On 09/09/25, an IJ situation was determined to exist related to the facility's failure to provide protection from sexual abuse/inappropriate touching from two residents towards three residents sampled for abuse.On 09/09/25 at 11:19 a.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On 09/09/25 at 11:54 a.m., the administrator and ADON were notified of the IJ situation and the IJ template was provided.On 09/10/25 at 11:53 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Identification of total number of residents at risk for the same failed practice:42Actions taken to remove the immediacy of the alleged failed practice:o There are 3 residents identified as affected by this alleged deficient practice with the potential for 42 residents overall to be affected including the 2 residents alleged to have had the behaviors affecting others. Resident #1 and Resident #4 have dementia related conditions as does the entire population of this Specialized Dementia Care Facilityo Resident #1 was placed on 1:1 supervision on 08-20-2025 for 72 hours and was no longer exhibiting sexuality toward others-[they] was already on medication to curb sexual impulses at that time and had been on it since 06-07-2025 despite having no behaviors at that time due to making comments toward women staff but no behaviors related to sexual contact or attempts for contact at that point. Resident #1 was placed back on 1:1 supervision on 08-26-2025 and his psychoactive medications were increased (and [they] remained on the previous ordered medication to curb sexuality) by the PA when [they] was notified of an episode of sexuality toward another resident and was removed from 1:1 supervision at 72 hours when no further behaviors of increased sexuality noted and a room change put him into less proximity to women in that room change. On 08-31-2025 a [identity withheld] resident entered Resident #1 room when a contact occurred, so we were unable to determine who initiated that contact since both residents have cognitive impairment. Resident #1 was placed on 1:1 supervision on 08-31-2025 at the time of the identified incident affecting other resident. Resident #1 was sent out to the hospital related to behaviors on 08-31-2025 and returned on 09-01-2025 and remained on 1:1 and continues to be on 1:1 supervision. Resident #4 remains on 1:1 supervision as well since his conduct on 08-31-2025.o The PA was notified of the incidents at the time of occurrence of each. The PA did not state to the facility staff at that time or any other time that [they] felt a discharge was in order for either resident. PA had made medication changes each time for resident #1 in addition to facility interventions but did not make any changes to resident #4 medications stating it was because the [other] resident in that situation was in resident #4 room and resident #4 had no increased sexually motivated behaviors noted before.o All residents that were interviewable have been interviewed and those that are non-interviewable were assessed with no evidence of abuse or inappropriate/ nonconsensual contact identified based on assessment/interview/observation.o Training of all staff in the areas of abuse/neglect risk including sexual behaviors and potential for such behaviors, identification of those at risk for neglect/abuse, protection measures to prevent abuse and neglect, and dementia care including documentation of 1:1 when provided and in-service lasted for 30 minutes for all current staff by the Nursing Leadership Team staff at 12:15pm September 9, 2025 and no other staff will be permitted to work until they have been in-serviced before their next scheduled shift by phone contact or in-person. The information for in-service covered is attached.o The facility will monitor residents (current and future) behaviors to observe for potential to administer/receive abuse or neglect, and verbalization of signs of behaviors that could escalate to abuse or neglect including sexual abuse. New admits will be screened through interviews and record reviews for at risk behavior including abuse and neglect potential including sexual abuse or behaviors that have the potential to affect others. If a resident is determined to be at risk, then this information will be care planned with individualized interventions for that resident will be determined and implemented which may include 1:1 supervision and/or safe discharge. This information will be captured on the initial baseline care plan for new admissions and on regular care plans for current residents. Any behaviors exhibited would be captured in behavior notes and screened daily by the DON or designee to identify behaviors that might lead to abuse/neglect including potential/actual sexual behaviors. The staff will also notify the DON or Administrator of residents that are having signs of increased sexuality at the time of the event so an immediate intervention can be placed and remain in-place until the behaviors are no longer putting anyone at risk. Psych plus services were recently added to our service offering at South Park East. Actions taken to prevent recurrence of alleged failed practice: DON or designee will:o Daily review of all incidents and behavior notes to identify residents at risk for behaviors affecting others including abuse/neglect including sexual behaviorso Reviews will include protection of residents from abuse/neglect including sexual abuse and interventions to reduce abuse/neglect while still protecting resident rights including consensual contacto Training for staff will continue re: dementia including protective measures from abuse/neglect as well as dementia care and behaviors prevention/management and including documentation for 1:1 care when provided, on an on-going basis by the DON, ADON, MDS, Corporate staff or Administrator and will include new hires on 09-09-2025 and on-goingo The facility will monitor resident (current and future) behaviors to observe for potential abuse or increasing sexuality towards others that may put others at risk. New admits will be screened through interviews and record review for at risk behavior including potential risk of abuse or neglect toward others. If a resident is determined to be at risk, then this information will be care planned with individualized interventions for that resident will be determined and implemented. This information will be captured on the initial baseline care plan for new admissions and on regular care plans for current residents. Any behavior exhibited would be captured in the behavior notes and screened daily by the DON or designee to identify behaviors that might lead to abuse/neglect including non-consensual sexual contact. The staff will also notify the DON or Administrator for residents that are exhibiting behaviors that put themselves or others at potential/actual risk at the time of the event so an immediate intervention can be placed.Actions will be completed by: 09-09-2025 3:00PM and no staff will be permitted to work until they have completed the training, and this training will be completed before the start of their next worked shift. All current working staff will be in-serviced about this as of 09-09-2025 on 09-09-2025.Monitoring implementation of the plan:o Administrator or designee will monitor abuse/neglect identification, protection from abuse/neglect and dementia care including behaviors that put self or others at risk.o Daily review allegations and incidents, as well as behaviors that put or potentially put self or others at risk as well as documentation for 1:1 when providedo Review of residents with allegations and incidents, and behaviors that put or potentially put self or others at risk as well as documentation for 1;1 when provided will be conducted daily and the information carried through the Quality Assurance Performance Improvement Processo All residents that can be interviewed will be interviewed and those that are noninterviewable (sic) will be assessed for evidence of abuse or inappropriate/ nonconsensual contact based on assessment/interview/observation.o The facility will monitor resident (current and future) behaviors to observe for risk of abuse/neglect including nonconsensual sexual contact. New admits will be screened through interview and record review for at risk behavior including potential risk of putting others at risk of abuse/neglect including but not limited to nonconsensual sexual contact. If a resident is determined to put others at risk , then this information will be care planned with individualized interventions for that resident to be determined and implemented to protect others and self. This information will be captured on the initial baseline care plan for new admissions and on regular care plans for current residents. Any behaviors exhibited would be captured in the behavior notes and screened daily by the DON or designee to identify behaviors that might lead to abuse/neglect of others. The staff will also notify the DON or Administrator for residents that are or potentially at risk of behaviors affecting others at the time of the event so an immediate intervention can be placed and maintained as indicated. Information will be carried through the Quality Assurance Performance Improvement Process. On 09/10/25 at 4:05 p.m., the IJ was lifted after review to ensure all the components of the POR were reviewed which included 1:1 documentation, resident assessments for injury, and staff interviews regarding education for abuse and dementia, The deficient practice remained at an isolated level with the potential for harm. Based on observation, record review and interview, the facility failed to ensure protection from sexual abuse/inappropriate touching was provided for 3 (#2,3, and #5) of 3 sampled residents reviewed for abuse.The operating officer identified 42 residents resided in the facility.Findings:A policy titled Abuse and Neglect - Clinical Protocol, revised July 2017, read in part, 1. Abuse .Includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes . Sexual abuse .non-consensual sexual contact of any type with a resident.1. 1. Resident #1's order summary, dated 09/04/25, showed Resident #1 had diagnoses of sexual dysfunction and dementia.A quarterly assessment, dated 07/25/25, showed the BIMS of 3 which indicated severe cognitive impairment. The assessment showed verbal and other behaviors, rejection of care and independent mobility. A care plan, initiated 06/12/25, showed Resident #1 had times of making sexually inappropriate actions towards themself or others and had a diagnosis of sexual disfunction. An Initial INCIDENT REPORT FORM, dated 08/20/25, showed Resident #1 was witnessed by staff to place their hand down Resident #3's shirt in the hallway. The report showed Resident #1 was to be placed on 1:1.An Initial INCIDENT REPORT FORM, dated 08/26/25, showed Resident #1 was observed touching Resident #2 inappropriately. The report showed Resident #1 was to be placed on 1:1 and was to receive a psychological evaluation related to current behaviors and care plan would be updated to reflect residents' current status.The care plan was not updated timely following the incident.An initial INCIDENT REPORT FORM, dated 08/31/25, showed Resident #1 was observed touching Resident #5's breast. The report showed Resident #1 was sent out to hospital for psychological evaluation and the care plan was to be updated to reflect current status. 2. 2. Resident #4's care plan, dated 06/12/25, showed diagnoses which included unspecified dementia with agitation. A quarterly assessment, dated 06/24/25, showed a BIMS of 3 indicating severe cognitive impairment. The assessment showed rejection of care and wandering, and mobility assistance. AAn Incident Note, dated 08/31/25, showed Resident #4 was observed touching Resident #2 inappropriately. An Alert Note, dated 08/31/25, showed staff observed Resident #4 with hands on top of the resident's (#2) brief and under shirt. An Initial INCIDENT REPORT FORM, dated 08/31/25, showed Resident #4 was observed touching Resident #2's breast. The report showed Resident #4 was placed on 1:1 and the care plan was to be updated to reflect current status.3. 3. Resident #2's care plan, dated, 06/25/25, showed diagnoses which included Alzheimer's disease and unspecified dementia. A significant change assessment, dated 06/04/25, showed Resident #2 had a BIMS of 00 indicating severe cognitive impairment. The assessment showed rejection of care, wandering, and showed the resident required assistance with mobility and used a wheelchair.An Incident Note, dated 08/26/25 at 3:57 p.m., showed Resident #2 was touched inappropriately by Resident #1.An Alert Note, dated 08/31/25 at 8:47 p.m., showed Resident #4 was observed with their hands on top of Resident #2's brief and under their shirt. 4. 4. Resident #3's quarterly assessment, dated 07/04/25 showed Resident #3 had a BIMS of 00 indicating severe cognitive impairment, physical and verbal behaviors, and wandering. It showed they were independent with mobility. It showed a diagnosis of dementia. An Incident Note, dated 08/20/25 at 6:36 p.m., showed Resident #3 was sitting in a chair in the hallway when Resident #1 touched their breast. 5. 5. Resident #5's care plan, dated 01/07/25 showed diagnosis of Alzheimer's disease.A quarterly resident assessment dated , 07/30/25, showed Resident #5 with BIMS of severely impaired cognition, physical and verbal behaviors, wandering and independent with mobility. On 09/02/25 at 2:50 p.m., CNA #1 stated Resident #1 had touched two of the residents of the opposite sex. They stated Resident #1 had their hands down the resident's shirt and Resident #1 spoke sexually to both the staff and the residents. CNA #1 stated when Resident #1 had the behavior, they would redirect them back to their room and was placed on 1:1. CNA #1 stated Resident #1 had been on 1:1 back-to-back and had been sent to the hospital and came back the next day. They were not aware of anything else being done about the incident. CNA #1 stated they were aware of the incidents with Residents #2 and #3 with regarding Resident #1. CNA #1 stated their last abuse education was last week. CNA #1 was not aware of any sexual behaviors regarding Resident #4.On 09/02/25 at 3:06 p.m., CNA #2 stated they had not received any abuse education within the last two weeks with the last one being on 08/20/25. They stated the interventions to prevent other incidents was the 1:1 and to be within arm's length of the residents.On 09/04/25 at 12:50 p.m., LPN #1 stated Resident #1 had sexual behaviors and was aggressive. They stated they had not received any education on abuse at all in the month of August. LPN #1 stated they were aware of the sexual behaviors of Resident #1 with Resident #3 and another unknown resident the past weekend. LPN #1 stated the facility separated the residents, did 1:1 with Resident #1. They stated Resident #1 was monitored and the incident reported. Monitoring through the shift and monitoring for other behaviors. LPN #1 stated Resident #4 had also been inappropriate with another unknown resident as it had taken place at the same time as Resident #1 on 08/31/25. LPN #1 stated the unknown resident wandered into Resident #4's room. LPN #1 stated wandering was the problem with intermingling women and men. LPN #1 stated the process for 1:1 was for 72 hours, but for Residents #1 and #4 it was for a week. LPN #1 stated the incident with Resident #1 and Resident #3 had occurred in the hallway on evening shift. They stated they were not in the facility and did not know what was else had been done. LPN #1 stated the interventions were 1:1 and psychiatric evaluation. LPN #1 was not aware of the victim in the incident with Resident #4 touching another resident but knew the intervention was 1:1. On 09/05/25 at 2:35 p.m., the DON stated they attempted to prevent recurrence by continued monitoring and tried to keep them away from the other residents. There was no documentation to show the family of Resident #5 had been made aware of the incident that involved them. On 09/08/25 at 1:34 p.m., PA #1 stated they were aware of Resident #1's sexual behaviors towards other residents and placed them on estrogen and psychiatric medication. They stated Resident #1 had been sent to the hospital for behaviors and was sent back to the facility on antipsychotic medication. PA #1 stated the behaviors to expect from someone with a diagnosis of sexual dysfunction would be all the behaviors presented by Resident #1, and that there were a lot of residents of the opposite sex in the facility and the other gender does not know any better. The PA stated they could not get the psychiatric units to admit them. They stated the interventions to prevent recurrence was the 1:1, monitoring, keep them separated and to have family to come visit. On 09/08/25 at 2:00 p.m., PA #1 stated there was nothing else medically for them to do and they felt the perpetrators needed to be discharged . They stated the building was not big enough to deal with this population. PA #1 stated they did not feel the facility was able to provide adequate monitoring for a resident with sexual dysfunction who touched other residents when not on 1:1 monitoring with staff. On 09/08/25 at 2:03 p.m., PA #1 stated they were aware of the behavior of Resident #4 and the same interventions applied for them as for Resident #1. The PA stated the building was not big enough to deal with the population as it was all Alzheimer's and dementia related diagnosis.