/23. A health status progress note, dated 02/20/23 at 3:59 p.m., read in parts, .will d/c Tiagabine since it is on back order over a month and will adjust the remains medication as needed . On 02/17/23 at 8:42 a.m., CMA #2 stated Resident #39 had been out of medications since the first of the year and it was for seizures. On 02/17/23 at 8:45 a.m., CMA #1 stated Resident #39 had an order for Tiagabine 4 mg for seizures and convulsions because the facility did not have the medications. The CMA then stated they did not know why the medications ran out. On 02/24/23 at 10:33 a.m., the DON stated Resident #39 was to receive all her medications and the Iagabine was not discontinued. On 02/24/23 at 11:08 a.m., the Medical Director, who was also the attending physician, stated they would have adjusted the medications to account for the missing anticonvulsant.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #10 had diagnoses which included diabetes mellitus due to underlying condition with diabetic amyotrophy, hepatitis C, and unspecified convulsions. A Physician's order for Resident #10, dated 01/26/23, read in parts, .metformin HCI oral tablet 1000 mg .Give 1000 tablet by mouth two times a day for diabetic amyotrophy . A January 2023 TAR documented six of six doses of metformin 1000 mg were not administered. A February 2023 TAR documented 56 of 56 doses of metformin 1000 mg were not administered. On 02/28/23 at 9:32 a.m., ACMA #1 was asked if Resident #10 had metformin on the cart. They stated no. On 02/28/23 at 2:35 p.m., the DON as asked if there was a physician's order for Resident #10 for metformin 1000 mg. She stated yes. She stated the order was placed on 01/26/23 and was to be given twice a day. The DON was asked if the medication had been given in January and February, she stated no it had not been given. On 02/28/23 at 2:54 p.m., the DON and ACMA #3 were observed to look through the medication cart and stated there was no medication for Resident #3 in the medication cart. On 02/28/23 at 3:00 p.m., the DON and ACMA #3 were asked it there was any metformin for Resident #10 in the medication room. Both staff members went to the medication room, looked through his medications and stated no. DON was asked if there was any metformin for Resident #10 in the discontinued medications bin, she stated yes. Four blister packs were observed to be in the bin. One 30 count blister pack contained 4 remaining metformin pills, one 30 count blister pack contained 30 remaining metformin pills, one 30 count blister pack contained 30 remaining metformin pills, one 30 count blister pack contained 22 remaining metformin pills. On 02/28/23 at 3:05 p.m. the DON stated that the MAR was used to audit the medication carts, the medication did not appear on the MAR, so the medication was pulled from the cart. On 02/24/23 at the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy situation related significant medication errors. Resident #110 who had a diagnosis of schizophrenia did not receive their psychoactive medications. Resident #110 was admitted to the facility on [DATE] with diagnoses of schizophrenia and anxiety. The facility did not complete a baseline care plan that addressed the mental health diagnoses. The admission orders documented the resident was to receive Risperidone 1 milligram two times a day for schizophrenia and Buspirone10 milligrams three times a day for anxiety. A review of the progress notes documented the medication was on order and not received from 01/11/23 through 01/15/23. The medication administration record documented Risperidone was not provided as ordered in the morning with notes to indicate the medication was on order. The Buspirone was not administered as ordered also with notes indicating the medication was on order. A review of the pharmacy manifest documented the facility had received 60 tablets of the Risperidone and 42 tablets of Buspirone on 01/11/23 at 11:58 p.m. On 01/15/23 Resident #110 attacked another resident pulling their hair, gouging their eyes and choking them. Resident #110 was arrested when police was called and the victim pressed charges. On 02/24/23 at 1:40 p.m., the Administrator, and Administrator #1 was notified of the existence of the immediate jeopardy. On 02/27/23 at 5:50 p.m., the facility provided an acceptable plan of removal for the immediacy. The plan documented the following: Plan of Removal 2/26/2023 1. All resident's medications that are not administered will be properly documented in the progress note and will be documented when the doctor is notified to ensure continuity of care and to prevent harm, abuse, or neglect. 2. All residents in the facility with mental health diagnosis will be audited to ensure proper medication management by ensuring medications are in the building and available to resident according physician order, if medications are not available, the pharmacy and Dr. [Name deleted] will be notified. 3. All resident's medications and orders were audited to ensure residents are receiving the care based off the physician's orders. 4. In-services will be initiated immediately for all licensed staff concerning the process of medication orders and re-ordering and medication unavailable process. 5. In-services will be initiated immediately for all licensed agency staff concerning the process of medication orders, re-ordering, medication unavailable process and missed/refused medication dosages including how to contact the pharmacy and physician of record which was posted in medication room. 6. In-services will be initiated immediately for all licensed staff concerning the process of refilling medication carts, checking in medication upon arrival, checking to see if medications are on hand and notifying pharmacy when medication needs to be refilled. 7. All staff that are not working (i.e. on leave or vacation) currently will be in serviced via phone conversation. If we are unable to be reached by phone, an email or text will be sent to the employee with a return reply to ensure it was received and understood. 8. An audit was initiated immediately and finished within 24 hours concerning medication availability, all medication carts were audited to ensure the physician orders matched the medication available and any discrepancy in medication orders were flagged, corrected and/or a licensed staff notified the physician immediately. 9.The policy on receiving medications has been updated and it is required to have ordered psychotropic medications available to residents within 4 hours. If medications are unavailable, the physician and pharmacy must be notified immediately for a medication order change from the physician or the use of emergency local pharmacy. The pharmacy will now receive a call from the admitting nurse ensuring that the medication orders have been received. 10.The pharmacy consultants will conduct MAR/ Cart audits. Initiation Date: 2/24/2023 Completion Date: 5:00 PM on 2/28/2023 1. All residents in the facility shall receive a baseline care plan within 48 hours of admission to address the resident's POC. 2. In-services will be initiated immediately for all licensed staff concerning the baseline care plan and comprehensive care plan policy and procedure. 3. An audit will be initiated immediately and finished within 24 hours concerning new admits, readmits, new orders and the baseline care plan completion to ensure all basic care needs are being met. Initiation Date: 2/24/2023 Completion Date: 5:00 PM on 2/28/2023 On 03/01/23 after interviews, review of all in services and documentation all components of the plan of removal had been completed and the immediacy was lifted effective 03/01/23 at 4:45 p.m. The deficient practice remained at a level of harm. Based on record review, observation and interview, the facility failed to provide psychoactive, seizure, or diabetic medications and be free of significant medication errors for three (#110, #39 and #10) of seven residents reviewed for medications. Resident #110 did not receive his psychoactive medications for schizophrenia and anxiety. On 01/15/23 Resident #110 attacked Resident #34 pulling their hair, gouging their eyes and chocking them. The resident census and conditions of resident's form dated 02/22/23 documented 23 residents received psychoactive medications. Findings: A Medication Administration policy, revised on 03/08/23, read in part, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in the stat, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection 1. Resident #110 was admitted to the facility on [DATE] with diagnoses which included schizophrenia and anxiety. The hospital discharge order summary dated 01/11/23 documented the resident had orders for Risperidone for schizophrenia and Buspirone for anxiety. The medication manifest dated 01/11/23, for Resident #110 documented the facility received 60 tablets of 1 mg Risperidone and 42 tablets of 10 mg Buspirone on 01/11/23 at 11:58 p.m. Resident #110 medication order summery documented the resident was to receive Risperidone 1 mg one tablet by mouth two times a day for schizophrenia, order was first written on 01/11/23; and Buspirone 10 mg three times a day for anxiety. Both orders were first written on 01/11/23, the day of admission. A review of the clinical record contained no base line care plan for the resident to address his diagnoses of schizophrenia and anxiety and the use of Risperidone and Buspirone. The MAR for January 2023 documented Resident #110 was to receive Risperidone in the morning between 9:00 a.m. and 11:00 a.m.; and again between 7:00 p.m. and 11:00 p.m. Resident #110 did not receive their Risperidone in the morning on 01/12/23, 01/13/23, 01/14/23. The reason the medication was not provided indicated to see the progress notes. The MAR documented the Resident #110 had received their evening medications on 01/12/23; 01/13/23, and 01/14/15. A review of the progress notes, dated 01/12/23, 01/13/23, 01/14/23, documented Resident #110 Risperidone was on order. The MAR for January 2023 documented Resident #110 was to receive Buspirone at 8:00 a.m., 2:00 p.m., and 8:00 p.m. Resident #110 did not receive their Buspirone on 01/11/23 and 8:00 p.m.; 01/12/23 at 8:00 a.m. and 2:00 p.m.; 01/13/23 at 8:00 a.m. and 2:00 p.m., and 01/14/23 at 8:00 a.m. and 2:00 p.m. The reason the medication was not provided indicated to see the progress notes. The MAR documented the Resident #110 had received their 8:00 p.m. dose of Buspirone on 01/12/23, 01/13/23, and 01/14/23. A review of the progress notes, dated 01/12/23, 01/13/23, 01/14/23, documented Resident #110 Buspirone was on order. The MAR documented the residents' medications were not provided on 01/15/23 due to being out of the facility. A report to the Oklahoma State Department of Health, dated 01/15/23, read in parts, .location facility grounds-dining area .suspected criminal act local law enforcement 01/15 .time 8:13am received report [Resident #110] arguing with [Resident #34], which led to [Resident #110] chocking [Resident #34] police arrived [Resident #110] aggressively charged the policy officers .was arrested for assault and battery . There was no documentation in Resident #110 clinical record how the resident medications was disposed of after their arrest on 01/15/23. On 02/16/23 at 3:15 p.m., the family of Resident #110 stated the facility had spoken with her after discharge and told her the medications were not provided because they were not in the facility. The family member further stated when Resident #110 was on their medications they were stable, and added the resident currently was in the process of being admitted to a psychiatric hospital due to being unstable and being suicidal. When asked how long Resident #110 had these mental health diagnoses, they stated since Resident #110 had been young. On 02/17/23 at 12:10 p.m., Resident #34 stated they were in the dining room and they asked Resident #110 if they had come from prison. Resident #34 then stated, [ Resident #110] had grabbed their hair, gauged the eyes and chocked them. Resident #34 also stated Resident #110 had not been at the facility not even a week there had been no problems until that day. On 02/24/23 at 9:51 a.m., the DON stated she did not know if the medications were in the building or not. She stated she can only go by the documentation which stated the medications were on order. The DON then stated if the manifest said they were here they should have been provided and I cannot provide any documentation if the medications were sent with him to jail or he ever received them. The DON was asked about effects to Resident #110 without receiving psychoactive medication for schizophrenia and anxiety. The DON stated they could not answer that. On 02/24/23 at 11:10 a.m., the Medical Director, who was also the attending physician, stated Resident #110 would have been kept on his Risperidone and Buspirone when admitted due to them not knowing the resident. Physician #1 Stated if a resident is not receiving his psychoactive medication, they could have no effect or become more aggressive. He was asked if he was aware Resident #110 had not been receiving the medications for schizophrenia and anxiety. The physician stated they did not know and had they known changes would have been looked at. The physician was made aware of the 01/15/23 incident and they stated, That was a significant occurrence and had I known I would have made changes. On 02/23/23 at 12:32 p.m., the pharmacist was asked what effects on residents not having psychoactive medications provided as ordered. The pharmacist stated, they could have more behaviors. They then stated Resident #110 would also have more anxiety without medications. The pharmacist then stated they were no aware they did not receive the medications and why it stated they were on order. The pharmacist then stated this would be a significant medication error. 2. Resident #39 had diagnoses which included conversion disorder with seizures. A review of the current physician's orders documented the resident had the following medications ordered for seizures: Iagabine HCL 4 mg three times a day first started 12/15/21. A review of the MAR's dated January 2023, and February 2023 contained no documentation to indicate the Iagabine had been administered since 01/29/23. A health status progress note, dated 02/20/23 at 3:59 p.m., read in parts, .will d/c Tiagabine since it is on back order over a month and will adjust the remains medication as needed . On 02/24/23 at 10:33 a.m., the DON stated Resident #39 was to receive all her medications and the Iagabine was not discontinued. The DON asked if an anticonvulsant being missed would result in a significant medication error. The DON nodded her head up and down to indicate yes and made no additional comments. On 02/24/23 at 11:08 a.m., Physician #1 stated they would have adjusted the medications to account for the missing anticonvulsant.