South Park East

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Based on record review and interview, the facility failed to ensure a resident's family was notified of an allegation of abuse for 1 (#5) of 7 sampled residents reviewed for abuse.The administrator identified 42 residents resided in the facility. Findings:A policy titled Change in a Resident's Condition or Status, revised 12/2016, read in part, Our facility shall promptly notify the resident, his or her attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes

in level of care, billing/payments, resident rights, etc. A quarterly assessment, dated 07/30/25, showed Resident #5 had a BIMS score of 3, which indicated severe cognitive impairment. The assessment showed

they were independent with mobility.An incident report, dated 08/31/25, showed Resident #1 was observed touching Resident #5's breasts. The report showed the family was notified. An order summary, dated 09/04/25, showed Resident #5 had diagnoses which include Alzheimer's disease and dementia. A family representative interview with Resident #5's family stated they were not aware of any incidents with another resident. They stated they were not aware of residents of the opposite sex in the facility and not informed of any incident that occurred over the weekend. On 09/05/25 at 3:00 p.m., the DON stated they were not aware the family had not been contacted. The DON stated the family should have been notified that same night. On 09/08/25 at 10:52 a.m., the DON stated they had looked into the notification for Resident #5 and stated a note showed they attempted to reach but were unable to. They stated there was not a re-attempt noted, and they were to look into that and notify the family today.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

South Park East

225 Southwest 35th Street Oklahoma City, OK 73109

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety

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.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

South Park East

225 Southwest 35th Street Oklahoma City, OK 73109

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

Based on record review and interview, the facility failed to ensure allegations of abuse were thoroughly investigated for 5 (#1, 2, 3, 4, and #5) of 5 sampled residents reviewed for abuse. The administrator identified 42 residents resided in the facility. Findings:A policy titled Abuse and Neglect - Clinical Protocol, read in part, The nurse will assess the individual and document related findings.An OSDH incident report, dated 08/20/25, showed Resident #1 touched the breast of Resident #3. There were no safe surveys/assessments of other residents to assure safety, and there was no abuse education documented for all staff.An OSDH incident report, dated 08/26/25, showed Resident #1 touched the breast of Resident #2. There were no safe surveys/assessments of other residents to assure safety, and there was no abuse education documented for all staff. An OSDH incident report, dated 08/31/25, showed Resident #1 touched

the breast of Resident #5. There were no safe surveys/assessments of other residents to assure safety, and there was no abuse education documented for all staff.An OSDH incident report, dated 08/31/25, showed Resident #4 touched the breast of Resident #2. There were no safe surveys/assessments of other residents to assure safety, and there was no abuse education documented for all staff.On 09/04/25 at 3:07 p.m., the DON stated they were not aware they needed to complete part C (summary of the investigation details) of

the incident report.On 09/05/25 at 10:28 a.m., the DON stated they did not do staff education on the incidents regarding sexual abuse/inappropriate touching. The DON stated QA was done monthly and had not had a meeting for this month yet. They stated they do education on abuse often on their training system.

On 09/05/25 at 12:33 p.m., the DON stated they did not have documentation of the education but did do verbal education on abuse following each incident and they could write it down now. On 09/05/25 at 2:35 p.m., the DON stated the charge nurse or whoever finds the issue does the incident report. They stated the results of the assessments on the other residents potentially affected was done visually and not documented.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

South Park East

225 Southwest 35th Street Oklahoma City, OK 73109

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Based on record review and interview, the facility failed to revise/update care plan timely following incidents of abuse for 1 (#1) of 2 sampled residents reviewed for abuse allegations.The administrator identified 42 residents resided in the facility.Findings:A policy titled Care Plans, Comprehensive Person-Centered, dated 12/2016, read in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. The Interdisciplinary Team must

review and update the care plan: . When the desired outcome is not met.A care plan, initiated on 06/12/25, read in part, I do at times make sexually inappropriate actions towards myself or others. I have a dx of sexual disfunction. The care plan showed an incident, dated 06/06/25, of Resident #1 grabbing staff private parts and making sexual comments about staff. The care plan showed a revision on 09/05/25.A quarterly assessment, dated 07/25/25, showed Resident #1 had a BIMS 3, which indicates severe cognitive impairment. The assessment showed they were independent with mobility. Review of the care plan changes since last review per the electronic record showed the incident on 08/31/25 was dated for 09/01/25. The incident on 08/20/25 was dated for 09/02/25. The incident on 08/26/25 was dated for 09/05/25. An order summary, dated 09/04/25, showed Resident #1 had diagnoses which included sexual dysfunction and dementia.On 09/05/25 at 2:06 p.m., the MDS coordinator stated the care plans were updated every three months and as necessary. They stated if a fall or something physical then they had to add something. The MDS coordinator was asked when Resident #1's care plan had been updated. The MDS coordinator stated

they were in it on 09/05/25 and had added on 08/31/25. The MDS coordinator stated they added the behaviors on the 31st. They stated the care plan was updated after each incident of abuse on 6/6/25, 8/20/25, 8/26/25, and 8/31/25. After they reviewed the history of the care plan updates in the electronic record, the MDS coordinator acknowledged they were updated on 09/01/25 and not after the 08/20/25 or

the 08/26/25 incidents of abuse. The MDS coordinator stated the care plan should have been updated prior 09/01/25 or 09/05/25 for the related incidents and they were the only ones to update the care plans.

Event ID:

Facility ID:

If continuation sheet