Based on observation, record review, and interview, the facility failed to ensure a resident was not touched sexually by another resident for 1 (#3) of 3 sampled residents reviewed for abuse. The facility's failure to prevent this type of inappropriate, unwanted sexual contact would reasonably cause anyone to have psychosocial harm.The administrator identified 54 residents resided in the facility. On 09/08/25 at 10:43 a.m., Resident #3 was observed lying in bed, with the bed in the low position, with fall mat in place. Their room was clutter free and the trash can was empty. Resident #3's room was next to the nurse's station on hall 300. Resident #3 was unable to appropriately respond to surveyor.On 09/09/25 at 1:08 p.m., Resident #27 was in attendance during resident council.On 09/09/25 at 2:00 p.m., Resident #27 was observed playing bingo in the dining room.On 09/10/25 at 10:25 a.m., LPN #2 and CNA #3 were observed coming out of Resident #3's room. Resident #3 was observed in bed repeating well, well, well, okay, okay, okay. The fall mat was observed in place next to bed. The bed was in low position, and the call light was in their hand.An Oklahoma State Department of Health final report, for an incident dated 09/02/25, showed LPN #2 went to Resident #3's room and found Resident #27 with their hand underneath Resident #3's gown near their groin with a fondling motion. Resident #27 asked Resident #3 if they liked it. LPN#2 asked Resident #27 what they were doing and Resident #27 stated they were trying to help Resident #3 into bed. Resident #3 was unaware of their circumstances or surroundings currently. Resident #27 was instructed not to go into other residents' rooms and Resident #27 stated they did not know what LPN #2 was talking about and then left the room. Resident #27 was immediately placed on 1:1 monitoring. Resident #3 had a head-to-toe assessment completed with no abnormalities noted. The physician, administrator, DON, local police and APS were notified. Resident #27 remained on 1:1 observation for 72 hours with no attempts to go into any other resident's room or exhibit any behaviors. The facility sent medical paperwork into numerous behavioral hospitals, and the resident had been accepted for in-patient evaluation once a bed became open. Resident #27's care plan would be updated for any new medication changes upon return from the hospital. If any future incidents occurred after return, the facility would look at alternative placement.A policy Abuse, Neglect and Exploitation, revised 01/18/25, 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. Sexual Abuse is non-consensual sexual contact of any type with a resident.Resident #3's Significant Change assessment, dated 07/03/25, showed Resident #3 had a BIMS score of 2 indicating severe problems with thinking and memory. The assessment showed Resident #3 had a diagnosis of metabolic encephalopathy [a brain dysfunction with symptoms that include confusion, memory loss, and altered consciousness]. The assessment showed Resident #3 was dependent upon staff for personal hygiene, dressing, bathing, transfers, toileting, and mobilization.A Nurse Progress Note, dated 09/02/25 at 1:59 p.m., showed Resident #3 was lying in their bed with the door open, and Resident #27 was found fondling underneath Resident #3's gown and asking if they liked it. Resident #3 was unable to respond appropriately to actions or questions from Resident #27. LPN #2 interrupted Resident #27's actions and asked what they were doing. Resident #27 stated they were trying to help Resident #3 get into bed. Resident #27 was instructed not to enter anyone's room without permission or staff presence.A Nurse Progress Note, dated 09/02/25 at 2:42 p.m., showed the evening shift nurse performed a head-to-toe assessment with no physical injuries or bruises noted. Resident #3 refused any pain medication but was anxious. Anxiety medication was last administered at 2:00 p.m.A Quarterly assessment for Resident #27, dated 08/09/25, showed a BIMS score of 6 which indicated severe problems with thinking and memory. The assessment showed Resident #27 had a diagnosis of dementia. The assessment showed Resident #27 required cues from staff for dressing, partial assistance with bathing, and substantial assistance with toileting.On 09/08/25 at 1:30 p.m., Resident #3's emergency contact #1 stated they lived in a different state and did not see Resident #3 often. They stated they were not aware of any abuse, but the facility did inform them of hospitalizations, Resident #3's refusal to eat and their rapid decline a few weeks ago. They stated Resident #3 gets taken care of as far as they know.On 09/09/25 at 9:30 a.m., LPN #2 stated the housekeeper noticed Resident #27 in Resident #3's room and alerted CNA #3, who then proceeded to alert them. LPN #1 stated they heard Resident #27 saying you like that, while they were touching Resident #3 under their gown around the groin area. LPN #2 stated Resident #27 had gotten more confused within the last two weeks. LPN #2 stated they asked Resident #27 about it the next day, but Resident #27 did not remember. LPN #2 stated they had never witnessed Resident #27 ever trying to enter Resident #3's room before. LPN #2 stated Resident #27 had entered another resident's room to go to the bathroom before. LPN #2 stated Resident #27 was easy to redirect.On 09/09/25 at 11:48 a.m., CNA #3 stated when they walked past Resident #3's room, Resident #27 was lifting the cover off of Resident #3, so they went to get the nurse. CNA #3 stated they had not seen Resident #27 do anything like that before.On 09/09/25 at 11:52 a.m., the administrator stated Resident #27 was put on 1:1 observation for 72 hours. The administrator stated Resident #27 did not go into any other resident's rooms or have any behaviors during that time. The administrator stated Resident #27 did not even remember the incident happened. The administrator stated they sent out referrals to three different behavioral health facilities to get Resident #27 evaluated. The administrator stated ultimately by the time a bed was available Resident #27 no longer qualified due to having no behaviors within the last 72 hours. The administrator stated their psychiatric doctor came to the facility once a month, but the facility was trying to get psychiatric to come weekly. The administrator stated Resident #3 and Resident #27 were their own responsible parties. The administrator stated there had been no other concerns since the incident. They stated they did not do Safe Surveys or any additional in-service training because the incident had been witnessed and stopped by staff. The administrator stated the facility had dementia training with a speaker in March of 2025. The administrator stated Resident #3 had not shown any signs of distress or acted any differently than previous to the incident.On 09/09/25 at 2:03 p.m., MDS coordinator #1 stated interventions were discussed in the morning stand up meeting. They stated Resident #27 was in the dining room with other residents 90% of the time. MDS Coordinator #1 stated the staff were made aware of the interventions through digital communication, and face to face shift report. They stated after the initial 72 hours of 1:1 observation, the staff were monitoring Resident #27's whereabouts.On 09/09/25 at 2:11 p.m., CMA #1 stated they were aware of the inappropriate touching, and that staff were instructed to keep an eye on Resident #27. CMA #1 stated Resident #27 was confused but was usually seen in the dining room playing games with other residents they lived with prior to being in the facility. CMA #1 stated they had never heard of Resident #27 doing anything like that before.On 09/09/25 at 2:13 p.m., LPN #3 stated they were aware of the incident and Resident #27 had been put on 1:1 monitoring but was unsure if that was still in effect. LPN #3 stated their responsibility when made aware of allegations of abuse was to make sure all the residents were safe, separate the residents, and try to educate the residents were able to comprehend. LPN #3 stated Resident #27 had never done anything like that before, and Resident #27 was usually in the dining room with their spouse, that is also a resident.On 09/09/25 at 2:17 p.m., CNA #1 stated they had provided 1:1 observation on a morning shift after the incident. CNA #1 stated Resident #27 stayed in the dining room most of the day, ate popcorn, and went out to the patio. CNA #1 stated they did not see any inappropriate behavior, and they were not aware of any other incidents involving Resident #27.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a physician's order for monthly catheter changes was followed and failed to ensure a resident with a indwelling urinary catheter received services to help prevent urinary tract infections for one (#35) of two sampled residents reviewed for catheters. The deficient practice resulted in a bladder stone. The MDS Resident Matrix, dated 09/23/24, identified four residents with catheters. Findings: A Clinical Supplies in Case of Emergency policy, reviewed 09/17/24, read in part, It is the policy of this facility to establish procedures to ensure that needed clinical supplies are available to maintain continuity of care in the case of emergency. It also read, Par levels of various supplies will be set, base on use, and procedures for reordering will be followed accordingly to ensure availability of supplies on an ongoing basis. Res #35 had diagnoses which included acute kidney failure and retention of urine. The admission assessment, dated 04/29/24, documented the Brief Interview for Mental Status score of 15 indicating this resident was cognitively intact. A physician order, dated 04/22/24, documented to change indwelling catheter on the 15th of every month on the 10-6 shift starting on the 15th and ending on the 18th every month. The care plan did not mention their refusal to allow nurses to change catheter, or their request for urologist to provide this care. A progress note, dated 05/16/24 at 9:58 a.m., documented the catheter size was not currently in the building. A progress note, dated 05/17/24 at 6:14 a.m., documented the catheter size was on order. A progress note, dated 05/18/24 at 2:25 a.m., documented the catheter size not available that it was on order. There was no documentation that the physician or DON was notified that the catheter had not been replaced. After three days the order was removed from the medication administration notifying the staff that it needed to be done until it appeared again on the following month administration record for the 15th through the 18th. A progress note, dated 06/14/24 at 9:40 p.m., documented the catheter was draining cloudy yellow urine with foul odor and cream sediment observed in the drainage tube. It was documented the physician was notified and Macrobid (antibiotic medication) 100mg twice daily initiated. A progress note, dated 06/15/24 at 10:18 p.m., documented the catheter continues to drain cloudy yellow urine with foul odor and cream color sediment in tube. The catheter was not changed. A progress note, dated 06/16/24 at 9:38 p.m., documented the catheter was draining cloudy yellow urine with foul odor. It was documented the resident was on an antibiotic for UTI. A progress note, dated 06/17/24 at 6:05 a.m., documented the resident refused to have their catheter changed and was witnessed by two nurses. It was documented the resident continued on antibiotics and would continue to monitor. There was no notification of the refusal to the physician or DON. A progress note, dated 06/18/24 at 7:29 a.m., documented resident refused to allow any nurse to change their catheter, as they insisted on the urologist to change catheter. It was documented the physician was notified and gave an order to send to the ER for catheter change. It was documented the resident refused to go to ER. There was no documentation the physician or DON was made aware of their refusal to go to ER or that their catheter had remained unchanged since prior to the 04/22/24 admission date. A progress note, dated 07/16/24 at 6:09 a.m., documented the resident refused catheter change. It was documented they verbalized they would wait unit Wednesday to talk to their new primary care physician to refer them to a urologist instead. It was documented the ADON was notified. A progress note, dated 07/26/24 at 11:12 a.m., documented that resident's catheter was leaking. It was documented two nurses went to room to reinforce the resident's catheter. A progress note, dated 08/02/24 at 6:33 a.m., documented the resident reported not having any urine flow via catheter at 4:45 a.m. It was documented a nurse assessed and found 60cc urine in bag with no leak and abdomen distended. It was documented the resident complained of lower abdominal pain and felt like they were peeing. It was documented the physician was notified and an order was received to change the catheter. It was documented the resident refused stating they wanted a urologist to put in the catheter and wanted to go to ER. It was documented the DON was notified and the resident was transferred to hospital. A hospital update, faxed to the facility on [DATE], documented the resident had a new diagnosis of a bladder stone received on 08/02/24. A progress note, dated 08/08/24 at 4:48 p.m., documented the resident returned from the hospital on [DATE] at 3:40 p.m. It was documented a new order for finasteride (5-alpha reductase inhibitor) 5mg was sent with resident. A progress note, dated 08/18/24 at 1:44 a.m., documented the resident refused catheter change stating it was changed in the hospital. A progress note, dated 08/24/24 at 9:18 a.m., documented the resident told the nurse their catheter was leaking and had been disconnected at the hub and they had been reconnecting it. A progress note, dated 08/24/24 at 9:37 a.m., documented the DON and ADON were notified. It was documented the ADON instructed the nurse to send the resident to the hospital to have the catheter changed out. It was documented the resident refused stating they had an appointment with the urologist coming up. A progress note, dated 08/24/24 at 2:56 p.m., documented nurse was allowed by resident to change out the drainage containment part to see if that would help with the leaking. A progress note, dated 09/16/24 at 4:51 a.m., documented the resident refused to have their catheter changed. On 09/26/24 at 2:42 p.m., the ADON was asked the reason the resident was allowed to go so long without having their catheter changed. They stated, Hindsight is 20/20, coulda, shoulda, woulda. I don't know. On 09/27/24 at 9:43 a.m., the administrator and corporate nurse #2 stated the protocol was to notify the DON or administrator if supplies were not in the facility so the administrator could place an order. Corporate Nurse #2 stated the resident should have been educated on the consequences of not changing catheter or allowing staff to provide care. They stated going forward they will just make sure Resident #35 had a urologist appointment monthly to allow the urologist to change their catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure residents were provided supervision to prevent falls and implement interventions to prevent falls for two (#1 and #2) of three sampled residents reviewed for falls. Resident #1 had seven falls without having any interventions in place and sustained a fracture to the face on 05/09/23. Resident #2 had 22 falls in a six month period without changes in fall interventions and sustained hematoma, bruising, and lacerations that required stitches. The DON identified 43 residents who were moderate to high risk for falls. Findings: The facility's Fall Policy, implemented 01/01/23, read in part, .Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls .the nurse will indicate .the resident's fall risk and initiate interventions on the baseline care plan in accordance with the resident's level of risk each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care .interventions will be monitored for effectiveness .the plan of care will be revised as needed .when any resident experiences a fall, the facility will .review the resident's care plan and update as indicated . 1. Resident #1 was admitted to the facility on [DATE] with diagnoses which included respiratory failure, chronic kidney disease, anxiety, chronic pain insomnia, convulsions, fracture of the lower end of left radius and fracture of shaft of humerus left arm. A fall risk assessment, dated 01/28/23, documented the resident was a moderate risk for falls. A base line car plan, dated 01/28/23, did not address the resident was at risk for falls on admission. An admission assessment, dated 02/08/23, documented Resident #1's cognition was severely impaired, and totally dependent on staff for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. The assessment documented the resident was incontinent of bowel and bladder, and no history of falls prior to admission. A fall risk assessment, dated 02/10/23, documented the resident was at moderate risk for falls. Resident #1 admission comprehensive care plan, dated 02/12/23, did not address the resident was a moderate risk for falls. An incident report, dated 03/04/23, at 2:00 p.m., documented Resident #1 was found sitting on the floor in front of their wheel chair and stated they had fell. An incident report, dated 03/04/23, at 11:28 p.m., documented Resident #1 fell from her wheelchair with no injures. A fall risk assessment, dated 03/06/23, documented Resident #1 was at high risk for falls. An incident report, dated 03/17/23, documented staff heard Resident #1 screaming and found them on the floor, floor mat in place, and bed was in the lowest position. A fall risk assessment, dated 03/19/23, documented Resident #1 was a moderate risk for falls. An incident report, dated 03/23/23 at 4:31 a.m., documented staff saw Resident #1 sitting on the floor mat upright on their buttocks. Resident #1 had stated they were trying to go to the bathroom. A fall risk assessment, dated 03/23/23, documented the resident was a high risk for falls. There was no documentation the facility assessed Resident #1's four falls in March and implemented interventions to aide in the prevention of further falls. An incident report, dated 04/14/23 at 10:10 p.m., documented the nurse heard a loud noise and observed Resident #1's upper extremity on the floor mat with the bed in the lowest position. A fall risk assessment, dated 04/15/23 and 04/16/23, documented the resident was a moderate risk for falls. A fall risk assessment, dated 04/19/23 and 04/25/23, documented the resident was a high risk for falls. An incident report, dated 04/30/23 at 8:00 a.m., documented Resident #1 was observed sitting on the floor mat. Resident #1 stated they fell and the report documented the intervention was to educate the resident on the use of call light. Another incident report, dated 04/30/2 at 10:15 a.m., documented a CMA screamed that Resident #1 was on the floor. A fall risk assessment, dated 05/01/23, documented Resident #1 was a high risk for falls. There was no documentation the facility assessed Resident #1's three falls in April to determine the root cause and develop interventions to aide in the prevention of further falls. Resident #1's care plan, dated 05/05/23, read in part, .I have risk for falls because I am unsteady in my walking and balance (and from my fall score assessment). I had an actual fall in the last 30 days - I fell on [DATE] twice; 04/14/23, 03/23/23, 03/17/23 .I have frequent falls because I am forgetful with impaired cognition and unaware of my safety needs .Interventions .Attempt to anticipate and meet my needs .Avoid repositioning furniture in my room .Be sure my call light is within reach and encourage me to use it for assistance as needed. Answer my call light in timely manner .Beveled edge fall mat to floor at bedside .Continue to encourage me to work with physical therapy (PT) to work on my .Keep Call-light within reach and answer in a timely manner .Place my bed in a low position when I am not receiving care .Place non skid pad in my chair .Please review if I need or need a change in adaptive equipment or devices as needed .Review information if I have a fall and attempt to determine cause of fall. Record possible root cause. Alter and remove any potential cause if possible. Educate me, my family/caregivers as to the cause .Staff will continue to anticipate and meet my needs everyday . Resident #1 had seven falls since admission and the care plan, dated 05/05/23, this was the first care plan that addressed the residents falls and risk for falls. A quarterly assessment, dated 05/09/23, documented Resident #1 had two or more falls without injury and one fall with a minor injury. Two fall risks assessments, dated 05/09/23, documented Resident #1 was a high risk for falls. An incident report, dated 05/09/23 at 1:11 a.m., read in part, . resident had an unwitnessed fall in her room .hit the right side of her face, swelling/redness noted to right side of face .resident transferred via stretcher .to ER for eval and treat for facial/head injury . An incident report, dated 05/09/23 at 11:25 a.m., documented Resident #1 had fallen out of their wheelchair onto their buttocks. A nurse's note dated 05/09/23 at 1:54 p.m., read in part, .CNA called this nurse to resident's room that she fell on floor. This nurse immediately entered resident's room and observed her lying on her right side on floor mat .Head to toe assessment done by this nurse. Swollen noted to her upper right cheek .New order to transfer to ER for evaluate and treat as indicated d/t fall with head injury .injury location face . A nurse's note dated 05/09/23 at 6:22 p.m., read in part, .Received report from .Hospital .that resident has fracture of right cheek bone . A nurse's note dated 05/09/23 at 8:28 p.m., read in part, .1955 [7:55 p.m.] returned to facility from .Hospital Discharge instructions received to schedule appointment with .DDS as soon as possible for a visit .Bruise observed to right eye . There was no documentation the facility assessed Resident #1's two fall on 05/09/23 to determine the root cause and develop interventions to aide in the prevention of further falls. An incident report, dated 05/19/23 at 1:55 p.m., documented Resident #1 had an unwitnessed fall due to throwing themselves onto the floor onto the right side. A corresponding nurse's note dated 05/19/23 at 8:49 p.m., read in part, .1355 [1:55 p.m.] Resident was sitting her bed, threw self onto the floor on her right side .Resident stated that she is a vegin, that she is not afraid . A nurse's note dated 05/31/23 at 7:07 p.m., read in part, .Resident f/u charting r/t fall no injuries noted . There was no additional documentation in the clinical record or an incident report regarding Resident #1's fall referenced in the nurse's note. An incident report dated 06/03/23 at 1:25 a.m. documented Resident #1 had a fall in her room, was on all fours and confused. A nurse's note dated 06/03/23 at 1:31 a.m., read in part, .focused charting r/t resident out of bed on the side on all fours resident is confused .this nurse asked why resident is on the ground resident do not know why .resident on using call light . A nurse's note dated 06/08/23 at 8:21 p.m., read in part, .1940 [7:40 p.m.] This nurse observed resident crawling on the floor picking things sister-in-law sitting in the chair in resident's room stated that resident was sitting in her w/c trying to put on her shoes, the w/c went away from her . There was no further documentation of Resident #1's fall from the wheelchair while putting on her shoes. An incident report dated 06/10/23 at 11:45 p.m., documented Resident #1 was on the ground and didn't know what happened. The incident report further documented Resident #1 was sent to ER due to their catheter being pulled out. There was no additional documentation in the clinical record regarding the resident's fall. An incident report dated 06/26/23 at 11:45 p.m., documented Resident #1 had a fall in their room while attempting to go to the bathroom unassisted. A nurse's note dated 06/26/23 at 1:23 p.m., read in part, .CNA called this nurse to resident's room that she fell and on floor .resident lying on floor on her left side in bathroom .therapists said that resident went to bathroom unassisted and unable to get back on w/c by herself .Staff to continue to monitor resident frequently . A nurses note dated 07/04/23 at 11:57 p.m., read in part, .Focused charting r/t fall unwitnessed @ 2357 [11:57 p.m.] this nurse walked by resident room and noticed resident was on the ground on fall mat on left side, bed was at lowest position, this nurse asked resident what happen Res is alert but confused, unable to give description of incident. Head to toe assessment was preformed .there is a c/o pain to left arm 2/10 pain medication was given, this nurse order x ray to left arm order number #2757 . A nurse's note dated 07/05/23 at 12:09 p.m., read in part, .Resident had a x-ray of left forearm done today, results shows forearm demonstrates normal bony ossification . Resident #1 had four falls in the month of June and one on 07/04/23. There was no documentation the facility assessed Resident #1 falls for root cause analysis and reviewed and revised any interventions to aide in the prevention of further falls. On 07/21/23 at 1:58 p.m., Resident #1 was observed up in the wheelchair propelling themselves around their room and out into the hall. There was a mat in the room and the bed was in the lowest position. The resident was asked about their falls and they respond by saying they had to go to the airport. On 07/24/23 at 1:40 p.m., MDS coordinator #1 stated Resident #1 was a moderate risk for falls on admission and there should have been a comprehensive care plan to address the fall risk. The MDS coordinator was asked if the base line care plan should address a newly admit resident with a moderate risk for falls. They stated it should not be addressed on the base line care plan, but the comprehensive care plan should address the fall risk. On 07/25/23 at 8:23 a.m., CNA #1 stated Resident #1 was a fall risk due to attempting to stand and transfer on their own. CNA #1 further stated the resident had fallen one time and had a wound by her eye. The CNA further stated Resident #1 now had a low bed, mat, and a special pillow for their bed to prevent falls. When asked, the CNA was not sure how long the interventions had been in place. On 07/25/23 at 8:40 a.m., LPN #1 stated Resident #1 had a low bed, fall mat, and was at risk of falls. LPN #1 further stated they did not know how long the resident had been at risk for falls and had only been employed for two weeks. On 07/25/23 at 8:52 a.m., CMA #1 stated Resident #1 will have anxiety and get very impulsive and compulsive. CMA #1 stated they did not know if Resident #1 had falls but knew they were at risk because of the low bed a floor mat. CMA #1 further stated they were not aware of any further interventions in place for Resident #1. On 07/25/23 at 10:05 a.m., MDS Coordinator #1 stated Resident #1 was a moderate risk for falls on admission and had her first two falls on 03/04/23. The MDS Coordinator stated the resident had 14 falls since admission and sustained a fracture to the face on one of the falls. The MDS Coordinator was asked when fall interventions were first implemented. The MDS Coordinator stated on 05/05/23 and the care plan should have been developed on admission. On 07/25/23 at 10:57 a.m., the ADON stated they and the DON were responsible for investigating falls and determining the root cause. The ADON further stated the care plan should be reviewed for falls after a fall or when a MDS was completed. The ADON stated Resident #1 was a high risk for falls and had a lot of falls. The ADON further stated the resident had injuries from the falls but not after every fall. The ADON reviewed the care plan and stated Resident #1 should have had a care plan for falls on admission and it should not have taken several months to develop a care plan. On 07/25/23 at 11:34 a.m., the DON stated newly admitted residents that were moderate and high risk for falls should have a care plan developed for falls on admission and with the base line care plan. The DON further stated the post fall assessment would determine the root cause and interventions should be reviewed and implemented as needed. When asked about the root cause analysis for Resident #1 they stated they had not been completed due to not having an employee doing them and now they were not being completed consistently. The DON was made aware of the lack of care plan until May 2023 and they stated Resident #1's care plan was not developed and revised timely. 2. Resident #2 had diagnosis of disorder with seizures, chronic pain, insomnia, asthma, anxiety, dementia with behavioral disturbance, COPD, muscle weakness, and down syndrome, and recurrent depression. A fall risk assessment, dated 12/29/22, documented the resident was a moderate risk for falls. An incident report, dated 01/16/23 at 1:50 p.m., documented Resident #2 had fallen in the dining room and was lying in between the walker with the right side of the walker under his back. Resident #2 sustained a contusion to the back of their head and was sent to the hospital. A hospital emergency report, dated 01/16/23, read in part, .chief complaint .unwitnessed fall is on eliquis .radiology hematoma to posterior scalp .final diagnosis .closed head injury . A fall risk assessment, dated 01/17/23, documented the resident was a high risk for falls. An incident report, dated 01/17/23 at 9:55 a.m., and a nurse's note, at 10:35 a.m., read in part, .This nurse was notified by the housekeeper that the resident was on the floor. Upon arrival this nurse noticed that the resident was laying on his stomach and he was awake and alert to self which is the resident baseline. Head-to-toe assessment done. Resident had a red bruise with abrasion on the middle of his for head and his left nostril was bleeding .Resident does still having bruising to the back middle of his head d/t fall on 1/16/23 . EMSA arrived around 1015 and left around 1030 . An incident report, dated 02/07/23 at 6:00 a.m., documented Resident #2 was in the dining room and was observed trying to get out of the chair and fell. A fall risk assessment, dated 02/07/23, documented Resident #2 was a moderate risk for falls. There was no documentation the facility had assessed the two falls in January and one fall in February for the root cause and reviewed and revised the care plan interventions. A quarterly assessment, dated 02/27/23, documented Resident #2 had a severe cognitive impairment, required extensive assistance from staff for bed mobility, transfers, and toilet use. The assessment documented the resident was always incontinent of bowel and bladder and had two or more falls without injury and one fall with an injury. Resident #2's care plan, reviewed on 02/28/23, documented they were at risk for falls due to socks hanging on their feet causing them to trip and for not using a walker. It also documented the resident refused to wear a helmet. The care plan documented the interventions included the following: Assure I have shoes or non-slip socks on; Attempt to anticipate and meet my needs; Be sure my call light is within reach and encourage me to use it for assistance as needed. Answer my call light in timely manner; Give me verbal reminders to call for assistance when needing to transfer; Give verbal reminders to use my walker; I need a safe environment with keeping my assistive device within reach at all times; I use a walker with tennis balls on back legs; Floors free from spills and/or clutter; Adequate, glare-free light and personal items within reach; Review information if I have a fall and attempt to determine cause of fall and record possible root cause; Alter and remove any potential cause if possible; and Educate me, my family/caregivers as to the cause. All care plan interventions for Resident #2 had been implemented between 2019 and 2021. An incident report, dated 03/25/23 at 5:55 a.m., and a nurse's note, at 6:12 a.m., read in part, .Nurse was sitting at nursing station when resident was heard screaming. Upon going to patients room patient was found sitting on floor with legs crossed beside the bedside table/ nightstand. A wound to side of the head was observed (laceration/deep cut) wound area was assessed and cleaned and bleeding controlled .Order to send to ER for eval and treat . A hospital emergency report, dated 03/25/23, read in part, .assessment .closed head injury .facial laceration laceration repair .location scalp length (cm)3 .repair method .sutures .final diagnosis laceration without foreign body .long term (current) use of anticoagulants .external cause .fall . An incident report, dated 03/29/23 at 12:17 p.m., and a nurse's note, at 12:16 p.m., documented the resident had a witnessed fall with no injuries. Documented intervention was to make sure the resident had on non-skid socks. A fall risk assessment, dated 03/25/23 and 03/29/23, documented Resident #2 was a moderate risk for falls. There was no documentation the facility had assessed the two falls in March for the root cause and reviewed and revised the care plan interventions. An incident report, dated 04/06/23 at 8:00 a.m., and a nurse's note, at 8:08 a.m., read in part, .Res lost his balance in the lounge area while ambulating with walker Res was assisted from floor, non-skid sock put on . A fall risk assessment dated [DATE], documented Resident #2 was a moderate risk for falls. An incident report, dated 04/09/23 at 11:10 a.m., and a nurse's note, at 11:29 a.m., read in part, .walked into PT room to see co Nurse, cleaning up Pt face, fall mat folded in half on floor in front of Pt bed as well as walker lying over on its side .Pt had a cut in middle of forehead and one under right nostril .PT is on blood thinner, could not get bleeding to stop .called 911 and Pt was taken to ER . A hospital emergency report, dated 04/09/23, read in part, .impression .fall .closed head injury .accidental fall .epistaxis [nose bleed] .chief complaint .fall at nursing home .on Eliquis .final diagnosis .injury of head initial encounter .epistaxis .external cause fall . A fall risk assessment, dated 04/09/23, documented Resident #2 was a high risk for falls. An incident report, dated 04/12/23 at 8:20 p.m., documented Resident #2 had an unwitnessed fall in their room and non skid socks had to be placed on their feet. A nurse's note, dated 04/12/23 at 10:29 p.m., read in part, .1930 [7:30 p.m.] CMA found resident sitting on the floor next to bed .Resident was then assisted by this nurse and the CMA to bed. Non-skid sock put on .continues to take off his socks ambulate self with a walker to the dinning room and back to his bed . An incident report, dated 04/14/23 at 7:55 a.m., read in part, .This nurse was notified that res had a fall in the lounge area face down and was bleeding .res unable to articulate .active bleeding stopped .pain 7 [scale of 1:10] . A corresponding nurse's note, dated 04/14/23 at 8:01 a.m., read in part, .This nurse was notified that res was on the floor, face down in the lounge area. Res was assisted to sitting position, active bleeding stopped .Res refused to wear helmet this morning .Res transported via ambulance to .Hospital . A nurse's note, dated 04/14/23 at 8:30 a.m., read in part, .resident's sister and his Responsible party called back asking what happened and what hospital her brother sent to .This nurse told her that resident fell and probably broke his nose because blood coming out of his nose from hitting his head on the floor. That resident is on Eliquis which is a blood thinner with tendency to bleed more. Resident transported to .Medical Center for evaluate and treat as indicated d/t fall with head injury . A hospital emergency report, dated 04/14/23, read in part, .medical decision making problems addressed .closed head injury .epistaxis .has multiple abrasions to his face and I can tell he is had some epistaxis from right nares final diagnosis injuries of head .abrasions of other part of head .epistaxis .cause if injury .fall . An incident report, dated 04/15/23 at 1:22 p.m., documented Resident #2 was sent to the hospital due to a head injury after a fall in their room. A nurse's note, dated 04/15/23 at 1:45 p.m., read in part, .Resident sent out [hospital name withheld] .due to fall with injury to head . A hospital emergency room report, dated 04/15/23, read in part, patient had an unwitnessed fall .patient has approximately 2 inch laceration of left lateral eyebrow patient has existing sutures to above right eyebrow .upon arrival to the ED patient has previous stitches over right eyebrow from another recent fall. Nursing home staff reports to EMS that the patient has frequent falls. He arrives with a bleeding laceration superior to his left eye. The patient takes Eliquis [a blood thinner] .laceration repair .3 cm on the frontal region of head superior to left eyebrow .6 4-0 sutures placed .admission diagnosis .laceration without forgiven body of left eyelid and periocular area external cause of injury .fall . A fall risk assessment, dated 04/15/23, documented Resident #2 was a high risk for falls. A nurse's note, dated 04/18/23 at 9:59 p.m., read in part, .Res refused putting on the helmet during this shift .Res refused to wear non-skid socks . There was no documentation the facility had assessed the five falls, three with injuries in April for the root cause and reviewed and revised the care plan interventions. An incident report, dated 05/12/23 at 8:30 a.m., documented the resident had a non-injury fall in the dining room. A nurse's note, dated 05/12/23 at 9:35 a.m., read in part, .Focused charting r/t fall this nurse was told by staff that resident had a fall in the dining room. This nurse quickly went to dining area and resident was sitting upright in his wheel chair .This nurse told resident next time he needs help just call . An incident report, dated 05/22/23 at 6:30 a.m., documented Resident #2 had an unwitnessed fall in their room and sustained a laceration to the forehead and was transported to the hospital for treatment and evaluation. A nurse's note, dated 05/22/23 at 7:50 a.m., read in part, .CNA reported to this nurse that resident fell in his room. This nurse and another nurse immediately entered resident's room and observed him sitting on floor next to his floor mat. Resident stated that I fell .Head to toe assessment done and a small laceration noted to his forehead .New order to transfer to ER for evaluate and treat as indicated d/t fall with head injury . A hospital emergency report, dated 05/22/23, read in part, .admission diagnosis .injury of head .final diagnosis .abrasion of scalp .cause of injury .fall from bed . A fall risk assessment, dated 05/12/23 and 05/22/23, documented Resident #2 was a moderate risk for falls. There was no documentation the facility had assessed the two falls, one with an injury in May for the root cause and reviewed and revised the care plan interventions. An annual assessment, dated 06/01/23, documented Resident #2 required extensive assistance from staff for bed mobility, transfers,walking and eating. Resident #2 was totally dependent on staff for dressing, toilet use and personal hygiene. An incident report, dated 06/02/23 at 10:18 p.m., documented Resident #2 fell out of the bed and sustained a red mark above the left eyebrow. The documented intervention was to educate resident on using the call light. A nurse note, dated 06/02/23 at 10:22 p.m., read in part, .focused charting r/t fall out of bed this nurse was walking by resident room when this nurse noticed that resident was on the ground this nurse asked resident what happen resident cant not communicate well resident bed was at lowest position fall mat was down this nurse eval resident there were no bruise just red mark above left eyebrow .this nurse educated resident on how to use call light . A fall risk assessment, dated 06/05/23, documented Resident #2 was a high risk for falls. An incident report, dated 06/06/23 at 8:31 a.m., documented Resident #2 had an unwitnessed fall in their room and sustained a hematoma to the left forehead. Resident was transferred to the hospital for evaluation and treatment. A nurse's note, dated 06/06/23 at 9:35 a.m., read in part, .Nurse was called at 8:20 am that resident has fallen, this nurse found resident face down on the floor in resident room. Upon assessment, nurse found hematoma on resident left forehead .Resident could not tell this nurse if he has any pain .EMSA called and resident was transfer .for Evaluation and treatment. An incident report, dated 06/06/23 at 10:13 p.m., documented Resident #2 was found on the floor mat by his bed with no injuries. There were no documented interventions on the incident report or in the clinical record. A hospital emergency report, dated 06/06/23, read in part, .final diagnosis injury of head .cause of injury fall from bed . An incident report, dated 06/14/23 at 12:02 p.m., documented the resident had an unwitnessed fall in their room and the nurse found the resident yelled out in his room. Resident #2 was found lying supine with both legs straight on the floor mat. There were no documented interventions on the incident report or in the clinical record. An incident report, dated 06/19/23 at 2:44 a.m., and a nurse's note, at 3:12 a.m., read in part, .focused charting r/t fall in room this nurse saw resident on the fall mat on right side in front of bed. The bed was at the lowest position .resident has some red marks on face .this nurse educated resident on not getting out of bed and using call light . An incident report, dated 06/21/23 at 11:07 a.m., and a nurse's note, at 11:47 a.m., read in part, .This nurse called to the dinning room that resident has fallen. Nurse found resident lying on his right side with both legs straight . There were no documented interventions on the incident report or in the clinical record. There was no documentation the facility had assessed the five falls, one with an injury in June for the root cause and reviewed and revised the care plan interventions. An incident report, dated 06/26/23 at 12:15 a.m., documented Resident #2 was found on the ground by his dresser and was not able to communicate what had happened. The report documented the resident was sent to the hospital for evaluation and treatment. A hospital emergency report, dated 06/26/23, read in part, .reason for visit contusion of eyeball and orbital tissue left eye final diagnosis .contusion of eyeball and orbital tissue left eye .causes of injury .fall . A fall risk assessment, dated 06/07/23, 06/16/23, 06/19/23, 06/21/23, 06/22/23, and 06/27/23, documented Resident #2 was a moderate risk for falls. Resident #2's care plan, up-dated on 06/28/23, documented the following interventions were implemented: Beveled edge fall mat placed to floor at bedside; Be in view of staff when I am out of bed; Provide encouragement and monitoring helmet is on to decrease risk for head injuries; Keep my bed in a low position; Medication review; Physical therapy to evaluate and treat me as ordered; Restorative and ambulation with walker; Staff to do frequent checks while in bed; Staff to monitor for no-skid footwear; Staff to anticipate and meet needs; and standard fall mat at bedside. The interventions were the first documented since the last review of the care plan on 02/28/23. An incident report, dated 07/15/23 at 11:07 a.m., documented Resident #2 had an unwitnessed fall in the dining room and was bleeding above the left eye. A nurse's note, dated 07/15/23 at 11:07 a.m., read in part, .Resident was sent out this morning, due to a fall in the dining room with injury .was sent out with EMSA .wound above eye was no longer bleeding when he left . There were no documented interventions on the incident report or in the clinical record the facility assessed the fall for the root cause and reviewed and revised interventions. Resident #2 had 22 falls from 01/16/23 through 07/15/23 and the only care plan intervention changes was on 06/28/23. On 07/21/23 at 4:15 p.m., Resident #2 was observed in his bed with a floor mat on the floor and the bed in the lowest position and observed with bruising to their right temple. The resident was asked general questions and would not respond to them. LPN #5 entered the room and stated the resident had a fall in the dining room and was sent to the hospital because he was not responding a few days earlier. The nurse further stated Resident #2 could not ask for help or understand to use the call light. On 07/24/2023 at 3:56 p.m., Resident #2's power of attorney stated the resident had a lot of falls. The power of attorney stated the facility has a fall mat and a helmet but Resident #2 does not like wearing it. The power of attorney stated from what they had been told there was nothing more the facility could do about the falls. The power of attorney stated Resident #2 did not understand to ask for help and why they would need to wear the helmet or use the call light. On 07/25/23 at 8:31 a.m., CNA #1 stated the resident was a fall risk and they

A past noncompliance with harm was determined to exist effective 01/12/23 related to the facility's failure to provide correctly administered pain medication. The facility failed to follow their medication administration policy which resulted in a resident being sent to the ER for treatment of Narcan. The resident was sent from the facility 01/12/23 at 8:08 a.m., to the ER and was returned to the facility 01/13/23 at 5:11 p.m. On 01/18/23 at 10:45 a.m., the Oklahoma State Department of Health verified the existence of the past noncompliance with harm related to the improper administration of pain medications to a resident. Based on record review and interview, the facility failed to administer pain medication correctly to one (#1) of three sampled residents who were on a pain management program. The facility reported a resident census of 59. The facility reported 42 residents on a pain management program. Findings: Medication errors policy, read in part, .It is the policy of this facility to provide protections for the health, welfare, and right of each resident by ensuring resident receive care and services safely in an environment free of significant medication errors . Medication administration policy, read in part, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . LPN #3 was hired 05/24/21 and worked nights. Resident #1 admitted to the facility 08/07/21 with diagnoses to include chronic pain syndrome, acute respiratory failure with hypoxia and hypercapnia, shortness of breath, hemiplegia and hemiparesis/cerebrovascular disease affecting left non-dominant side, anxiety, depression, and COPD. A physician order, dated 06/27/22, to monitor O2 sats every shift. The January 2023 MAR documented O2 sats in the 90's with 4 L NC. A care plan, dated, 07/26/22, read in part, .I am resistive to care related to having anxiety and COPD which makes me have air hunger .I will request prn nebulizer 4-6 times per day, then will have manipulative behaviors saying I didn't get the treatments and call EMSA .I refuse my O2 at times and will have manipulative behaviors saying staff did not make O2 available to me .explain to me and/or my representative of the possible outcome or consequences that can occur if I do not comply with care or treatment . A nurses note, dated 01/09/23, read in part, .nurse noticed that the resident had his nasal cannula off each time. This nurse replaced the nasal cannula into the resident nose and educated the resident on the importance of wearing it . A nurses note, dated 01/10/23, read in part, .resident has been seen several times with his nasal cannula out of his nose. This nurse along with the CNA's placed it back on him and educated him on the importance of wearing it . A nurses note, dated 01/12/23 at 8:10 a.m., read in part, .when this nurse went into the resident room this nurse noticed that the resident did not have his nasal cannula on. The resident nasal cannula was on the floor. This nurse replace the nasal cannula. Resident oxygen level was 35%. B/P 87/56, pulse 76. This nurse administered the resident routine inhaler and prn breathing treatment. Resident oxygen level went up to 89-90% (B/P 92/65, pulse 86) with the breathing treatment but a few minutes afterward the resident oxygen level dropped down to 77-78%. Dr (name-deleted) notified and this nurse received an order to send the resident to the ER. EMSA notified. The resident representative (name-deleted) notified and verbalized understanding. EMSA and the fire department arrived and the resident stated that he did not want to go but the EMSA personnel explained to the resident of the importance of him going due to his low oxygen level. Resident left the building at 0808 [8:08 a.m.] . A nurses note, dated 01/12/23 at 11:54 a.m., read in part, .The ER nurse stated that the resident keeps taking off his oxygen and he refuses to get intubated . An incident report, dated 01/12/23, read in part, .notifications made to physician, family, adult protective services and the appropriate licensing board . Fax receipts were included of the notifications to APS and OBN. A medication error report form, dated 01/12/23, read in part, .incident details .occurred at 0438 .Discovered 1300 .by the hospital .Norco .description of error: nurse gave midnight and 0400 dose at the same time .wrong dose, wrong time . Notification of Incident .01/12/23 1330 Dr. (name-deleted) Notified .01/12/23 1340 (name-deleted) pharmacist notified .Results of investigation: nurse (LPN) administered 2 doses (Norco 7.5) at same time . Resident evaluation .resident unresponsive .sent to ER .intervention: Narcan and Narcan drip . Interventions/Corrections implemented: suspension of staff member, med cart audited, chart and record review. LPN (#3) educated on med administration procedures including PIG method, med audits on LPN (#3) x 7 shifts then every other shift x 7 shifts then 2/wk x 60 days . The individual narcotic count sheet, dated 01/12/23, documented a midnight dose and a 0400 dose of Norco 7.5 mg signed out by LPN (#3). The medication administration record, dated 01/12/23, documented the midnight dose and 0400 dose of Norco 7.5 mg being given at the same time through the RN's investigation and medication administration audit report. A written statement by the LPN (#3), dated 01/12/23, read in part, .01/12/23 at midnight dose of Lortab was held due to resident sleeping. Around 4-5 a.m. Lortab was popped out also and took to the resident room. Only 4 a.m. dose was given and 1 wasted the 12 midnight dose in the trash . There was no documentation of a waste. Employee disciplinary counseling action, dated 01/12/23, signed 01/13/23, read in part, .On 01/12/23 employee administered the 0000 and 0400 dose of Norco 7.5 at the same time 0438 to resident (#1). Resident was then found by day shift nurse as having a O2 sat of 35% resulting in resident being transferred via EMSA to the hospital. Hospital stated resident presented with hypercarbic respiratory failure (the level of carbon dioxide is too high usually because something prevents the person from breathing normally) and was given Narcan. Patient currently in ICU on Narcan drip and need for continuous monitoring . Resident #1 returned to the facility the following day, 01/13/23 at 1711. Physician ordered change of Norco from 7.5 mg to 5 mg. A nurses note, dated 01/13/23, read in part, .resident return form (name-deleted) hospital by stretcher van at about 5 p.m. Resident cont to be alert and oriented to time, place and self. No s/s of acute distress .B/P 121/68, HR 66, O2 93% 4 L NC. New order for BMP and to stop Xanax . A printed slide show presentation, controlled substances in long-term care facilities was included in the LPN (#3) training. Controlled substances in Long-term care facilities (quiz) was dated as completed 01/13/23. Medication regimen review, dated 01/13/23 through 01/17/23, as individual entries of RN audits of LPN (#3). Medication administration competencies, dated 01/13/23 through 01/17/23, as individual medication administration evaluations of LPN (#3) by an RN. A fax, dated 01/16/23, read in part, .Oklahoma board of nursing .ODH form 283 .Oklahoma board of nursing verification report . A nurse note, dated 01/16/23 at 0920, read in part, .when this nurse went to give the resident his morning medication this nurse noticed that he resident did not have his nasal cannula on and this placed the nasal cannula back on and educated the resident on the importance of wearing it . A nurses note, dated 01/17/23 at 0831, read in part, .The CNA informed this nurse on rounds that the resident did not have his nasal cannula on and she replaced it back in his nose. When this nurse went to give morning medication to the resident, the resident had his nasal cannula on his forehead. This nurse tried to replace the nasal cannula back in the resident nose. The resident told this nurse no that it is giving him a headache . On 01/17/23 at 3:33 p.m., Resident #2 had no concerns or complaints about receiving medications correctly. At 3:53 p.m., the DON stated (LPN #3) did not waste (narcotic) with anybody. There was no proof (documentation) it was wasted by reviewing the individual narcotic record. The DON stated it looked like both (Norco 7.5 mg midnight dose and 0400 dose) were given at the same time. On 01/18/23 at 12:10 p.m., Resident #1 was observed with head of bed elevated, awake, alert, not wearing O2. LPN #1 attempted to place O2, but resident refused. Resident #1 had no concerns or complaints about receiving medications correctly. At 12:25 p.m., Resident #3 had no concerns or complaints about receiving medications correctly. At 1:25 p.m., records were reviewed with the DON. Completed documentation was provided as evidence past non-compliance had been corrected and LPN (#3) would continue to be monitored.