NACOGDOCHES, TX – OAK MANOR NURSING HOME

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, the facility failed to ensure the right to be free from abuse and neglect was provided for 2 of 5 residents reviewed for abuse. (Residents #2 and #3)

The facility did not prevent Resident #1, a registered sex offender with a known history of sexually inappropriate behaviors from sexually abusing Resident #s 2 and 3. Resident #1 put his hands inside the front of Resident #2’s pants. Resident #1 touched Resident #3 in the breast area and the crotch area. The facility did not implement interventions to address Resident #1’s sexually inappropriate behaviors when he returned to the facility from a behavioral hospital.

During an interview on 12/10/18 at 10:20 a.m., the DON said Resident #1 returned to the facility late on Friday, 12/07/18, and was taken straight to bed and staff did not start monitoring him with 15-minute checks until 12/08/18.

During an observation on 12/10/18 10:35 a.m., Resident #1 was seated in front of the vending machines. Three female residents were seated in the television area and two female residents were seated in the dining room. There was no staff present. Two nurses were behind the nurses’ station, around the corner from the dining room and out of view of the residents.

During an interview on 12/11/18 at 10:06 a.m., LVN K said Resident #1 was not placed on 15-minute checks until Saturday, 12/08/18. LVN K said there was no monitoring in place for Resident #1 before this incident and none when he returned on 12/07/18.

During an interview on 12/11/18 at 11:25 a.m., the DON said she previously thought the 15-minute checks provided enough monitoring for Resident #1’s demonstrated sexually inappropriate behavior, but after surveyor intervention on 12/10/18, she realized the 15-minute count sheets were not always documented, so she placed Resident #1 on one on one supervision.