**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #32 had diagnoses which included, dementia, mood disturbance and anxiety. A five day assessment, dated [DATE], read in parts, ~ had severe cognitive impact; ~ inattentive behavior with fluctuations; ~ disorganized thinking, present with fluctuations; and ~ altered level of conciousness, present with fluctuations. A Nurse's Note dated, [DATE] at 9:00 a.m., read in part, .Late Entry: Note Text: DELAYED ENTRY: [Resident #32] was found visiting .[Resident #85] in [Resident #85's] room with the door shut. Informed by nurse it is fine to visit, but the door has to remain open. [Resident #32] shortly returned to .own room where .[Resident #85] followed and closed the door again. When nurse returned to room and opened door .[Resident #85] hands were groping at [Resident #32's ] lap asking why not and [Resident #32] was heard stating no because my pants are too tight. [Resident #32] informed that [Resident #85] is .married .and became upset stating that [Resident #85] lied to [Resident #32] and [Resident #32] informed [Resident #85] [they] didn't want anything to do with [Resident #85] anymore. [Resident #32's family] informed of the interaction . The clinical record contained no documentation an incident report had been completed. The clinical record contained no documentation an investigation had been completed for resident to resident sexual abuse. The clinical record contained no documentation the event had been thoroughly investigated, interventions placed to ensure protection of the residents, or that reporting had been initiated to OSDH and/or Local Law Enforcement. On [DATE] at 4:51 p.m., the DON was asked if an investigation had been completed for the incident on [DATE] involving Resident #32 and a male resident. The DON stated, I talked with all involved, the [resident #85], the female [resident #32], and [Resident #32's family member]. Spoke with CNA and nurse. The DON was asked did [Resident #85] have any more incidents with any other residents. The DON stated, It was stated, [Resident #85] went into [Resident #25's] room on [DATE]. Based on record review, observation and interview the facility failed to ensure residents were free from abuse for four of six residents reviewed for abuse. a. Three residents (#85, 25,and #32) were identified to be involved with resident to resident sexual encounters, to include touching, petting, and groping. b. One resident (#22) was identified to have physical aggression toward other residents, to include hitting, scratching, and attempting to run into residents while propelling self in hallway. The Resident Census and Condition of Residents identified 34 residents resided in the facility. Findings: The facility's, undated, Abuse and Neglect - Administrative Protocol policy, read in parts, .residents of this facility will be free of abuse, neglect . Prevention .will provide protection of residents in the case of any allegations of abuse, neglect .conduct any investigations in a timely manner . Identify .recognize and report any and all signs of abuse, neglect .teach the staff signs to identify abuse . Protect .will act immediately to protect the resident when being notified of any allegation .will take measures as appropriate to protect one resident from another, on a case by case basis . 1. Resident #85 had diagnosis to include cerebral infarction, dementia with behavioral disturbance, and cognitive communication deficit. An admission assessment, dated [DATE], documented Resident #85 as follows: ~had clear speech, was understood and understood others; ~moderate cognitive impairment for daily decision making; ~inattentive, disorganized thinking, and altered level of consciousness that did not fluctuate; ~no behaviors; ~required limited assistance for bed mobility, transfers, walking, locomotion, toileting, hygiene and bathing; and ~utilized a w/c for mobility and locomotion. The [DATE] physician orders did not document any identified targeted behaviors to monitor. A nurse's note, dated [DATE] at 10:00 p.m., read in parts, .has been observed exhibiting flirtatious and hypersexualized behaviors throughout the weekend with peers to include getting close to individuals, groping peer in .room behind closed doors even after being informed by nurse if [Resident #85] is visiting doors must remain open. Resident was found with hands in the lap of a peer tugging on .pants asking why not. As the weekend progressed it has been stated by another resident that [Resident #85] was present in their room and giving unwanted attention. Redirection attempted by staff bringing up the topic of resident's wife or asking resident if he'd like to go on a walk in the building to go visit the birds. Redirection attempts appeared to work well . The clinical record contained no other documentation of flirtatious/hypersexualized behaviors. A nurse's note, dated [DATE] at 6:47 a.m., documented Resident #85 had expired. The only comprehensive care plan, dated [DATE], provided by the facility, did not identify or address hypersexuality, other behaviors, or the history of behaviors. The clinical record did not document how the peer/residents were protected when Resident #85 exhibited flirtatious and hypersexualized behaviors. The clinical record did not document the resident to resident behaviors had been reported to supervisors or that an abuse investigation was initiated. The incident was not reported to OSDH or local law enforcement. On [DATE] at 10:56 a.m., in the presence of the administrator and Consultant #3, the DON was asked to review Resident #85's nurse notes dated [DATE]. The DON was asked if the DON was aware of the entry. The DON stated, Eventually. The DON was asked if the allegation was investigated. The DON stated the facility did an investigation and the event did not appear as described in the nurse's documentation. The DON was asked where were the investigative notes and the incident reports. The DON stated the nurse that documented the event should have completed the incident report. The DON stated we talked to other staff that was on the shift the progress note was entered and there were conflicting stories. The DON was asked what residents were identified during their investigations. The DON stated Resident #32 was the first person, but the door was opened. The second resident identified was Resident #25. Resident #25 reported resident #85 had come into Resident #25's room briefly and left. Resident #25 had reported to therapy and paid no concern. The DON stated Resident #85 had a history to wander. The DON was asked what interventions were put into place to protect the residents. The DON did not respond. The DON was asked what the facility's abuse policy documented should be put into place. The DON stated, Investigate. Report it. Notify family, doctor and state. The nurse should have notified the DON immediately. The DON was asked if the facility followed their abuse policy for reporting. No response was provided. The administrator, DON and Consultant #3 were asked when should the event have been reported. Consultant #3 stated the event should have been reported within 24 hour, maybe 2 hours. The DON stated the facility talked to all individuals involved and the families were made aware. At 11:10 a.m., the BOM entered the interview. The DON was asked if Resident #85 had been assessed and care planned for dementia with behaviors. The BOM stated the behavior notes were in hospital records. At 11:35, the administrator, DON and the MDS coordinator were asked when did they become aware of the entry on Resident #85's record. The DON stated on Monday when the records were reviewed for weekend issues. They were asked if the facility had followed their policy to prevent abuse/neglect. The DON stated, No. The administrator, DON and Consultant #3 were asked, when the allegation was identified, what was put into place to protect all residents during and after the investigation. Consultant #3 stated the nurse note documented the staff redirected Resident #85. They were asked if the staff did continuous monitoring of Resident #85 to ensure the safety of other residents. No response was provided. 2. Resident #25 had diagnoses to include anxiety disorder, depressive disorder, and PTSD. A quarterly assessment, dated [DATE], documented Resident #25 as follows: ~clear speech, usually understood, usually understands; ~cognitively intact for daily decision making; ~is inattentive, had disorganized thinking and altered level of consciousness that does not fluctuate; and ~had delusion. A care plan, dated [DATE], documented as follows: ~ .Depression .orders per my PCP for an antidepressant .observe me for decline in mood, increase in self isolation, depression .Report to Nurse/PCP s/sx of depression, including .verbalizing negative statements, repetitive anxious or health-related complaints . ~ .Antipsychotic .order .for antipsychotic medication brexiprazole .Report to nurse s/sx .confusion, mood change, change in normal behavior, hallucination/delusion . ~ .Delusional .at risk for delusional episodes .history of altered memories of recent events and feelings of being exploited .establish baseline level of functioning .Discuss with me and my family any concerns about delusions .Monitor and address environmental factors recent change in environment, environmental noise and commotion .Monitor and report to MD new onset s/sx of delusional episodes .delusions, hallucinations .Monitor my safety daily .sometimes because of my delusional thinking, I don't feel safe .attempt to remind me of known facts . The care plan did not address specific delusions held by Resident #25. A provider Progress Note, dated [DATE], documented Resident #25 was seen by a provider as a routine skilled nursing visit. The progress note documented Resident #25 was to be evaluated by mental health services due to increase of anxiety and taking two medications to improve anxiety. A provider Progress Note, dated [DATE], documented Resident #25 was seen by a provider as a routine skilled nursing visit. The progress note read in parts, .talking all about her last couple months of medical problems, but her stories do not make sense .ambulance personnel picked her up on a fire truck along with a lot of dancing girls . A second, provider Progress Note, dated [DATE], documented Resident #25 was being seen as a routine skilled nursing visit. The progress note read in parts, .states that this last weekend she had a situation that she did not want to talk about it, but she states that she thought this was her safe haven and now she is not sure. She states that this event triggered her PTSD . A nurse note, dated [DATE] at 11:30 a.m., read in parts, .approximately 10:45 [a.m.] resident requested to speak to nurse and ended up confiding in CMA that a peer at this facility entered her room the day prior during the morning and proceded to grope her breasts and other inappropriate behaviors while she was in bed. Resident stated that her peer told her he would return to do more later. Resident verbalized being scared to be viewed as a snitch, and scared of causing trouble because she doesn't want to be kicked out of the facility. Resident reassured her concerns are not being taken lightly. Resident informed that the facility's chain of command has been notified. Resident stated the incident triggered her PTSD to a similar event in her life that occurred in 2005. Resident also later confided in her daughter. Nurse informed the daughter that the DON and administrator have been notified and the situation is on going, but is being taken seriously. Resident has cried several times throughout the day when recounting the event. Resident is also requesting a 'stop sign' in front of her doorway . A nurse note, dated [DATE] at 7:30 a.m., read in parts, .This nurse was informed of an incident that took place on Saturday 8/13 .asked the resident about the incident .stated she was up in wheelchair when the male came into her room .he touched her chest when stating cold hands warm heart .memory of the situation was different than the previous chart entry .like the stop sign reminder placed on her doorway . A nurse note, dated [DATE] at 11:14 p.m., read in parts, .Resident was adamant .did not receive her gabapentin .contacted evening shift charge to confirm if medication was given .Due to uncertainty and the medication being documented as given night shift did not administer the medication . The nurse progress notes contained no other documentation of behaviors or delusions, prior to the resident to resident sexual altercation with Resident #85 on [DATE]. On [DATE] at 1:15 p.m., Resident #25 was asked if it was okay to discuss an encounter she had briefly mentioned previously the day before regarding a male resident having entered her room. Resident #25 agreed to the interview. Resident #25 was asked if Resident #25 recalled having mentioned a male resident that came into Resident #25's room. Resident #25 stated she did and identified Resident #85. Resident #25 stated Resident #85 had entered the room and at first patted her hand and told her that her hands were cold. Resident #25 stated a reply was made, Cold hands, Warm heart. At that time, Resident #85 grabbed the breast of Resident #25. Resident #25 stated a history of PTSD due to having been raped, beaten and left in an apartment alone to die, so the event was very upsetting. Resident #25 stated she felt comfortable to report to the physical therapist and a certain nurse aide. Resident #25 stated the DON came and visited about the event and Resident #25 had voiced the event was frightening. Resident #25 stated no further information had been shared regarding the incident so was not aware if the facility had taken care of the issue. Resident #25 was asked if there were any other persons at the facility she was afraid of, leery of, or concerned about. Resident #25 stated there had not been a personal encounter or observation but other female residents had warned to watch out for [Resident #27]. Resident #25 stated had not seen anything first hand but have the ability to say no. Resident #25 stated worry/concern for female residents that are unable to have a voice. On [DATE] at 3:15 p.m., the DON was asked to clarify why Resident #25 was seen by a provider for a skilled visit twice on [DATE]. After review of the progress notes and personal e-mails which the notes were sent, the DON stated the second progress note was received via e-mail on [DATE], but would call the provider to clarify. No other information was provided regarding clarification of the provider progress notes. The clinical record contained no documentation how Resident #25 was protected after the allegation of sexual abuse was identified. The clinical record did not document the resident to resident sexual assault had been thoroughly investigated. The records did not document an investigation had been completed; a report submitted to OSDH; or Local Law Enforcement had been notified from [DATE] until [DATE]. The facility did not take action to follow their abuse policy until after the surveyor asked about the investigation and reports to the required agencies. 3 Resident #22 had diagnoses to include sequelae of cerebral infarction, cerebral ischemia, cognitive communication deficit, vascular dementia without behaviors, and personal history of other mental and behavioral disorders. A physician's order, dated [DATE], documented Resident #22 was to have behavior monitoring every shift with the target behaviors to include nervousness, anxious, agitation, insomnia, scratching, and pinching. A care plan, dated [DATE], read in part, .mood problem .Sometimes I am verbally aggressive to start and other residents . A nurse note, dated [DATE] at 12:06 p.m., read in parts, .is in hallway in wheelchair running resident/staff over and spitting on the floor . The clinical record did not contain an incident report to identify other residents involved, an investigation of the event, interventions to protect other residents in the immediate area, or report to the proper agencies. A care plan, dated [DATE], read in parts, .Monitor/record occurrence of for [sic] target behavior symptoms like pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others . A physician's order, dated [DATE], documented Resident #10 was to be administered Depakote 125 mg daily for history of other mental and behavioral disorders. On [DATE], the Depakote was increased to administer 125 mg two times a day. On [DATE], the Depakote was increased to administer 125 mg three times a day. A nurse noted, dated [DATE] at 4:36 p.m., read in parts, .rolled by another resident & reached out & scratched her on the arm, drawing blood . An incident report was not located in the record to determine if the resident to resident altercation with injury had been investigated, interventions placed to protect, or notification/reporting had been completed and submitted to required agencies. On [DATE] at 3:00 p.m., the DON and Consultants #1 and #2 were asked if incident reports were initiated/completed regarding resident to resident altercations for Resident #22. Consultant #2 stated she did not see one. The DON and Consultants #1 and #2 were asked if the abuse policy had been followed to ensure resident to resident altercations were investigated, interventions to protect other residents put into place and/or reporting to state/local agencies was completed as required. No response was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident #32 had diagnoses which included, dementia, mood disturbance and anxiety. A five day assessment, dated [DATE], read in parts, ~ had severe cognitive impact; ~ inattentive behavior with fluctuations; ~ disorganized thinking, present with fluctuations; and ~ altered level of consciousness, present with fluctuations. A Nurse's Note dated, [DATE] at 9:00 a.m., read in part, .Late Entry: Note Text: DELAYED ENTRY: [Resident #32] was found visiting .[Resident #85] in [Resident #85's] room with the door shut. Informed by nurse it is fine to visit, but the door has to remain open. [Resident #32] shortly returned to .own room where .[Resident #85] followed and closed the door again. When nurse returned to room and opened door .[Resident #85] hands were groping at [Resident #32's ] lap asking why not and [Resident #32] was heard stating no because my pants are too tight. [Resident #32] informed that [Resident #85] is .married .and became upset stating that [Resident #85] lied to [Resident #32] and [Resident #32] informed [Resident #85] [they] didn't want anything to do with [Resident #85] anymore. [Resident #32's family] informed of the interaction . The clinical record contained no documentation an incident report had been completed to ensure an investigation was initiated. The clinical record contained no documentation an investigation had been completed for resident to resident sexual abuse. The clinical record contained no documentation the event had been thoroughly investigated, or interventions placed to ensure protection of the residents. On [DATE] at 4:51 p.m., the DON was asked if an investigation had been completed for the incident on [DATE] involving Resident #32 and a male resident. The DON stated, I talked with all involved, the [resident #85], the female [resident #32], and [Resident #32's family member]. Spoke with CNA and nurse. The DON was asked did [Resident #85] have any more incidents with any other residents. The DON stated, It was stated, [Resident #85] went into [Resident #25's] room on [DATE]. Based on record review, observations and interviews, the facility failed to fully develop and/or implement an abuse policy to prevent, protect, investigate and report allegations of abuse. This affected: a. Five residents (#85, 25, 32, 27 and #10) with altered cognition for daily decision making who were identified to be involved with resident to resident sexual encounters. b. One resident (#22) was identified to have physical aggression toward other residents. The Resident Census and Condition of Residents identified 34 residents resided in the facility. Findings: The facility's, undated, Abuse and Neglect - Administrative Protocol policy, read in parts, .residents of this facility will be free of abuse, neglect .The facility will implement the following .for abuse prevention and investigation . Screening .Training .provide all new employees training in Abuse recognition, prevention and reporting before floor employment begins and retrain on a semi-annual basis thereafter . Prevention .will provide protection of residents in the case of any allegations of abuse, neglect .conduct any investigations in a timely manner . Identify .will train the staff to observe, recognize and report any and all signs of abuse, neglect .teach the staff signs to identify abuse . Investigate .will thoroughly investigate any and all allegations of abuse, neglect .Staff will notify Administrator and Director of Nursing of all allegations .will act immediately when being notified of an allegation .will conduct and/or facilitate interviews of the direct resident(s) involved in the allegation, all other interviewable residents and all staff members, and any visitors that have knowledge or witnessed the allegation will also be interviewed. A written report or statement will be gathered and maintained on all interviews will notify all parties of the outcomes of the investigation and forward all necessary reports to OSDH and any other officials warranted . Protect .will act immediately to protect the resident when being notified of any allegation .will notify and request Local Law Enforcement if the allegation warrants their involvement .will separate any residents as necessary if the allegation is a resident to resident abuse .will take measures as appropriate to protect one resident from another, on a case by case basis . Reporting .will sent a report to all reporting agencies as required by OSDH guidelines .will send a report to the Oklahoma State Department of Health and adult protective services immediately, but not later than 2 hours of being notified of the allegation, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serous bodily injury .will send copies and necessary forms to the Nurse Aide Registry for Certified Nurse Aides, Certified medication aides and nontechnical workers .will forward copies of the reports to the Oklahoma Board of Nursing if a Licensed Nurse is involved in the allegations . 1. Resident #85 had diagnosis to include cerebral infarction, dementia with behavioral disturbance, and cognitive communication deficit. An admission assessment, dated [DATE], documented Resident #85 as follows: ~had clear speech, was understood and understood others; ~moderate cognitive impairment for daily decision making; ~inattentive, disorganized thinking, and altered level of consciousness that did not fluctuate; ~no behaviors; ~required limited assistance for bed mobility, transfers, walking, locomotion, toileting, hygiene and bathing; and ~utilized a w/c for mobility and locomotion. The 08/2022, physician orders did not identify any targeted behavior to monitor. The physician orders did not include what behaviors Resident #85 displayed due to dementia with behavioral disturbance. A nurse's note, dated [DATE] at 10:00 p.m., read in parts, .has been observed exhibiting flirtatious and hypersexualized behaviors throughout the weekend with peers to include getting close to individuals, groping peer in .room behind closed doors even after being informed by nurse if [Resident #85] is visiting doors must remain open. Resident was found with hands in the lap of a peer tugging on .pants asking why not. As the weekend progressed it has been stated by another resident that [Resident #85] was present in their room and giving unwanted attention. Redirection attempted by staff bringing up the topic of resident's wife or asking resident if he'd like to go on a walk in the building to go visit the birds. Redirection attempts appeared to work well . The clinical record contained no other documentation of flirtatious/hypersexualized behaviors. A nurse's note, dated [DATE] at 6:47 a.m., documented Resident #85 had expired. The only comprehensive care plan, dated [DATE], provided by the facility, did not identify or address hypersexuality, other behaviors, or a history of behaviors. The clinical record did not document how the peer/residents were protected when Resident #85 exhibited flirtatious and hypersexualized behaviors. The clinical record did not document the hypersexualized behaviors had been reported to the supervisors and an investigation initiated. On [DATE] at 10:56 a.m., in the presence of the administrator and Consultant #3, the DON was asked to review Resident #85's nurse notes dated [DATE]. The DON was asked if the DON was aware of the entry. The DON stated, Eventually. The DON was asked if the allegation was investigated. The DON stated the facility did an investigation and the event did not appear as described in the nurse's documentation. The DON was asked where were the investigative notes and the incident reports. The DON stated the nurse that documented the event should have completed the incident report. The DON stated we talked to other staff that was on the shift the progress note was entered and there were conflicting stories. The DON was asked what residents were identified during their investigations. The DON stated Resident #32 was the first person, but the door was opened. The second resident identified was Resident #25. Resident #25 reported resident #85 had come into Resident #25's room briefly and left. Resident #25 had reported to therapy and paid no concern. The DON stated Resident #85 had a history to wander. The DON was asked what interventions were put into place to protect the residents. The DON did not respond. The DON was asked what the facility's abuse policy documented should be put into place. The DON stated, Investigate. Report it. Notify family, doctor and state. The nurse should have notified the DON immediately. At 11:10 a.m., the BOM entered the interview. The DON was asked if Resident #85 had been assessed and care planned for dementia with behaviors. The BOM stated the behavior notes were in hospital records. The DON did not provide additional information. At 11:35, the administrator, DON and the MDS coordinator were asked when did they become aware of the entry on Resident #85's record. The DON stated on Monday when the records were reviewed for weekend issues. The DON stated the LPN that made the entry on Resident #85 was a new hire to the facility. The DON was asked if new employees receive training at the time of hire regarding the abuse policy. The DON stated, Yes. They were asked if the facility had followed their policy to prevent abuse/neglect. The DON stated, No. They were asked if the facility completed a thorough investigation at the time of the event per their abuse policy. The administrator stated, No. The administrator, DON and Consultant #3 were asked if all staff and residents capable of interview, had been interviewed to identify if other residents had been involved. The DON stated we talked to staff that were here that shift and the resident's family. The administrator, DON and Consultant #3 were asked, when the allegation was identified, what interventions were put into place to protect all residents during and after the investigation. Consultant #3 stated the nurse note documented the staff redirected Resident #85. They were asked if the staff did continuous monitoring of Resident #85 to ensure the safety of other residents. No response was provided. 2. Resident #25 had diagnoses to include anxiety disorder, depressive disorder, and PTSD. A quarterly assessment, dated [DATE], documented Resident #25 as follows: ~clear speech, usually understood, usually understands; ~cognitively intact for daily decision making; ~is inattentive, had disorganized thinking and altered level of consciousness that does not fluctuate; and ~had delusion. A care plan, dated [DATE], documented as follows: ~ .Depression .orders per my PCP for an antidepressant .observe me for decline in mood, increase in self isolation, depression .Report to Nurse/PCP s/sx of depression, including .verbalizing negative statements, repetitive anxious or health-related complaints . ~ .Antipsychotic .order .for antipsychotic medication brexiprazole .Report to nurse s/sx .confusion, mood change, change in normal behavior, hallucination/delusion . The care plan did not address PTSD for Resident #25. A provider Progress Note, dated [DATE], documented Resident #25 was seen by a provider as a routine skilled nursing visit. The progress note documented Resident #25 was to be evaluated by mental health services due to increase of anxiety and taking two medications to improve anxiety. A provider Progress Note, dated [DATE], documented Resident #25 was seen by a provider as a routine skilled nursing visit. The progress note read in parts, .talking all about her last couple months of medical problems, but her stories do not make sense .ambulance personnel picked her up on a fire truck along with a lot of dancing girls . A second provider Progress Note, dated [DATE], documented Resident #25 was being seen as a routine skilled nursing visit. The progress note read in parts, .states that this last weekend she had a situation that she did not want to talk about it, but she states that she thought this was her safe haven and now she is not sure. She states that this event triggered her PTSD . A nurse note, dated [DATE] at 11:30 a.m., read in parts, .approximately 10:45 [a.m.] resident requested to speak to nurse and ended up confiding in CMA that a peer at this facility entered her room the day prior during the morning and proceded to grope her breasts and other inappropriate behaviors while she was in bed. Resident stated that her peer told her he would return to do more later. Resident verbalized being scared to be viewed as a snitch, and scared of causing trouble because she doesn't want to be kicked out of the facility. Resident reassured her concerns are not being taken lightly. Resident informed that the facility's chain of command has been notified. Resident stated the incident triggered her PTSD to a similar event in her life that occurred in 2005. Resident also later confided in her daughter. Nurse informed the daughter that the DON and administrator have been notified and the situation is on going, but is being taken seriously. Resident has cried several times throughout the day when recounting the event. Resident is also requesting a 'stop sign' in front of her doorway . A nurse note, dated [DATE] at 7:30 a.m., read in parts, .This nurse was informed of an incident that took place on Saturday 8/13 .asked the resident about the incident .stated she was up in wheelchair when the male came into her room .he touched her chest when stating cold hands warm heart .memory of the situation was different than the previous chart entry .like the stop sign reminder placed on her doorway . A nurse note, dated [DATE] at 11:14 p.m., read in parts, .Resident was adamant .did not receive her gabapentin .contacted evening shift charge to confirm if medication was given .Due to uncertainty and the medication being documented as given night shift did not administer the medication . The nurse progress notes contained no other documentation of behaviors or delusions. On [DATE] at 1:15 p.m., Resident #25 was asked if it was okay to discuss an encounter she had briefly mentioned previously the day before regarding a male resident having entered her room. Resident #25 agreed to the interview. Resident #25 was asked if Resident #25 recalled having mentioned a male resident that came into Resident #25's room. Resident #25 stated she did and identified Resident #85. Resident #25 stated Resident #85 had entered the room and at first patted her hand and told her that her hands were cold. Resident #25 stated a reply was made, Cold hands, Warm heart. At that time, Resident #85 grabbed the breast of Resident #25. Resident #25 stated a history of PTSD due to having been raped, beaten and left in an apartment alone to die, so the event was very upsetting. Resident #25 stated she felt comfortable to report to the physical therapist and a certain nurse aide. Resident #25 stated the DON came and visited about the event and Resident #25 had voiced the event was frightening. Resident #25 stated no further information had been shared regarding the incident so was not aware if the facility had taken care of the issue. On [DATE] at 3:15 p.m., the DON was asked to clarify why Resident #25 was seen by a provider for a skilled visit twice on [DATE]. After review of the progress notes and personal e-mails which the notes were sent, the DON stated the second progress note was received via e-mail on [DATE], but would call the provider to clarify. No other information was provided regarding clarification of the provider progress notes. The clinical record contained no documentation how Resident #25 was protected after the allegation of sexual abuse was identified. The clinical record did not document the resident to resident sexual assault had been thoroughly investigated. The records did not document an investigation had been completed. The facility did not take action to follow their abuse policy until after the surveyor asked about the investigation and reports to the required agencies. 3. Resident #27 was admitted with diagnoses to include anxiety, history of transient ischemic attack, cerebral infarction, and dementia without behaviors. Physician orders, dated [DATE] and continued to current, documented Resident #27 was to have behavior monitoring every shift for the target behavior of wandering, restlessness, insomnia, sadness, anxiety, and irritation/upset. A physician order, dated [DATE] and continued to current, documented Resident #27 was to receive Donapezil 10 mg at bedtime for dementia without behaviors. An annual assessment, dated [DATE], documented Resident #27 as follows: ~speech is unclear, rarely/never understood, and sometimes understands; ~short/long term memory deficits; ~modified independence for daily decision making; ~independent in walking, locomotion, eating, toileting, and hygiene; ~required supervision for bed mobility, and transfers; ~required limited assistance for dressing and bathing; and ~no behaviors had been observed during the assessment period. A care plan, dated [DATE], read in parts, .staff for reminders, cueing and direction for activities, cognitive stimulation, social interaction r/t cognitive deficits .need assistance of one for many ADLs due to weakness and forgetfulness .enjoys passing out clothing protectors in dining room .Impaired Cognitive function r/t hx CVA and TIAs with problems with decision making .need cueing, reminders and supervision/assistance with all decision making . A care plan, dated [DATE], read in parts, .sexuality .attracted to an alert consensual female. We enjoy private time together occasionally .allow mutually consensual intimacy as desired .wife is aware of my attraction for another resident .respects my rights .only asks that [Resident #27] be reminded that he is married .Provide privacy as requested. Close privacy curtain and door when privacy desired . The care plan regarding sexuality for Resident #27 was initiated on [DATE] and not revised until [DATE]. A care plan regarding anxiety, initiated [DATE], and last revised on [DATE], read in parts, .anti-anxiety medication r/t Anxiety disorder .Monitor/document side effects .Mania, Hostility and rage, Aggressive or impulsive behavior, Hallucinations . The clinical record did not document Resident #27 had been assessed to ensure the cognitive capacity was intact to consent in a sexual relationship. The clinical record did not contain documentation to the frequency/extent of the relationship between Resident #27 and Resident #10. No entries were provided to indicate staff were monitoring Resident #27 and/or Resident #10. The facility abuse policy did not address how staff were to identify consensual resident to resident physical contact versus how to identify inappropriate touching/sexuality between residents with impaired cognition. On [DATE] at 3:31 p.m., Resident #29 stated that Resident #10 and Resident #22 wander throughout the facility and do not have cognitive skills to make good choices. Resident #29 stated that Resident #10 lived across hall from a male resident, which only knew the first name of the male resident. Resident #29 stated Resident #10 goes into the male resident room frequently. Resident #10 and the male resident have been observed to kiss and male resident have his hands under Resident #10's blouse. Resident #29 stated she did not feel other residents should have to watch/observe this public display. On [DATE] at 11:35 a.m., the administrator, DON and Consultant #3 were asked if they were aware residents in the facility had concerns of inappropriate sexual touching between residents was occurring without supervision. They were informed only a first name had been identified. The administrator and DON identified the residents as Resident #27 and Resident #10. The administrator stated, Resident #27 and Resident #10 sat in the church service the weekend prior, holding hands through the church services. On [DATE] at 12:55 p.m., Resident #27's wife was asked if Resident #27 required cues/reminders. She stated the resident does have trouble communicating and may say the wrong words than what was meant. Resident #27's wife was asked if there had ever been any concerns with behaviors. Resident #27's wife stated none that she was aware of. Resident #27's wife was asked if she had ever been informed of resident touching other female residents. The wife stated Resident #27 has always been one to pat or give hugs. The wife was asked if the facility had spoken to her about Resident #27 having a female friend which he spend time with, and/or holding hands. The wife stated she had been notified of an indiscretion several years ago, she did not like it but did not feel she had any say in the matter. The wife stated she understood that it had ended, as the female resident involved had passed away. The wife was asked if she had been informed of a current female resident he was fond of. The wife stated she was aware he visited with another female resident but only that they spend time to visit each other. The wife was asked if Resident #27 had the capability to make good choices, what he would think if he thought others believed he was sexually inappropriate with the touch/pats/hugs. The wife stated Resident #27 would be very upset, if Resident #27 thought people believed he was inappropriate with female residents. On [DATE] at 2:40 p.m., the DON, Consultant #1 and Consultant #2 were asked if Resident #27's care plan was initiated on [DATE] for sexuality, why was this portion of the care plan not updated at any time until [DATE]. Consultant #1 reviewed the care plan and stated it appeared the issue had been resolved on the care plan at some time and was recently re-opened and put back into the care plan. The DON, Consultant #1 and #2 were asked if this was the same female as having been discussed on [DATE]. The DON stated there have been two female residents that Resident #27 had been involved with. The DON, Consultant #1 and #2 were asked if Resident #27's family was aware of the current relationship. The DON stated the wife was aware. The DON was asked if the wife had been told the entirety of the relationship due to the wife's belief of the current relationship was verbal exchange only. The DON stated she was not sure why the wife would say that. The DON stated she would have to look in the nurse notes to find the documentation the wife had been made aware of the situation. They were asked if the resident's with cognition impairment had been assessed to ensure they were able to give consent to a physical relationship. No information was provided. The DON was asked if an in-service had been provided to the staff after initiating the discussion of resident to resident physical altercation/relationships on [DATE]. The DON acknowledged staff had been in-serviced on the abuse policy. The DON was asked what information was provided to staff to ensure staff could determine the difference between consensual touching/relationships versus an event that a cognitive impaired resident should be protected from. No response was provided. The DON was asked how Resident #27 was being monitored in his relationship with Resident #10 to ensure the physical relationship remained consensual. No response was provided. The DON was asked if the relationship was consensual, how often did the facility re-evaluate/re-assess both residents to ensure the extent of the physical relationship and if it continued to be consensual for both residents. No response was provided. A policy was not provided regarding determination of consensual sexual relationships between residents that reside in the facility. 4. Resident #10 had diagnoses to include depressive disorder and dementia without behaviors. The physician orders, dated [DATE], documented Resident #10 was to be monitored for behaviors due to medication side effects of a hypnotic and anti-depressant, to include sadness and crying. A care plan, dated [DATE], read in parts, .Cognitive Loss .forgetful .make my own decisions but please intervene if indicated .Keep My routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion . A significant change of status/five day skilled assessment, dated [DATE], documented the resident as follows: ~clear speech, understands and is understood; ~moderately impaired for daily decision making; ~is inattentive, has disorganized thinking, and altered level of consciousness that does not fluctuate; and ~required supervision with one person assist for bed mobility, transfers, dressing, and toileting. A care plan, dated [DATE], read in parts, .Sexuality .am attracted to an alert consensual male. We enjoy private time together .Allow mutually consensual intimacy as desired .Physician is aware of my desire for mutually consensual intimacy with another resident .Provide privacy as requested. Close privacy curtain and door when privacy is desired . The care plan did not address a consensual sexual relationship with a male resident prior to [DATE]. The clinical record did not contain documentation regarding when the relationship began between Resident #10 and resident #27. The clinical record did not contain documentation Resident #10 was assessed to ensure cognitive skills were intact to consent to a sexual relationship. The clinical records of Resident #10 and #27 did not contain documentation the residents had been monitored do ensure the relationship was/continued to be consensual. The facility's abuse policy did not address how residents would be determined to enter into a consensual sexual relationship, or to provide guidance to the staff in determining consensual sexual relationship versus resident to resident altercation that would require protection, investigation and reporting. On [DATE] at 3:31 p.m., Resident #29 stated Resident #10 and Resident #22 wander throughout the facility and do not have cognitive skills to make good choices. Resident #29 stated that Resident #10 lived across hall from a male resident, which only knew the first name of the male resident. Resident #29 stated Resident #10 goes into the male resident room frequently. Resident #10 and the male resident have been observed to kiss and male resident have his hands under Resident #10's blouse. Resident #29 stated she did not feel other residents should have to watch/observe this public display. On [DATE] at 11:35 a.m., the administrator, DON and Consultant #3 were asked if they were aware residents in the facility had concerns of inappropriate sexual touching between residents was occurring without supervision. They were informed only a first name had been identified. The administrator and DON identified the residents as Resident #27 and Resident #10. The administrator stated, Resident #27 and Resident #10 sat in the church service the weekend prior, holding hands through the church services. On [DATE] at 2:45 p.m., the DON, Consultant #1 and Consultant #2 were asked when did the sexual relationship begin between Resident #10 and Resident #27. The DON stated, Not sure. The DON, Consultant #1 and #2 were asked if Resident #10 had documentation of the relationship in the clinical record. No response was provided. They were asked if the care plan had addressed the sexual relationship between Resident #10 and Resident #27, prior to the initial discussion on [DATE]. Consultant #2 stated it does not look like it by looking at the current care plan. The DON and Consultant #1 and #2 were asked if the situation was being monitored by the facility, where would the encounters between the residents be documented. No response was provided. The DON and Consultant #1 and #2 were asked what intervention/consents were placed prior to [DATE]. The DON stated the families knew. No documentation of family awareness prior to [DATE] was provided. The DON and Consultant #1 and #2 were asked if the facility had at any time considered an investigation and/or incident report to ensure Resident #10 and Resident #27 had in fact began as a consensual sexual relationship. No information was provided. The DON and Consultant #1 and #2 were asked if the required assessments documented Resident #10 to be moderately impaired for daily decision making, how was it determined a resident with cognitive deficit had the ability to provide consensual sexual consent. No response was provided. The DON was asked if the staff had been in-served between [DATE] and [DATE] regarding abuse. The DON stated the staff had been in-serviced for abuse. The DON was asked what information was provided to the staff to ensure staff could recognize the difference between consensual sexual relationships versus a resident to resident encounter that would meet the requirements to investigate, and protect. No information was provided. A copy of the in-services for abuse was provided. The facility abuse policy remained the same as the policy provided to the surveyor on [DATE]. The policy did not contain information to provide education/guidance for resident to resident sexual relationships/encounters. 5. Resident #22 had diagnoses to include sequelae of cerebral infarction, cerebral ischemia, cognitive communication deficit, vascular dementia without behaviors, and personal history of other mental and behavioral disorders. A physician's order, dated [DATE], documented Resident #22 was to have behavior monitoring every shift with the target behaviors to include nervousness, anxious, agitation, insomnia, scratching, and pinching. A care plan, dated [DATE], read in part, .mood problem .Sometimes I am verbally aggressive to start and other residents . A nurse note, dated [DATE] at 12:06 p.m., read in parts, .is in hallway in wheelchair running resident/staff over and spitting on the floor . The clinical record did not contain an incident report to identify other residents involved, an investigation of the event, interventions to protect other residents in the immediate area, or report to the proper agencies. A care plan, dated [DATE], read in parts, .Monitor/record occurrence of for [sic] target behavior symptoms like pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others . A physician's order, dated [DATE], documented Resident #10 was to be administered Depakote 125 mg daily for history of other mental and behavioral disorders. On [DATE], the Depakote was increased to administer 125 mg two times a day. On [DATE], the Depakote was increased to administer 125 mg three times a day. A nurse noted, dated [DATE] at 4:36 p.m., read in parts, .rolled by another resident & reached out & scratched her on the arm, drawing blood . The clinical records did not contain documentation the resident to resident altercation with injury had been investigated, or interventions placed to protect residents during or after the investigation. On [DATE] at 3:00 p.m., the DON and Consultants #1 and #2 were asked if incident reports we[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #32 had diagnoses which included, dementia, mood disturbance and anxiety. A five day assessment, dated [DATE], read in parts, ~ had severe cognitive impact; ~ inattentive behavior with fluctuations; ~ disorganized thinking, present with fluctuations; and ~ altered level of conciousness, present with fluctuations. A Nurse's Note dated, [DATE] at 9:00 a.m., read in part, .Late Entry: Note Text: DELAYED ENTRY: [Resident #32] was found visiting .[Resident #85] in [Resident #85's] room with the door shut. Informed by nurse it is fine to visit, but the door has to remain open. [Resident #32] shortly returned to .own room where .[Resident #85] followed and closed the door again. When nurse returned to room and opened door .[Resident #85] hands were groping at [Resident #32's ] lap asking why not and [Resident #32] was heard stating no because my pants are too tight. [Resident #32] informed that [Resident #85] is .married .and became upset stating that [Resident #85] lied to [Resident #32] and [Resident #32] informed [Resident #85] [they] didn't want anything to do with [Resident #85] anymore. [Resident #32's family] informed of the interaction . The clinical record contained no documentation the event had been thoroughly investigated, interventions placed to ensure protection of the residents, or that reporting had been initiated to OSDH and/or Local Law Enforcement. On [DATE] at 4:51 p.m., the DON was asked if an investigation had been completed for the incident on [DATE] involving Resident #32 and a male resident. The DON stated, I talked with all involved, the [resident #85], the female [resident #32], and [Resident #32's family member]. Spoke with CNA and nurse. The DON was asked did [Resident #85] have any more incidents with any other residents. The DON stated, It was stated, [Resident #85] went into [Resident #25's] room on [DATE]. On [DATE] at 4:51 p.m., the DON was asked why staff had not reported the incident. The DON stated, I don't know. Based on record review and interview the facility failed to report allegations of abuse and neglect to local law enforcement and OSDH for for four (#85, 25, 32, and #22) of six sampled residents reviewed for abuse. a. Three (#85, 25, and #32) of six sampled residents were identified to be involved with resident to resident sexual encounters, to include touching, petting, and groping. b. One resident (#22) was identified to have physical aggression toward other residents, to include hitting, scratching, and attempting to run into residents while propelling self in hallway. The Resident Census and Condition of Residents identified 34 residents resided in the facility. Findings: The facility's, undated, Abuse and Neglect - Administrative Protocol policy, read in parts, .residents of this facility will be free of abuse, neglect .The facility will implement the following . Reporting .will sent a report to all reporting agencies as required by OSDH guidelines .will send a report to the Oklahoma State Department of Health and adult protective services immediately, but not later than 2 hours of being notified of the allegation, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serous bodily injury .will send copies and necessary forms to the Nurse Aide Registry for Certified Nurse Aides, Certified medication aides and nontechnical workers .will forward copies of the reports to the Oklahoma Board of Nursing if a Licensed Nurse is involved in the allegations . 1. Resident #85 had diagnosis to include cerebral infarction, dementia with behavioral disturbance, and cognitive communication deficit. An admission assessment, dated [DATE], documented Resident #85 as follows: ~had clear speech, was understood and understood others; ~moderate cognitive impairment for daily decision making; ~inattentive, disorganized thinking, and altered level of consciousness that did not fluctuate; ~no behaviors; ~required limited assistance for bed mobility, transfers, walking, locomotion, toileting, hygiene and bathing; and ~utilized a w/c for mobility and locomotion The physician orders, dated 08/2022, did not contain medication orders for behavioral issues. The physician orders did not include what behaviors Resident #85 displayed due to dementia with behavioral disturbance. A nurse's note, dated [DATE] at 10:00 p.m., read in parts, .has been observed exhibiting flirtatious and hypersexualized behaviors throughout the weekend with peers to include getting close to individuals, groping peer in .room behind closed doors even after being informed by nurse if [Resident #85] is visiting doors must remain open. Resident was found with hands in the lap of a peer tugging on .pants asking why not. As the weekend progressed it has been stated by another resident that [Resident #85] was present in their room and giving unwanted attention. Redirection attempted by staff bringing up the topic of resident's wife or asking resident if he'd like to go on a walk in the building to go visit the birds. Redirection attempts appeared to work well . A nurse's note, dated [DATE] at 6:47 a.m., documented Resident #85 had expired. The care plan, dated [DATE], did not address behaviors or the history of behaviors. The care plan provided did not include any identified issues or interventions prior to [DATE]. The clinical record contained no other documentation of flirtatious/hypersexualized behaviors. The care plan did not address Resident #85's hypersexuality. The clinical record did not document the resident to resident behaviors had been reported to supervisors or that an abuse investigation was initiated. The incident was not reported to OSDH or local law enforcement. On [DATE] at 10:56 a.m., in the presence of the administrator and Consultant #3, the DON was asked to review Resident #85's nurse notes dated [DATE]. The DON was asked if the DON was aware of the entry. The DON stated, Eventually. The DON was asked if the allegation was investigated. The DON stated the facility did an investigation and the event did not appear as described in the nurse's documentation. The DON was asked where were the investigative notes and the incident reports. The DON stated the nurse that documented the event should have completed the incident report. The DON was asked what residents were identified during their investigations. The DON stated Resident #32 was the first person, but the door was opened. The second resident identified was Resident #25. Resident #25 reported resident #85 had come into Resident #25's room briefly and left. Resident #25 had reported to therapy and paid no concern. The DON stated Resident #85 had a history to wander. The DON was asked what the facility's abuse policy documented should be put into place. The DON stated, Investigate. Report it. Notify family, doctor and state. The nurse should have notified the DON immediately. The DON was asked if the facility followed their abuse policy for reporting. No response was provided. The administrator, DON and Consultant #3 were asked when should the event have been reported. Consultant #3 stated the event should have been reported within 24 hour, maybe 2 hours. The DON stated the facility talked to all individuals involved and the families were made aware. At 11:35, the administrator, DON and the MDS coordinator were asked when did they become aware of the entry on Resident #85's record. The DON stated on Monday when the records were reviewed for weekend issues. The DON stated the LPN that made the entry on Resident #85 was a new hire to the facility. The DON was asked if new employees receive training at the time of hire regarding the abuse policy. The DON stated, Yes. They were asked if the facility had followed their policy to prevent abuse/neglect. The DON stated, No. They were asked if the facility completed a thorough investigation at the time of the event per their abuse policy. The administrator stated, No. The administrator, DON and Consultant #3 were asked if all staff and residents capable of interview, had been interviewed to identify if other residents had been involved. The DON stated we talked to staff that were here that shift and the resident's family. They were asked if local law enforcement had been notified due to the allegation of an unwanted sexual encounter. The DON and administrator stated the allegation was not substantiated so it was not required to report the incident. The DON stated resident #25 nor the family of resident #32 wanted to press charges and did not feel it needed to be addressed further. The administrator, DON and Consultant #3 were asked if all allegation of sexual abuse had been reported to OSDH and/or Local Law Enforcement within 2 hours as required by guidelines. The administrator stated the facility did not report since their in-house investigation was not substantiated. The records did not document an incident report or a report submitted to OSDH from [DATE] until [DATE], after the surveyor asked about the investigation and reports to the required agencies. Local law enforcement was observed in the administrator's office on [DATE] at 2:45 p.m., as the surveyor exited the building. 2. Resident #25 had diagnoses to include anxiety disorder, depressive disorder, and PTSD. A quarterly assessment, dated [DATE], documented Resident #25 as follows: ~clear speech, usually understood, usually understands; ~cognitively intact for daily decision making; ~is inattentive, had disorganized thinking and altered level of consciousness that does not fluctuate; and ~had delusion. A care plan, dated [DATE], documented as follows: ~ .Depression .orders per my PCP for an antidepressant .observe me for decline in mood, increase in self isolation, depression .Report to Nurse/PCP s/sx of depression, including .verbalizing negative statements, repetitive anxious or health-related complaints . ~ .Antipsychotic .order .for antipsychotic medication brexiprazole .Report to nurse s/sx .confusion, mood change, change in normal behavior, hallucination/delusion . ~ .Delusional .at risk for delusional episodes .history of altered memories of recent events and feelings of being exploited .establish baseline level of functioning .Discuss with me and my family any concerns about delusions .Monitor and address environmental factors recent change in environment, environmental noise and commotion .Monitor and report to MD new onset s/sx of delusional episodes .delusions, hallucinations .Monitor my safety daily .sometimes because of my delusional thinking, I don't feel safe .attempt to remind me of known facts . The care plan did not address specific delusions held by Resident #25. A progress note, dated [DATE], documented Resident #25 was seen by a provider as a routine skilled nursing visit. The progress note documented Resident #25 was to be evaluated by mental health services due to increase of anxiety and taking two medications to improve anxiety. A progress note, dated [DATE], documented Resident #25 was seen by a provider as a routine skilled nursing visit. The progress note read in parts, .talking all about her last couple months of medical problems, but her stories do not make sense .ambulance personnel picked her up on a fire truck along with a lot of dancing girls . A second progress note, dated [DATE], documented Resident #25 was being seen as a routine skilled nursing visit. The progress note read in parts, .states that this last weekend she had a situation that she did not want to talk about it, but she states that she thought this was her safe haven and now she is not sure. She states that this event triggered her PTSD . A nurse note, dated [DATE] at 11:30 a.m., read in parts, .approximately 10:45 [a.m.] resident requested to speak to nurse and ended up confiding in CMA that a peer at this facility entered her room the day prior during the morning and proceded to grope her breasts and other inappropriate behaviors while she was in bed. Resident stated that her peer told her he would return to do more later. Resident verbalized being scared to be viewed as a snitch, and scared of causing trouble because she doesn't want to be kicked out of the facility. Resident reassured her concerns are not being taken lightly. Resident informed that the facility's chain of command has been notified. Resident stated the incident triggered her PTSD to a similar event in her life that occurred in 2005. Resident also later confided in her daughter. Nurse informed the daughter that the DON and administrator have been notified and the situation is on going, but is being taken seriously. Resident has cried several times throughout the day when recounting the event. Resident is also requesting a 'stop sign' in front of her doorway . A nurse note, dated [DATE] at 7:30 a.m., read in parts, .This nurse was informed of an incident that took place on Saturday 8/13 .asked the resident about the incident .stated she was up in wheelchair when the male came into her room .he touched her chest when stating cold hands warm heart .memory of the situation was different than the previous chart entry .like the stop sign reminder placed on her doorway . A nurse note, dated [DATE] at 11:14 p.m., read in parts, .Resident was adamant .did not receive her gabapentin .contacted evening shift charge to confirm if medication was given .Due to uncertainty and the medication being documented as given night shift did not administer the medication . The nurse progress notes contained no other documentation of behaviors or delusions. On [DATE] at 1:15 p.m., Resident #25 was asked if it was okay to discuss an encounter she had briefly mentioned previously the day before regarding a male resident having entered her room. Resident #25 agreed to the interview. Resident #25 was asked if Resident #25 recalled having mentioned a male resident that came into Resident #25's room. Resident #25 stated she did and identified Resident #85. Resident #25 stated Resident #85 had entered the room and at first patted her hand and told her that her hands were cold. Resident #25 stated a reply was made, Cold hands, Warm heart. At that time, Resident #85 grabbed the breast of Resident #25. Resident #25 stated a history of PTSD due to having been raped, beaten and left in an apartment alone to die, so the event was very upsetting. Resident #25 stated she felt comfortable to report to the physical therapist and a certain nurse aide. Resident #25 stated the DON came and visited about the event and Resident #25 had voiced the event was frightening. Resident #25 stated no further information had been shared regarding the incident so was not aware if the facility had taken care of the issue. Resident #25 was asked if there were any other persons at the facility she was afraid of, leery of, or concerned about. Resident #25 stated there had not been a personal encounter or observation but other female residents had warned to watch out for [Resident #27]. Resident #25 stated had not seen anything first hand but have the ability to say no. Resident #25 stated worry/concern for female residents that are unable to have a voice. The clinical record did not document the resident to resident sexual assault had been thoroughly reported. The records did not document an investigation had been completed; a report submitted to OSDH; or Local Law Enforcement had been notified from [DATE] until [DATE]. The facility did not take action to follow their abuse policy until after the surveyor asked about the investigation and reports to the required agencies. 3. Resident #22 had diagnoses to include sequelae of cerebral infarction, cerebral ischemia, cognitive communication deficit, vascular dementia without behaviors, and personal history of other mental and behavioral disorders. A physician's order, dated [DATE], documented Resident #22 was to have behavior monitoring every shift with the target behaviors to include nervousness, anxious, agitation, insomnia, scratching, and pinching. A care plan, dated [DATE], read in part, .mood problem .Sometimes I am verbally aggressive to start and other residents . A nurse note, dated [DATE] at 12:06 p.m., read in parts, .is in hallway in wheelchair running resident/staff over and spitting on the floor . The clinical record did not contain an incident report to identify other residents involved, an investigation of the event, interventions to protect other residents in the immediate area, or report to proper agencies. A care plan, dated [DATE], read in parts, .Monitor/record occurrence of for [sic] target behavior symptoms like pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others . A nurse noted, dated [DATE] at 4:36 p.m., read in parts, .rolled by another resident & reached out & scratched her on the arm, drawing blood . An incident report was not located in the record to determine if the resident to resident altercation with injury had been investigated, interventions placed to protect, or notification/reporting had been completed and submitted to the required agencies. On [DATE] at 3:00 p.m., the DON and Consultants #1 and #2 were asked if incident reports were initiated/completed regarding resident to resident altercations for Resident #22. Consultant #2 stated she did not see one. The DON and Consultants #1 and #2 were asked if the abuse policy had been followed to ensure resident to resident altercations fully investigated and reported to the required agencies. No response was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident #32 had diagnoses which included, dementia, mood disturbance and anxiety. A five day assessment, dated [DATE], read in parts, ~ had severe cognitive impact; ~ inattentive behavior with fluctuations; ~ disorganized thinking, present with fluctuations; and ~ altered level of conciousness, present with fluctuations. A Nurse's Note dated, [DATE] at 9:00 a.m., read in part, .Late Entry: Note Text: DELAYED ENTRY: [Resident #32] was found visiting .[Resident #85] in [Resident #85's] room with the door shut. Informed by nurse it is fine to visit, but the door has to remain open. [Resident #32] shortly returned to .own room where .[Resident #85] followed and closed the door again. When nurse returned to room and opened door .[Resident #85] hands were groping at [Resident #32's ] lap asking why not and [Resident #32] was heard stating no because my pants are too tight. [Resident #32] informed that [Resident #85] is .married .and became upset stating that [Resident #85] lied to [Resident #32] and [Resident #32] informed [Resident #85] [they] didn't want anything to do with [Resident #85] anymore. [Resident #32's family] informed of the interaction . The clinical record contained no documentation an incident report had been completed. The clinical record contained no documentation an investigation had been completed for resident to resident sexual abuse. The clinical record contained no documentation the event had been thoroughly investigated, interventions placed to ensure protection of the residents, or that reporting had been initiated to OSDH and/or Local Law Enforcement. On [DATE] at 4:51 p.m., the DON was asked was an investigation done for the incident on [DATE] involving Resident #32 and Resident #85. The DON stated, I talked with all involved, the [Resident #85] .[Resident #32], and [Resident #32's family member]. Spoke with CNA and nurse. On [DATE] at 4:51 p.m., the DON was asked did [Resident #85] have any more incidents with any other residents. The DON stated, It was stated, [Resident #85] went into [Resident #25's] room on [DATE]. [Resident #85] held [Resident #25's] hand, .touched [Resident #25's] heart, kissed [Resident #25's]cheek. On [DATE] at 4:51 p.m., the DON was asked what was done to protect the residents. The DON stated, [Resident #85] was told to stay out of [Resident #25's] room. On [DATE] at 4:51 p.m., the DON was asked why staff had not reported the incident. The DON stated, I don't know. Based on record review and interview, the facility failed to provide evidence that allegations of abuse were thoroughly investigated, implement interventions to protect residents from further abuse, and report abuse allegations within the appropriate time frame to OSDH, APS, and Local Law Enforcement. This affected four (#85, 22, 25, and #32) of six sampled residents reviewed for abuse. a. Three residents (#85, 25, and #32) of three sampled residents who were identified to be involved with resident to resident sexual encounters, to include touching, petting, and groping. b. One resident (#22) identified to have physical aggression toward other residents, to include hitting, scratching, and attempting to run into residents while propelling self in hallway. The Resident Census and Condition of Residents identified 34 residents resided in the facility. Findings: The facility's, undated, Abuse and Neglect - Administrative Protocol policy, read in parts, .residents of this facility will be free of abuse, neglect .The facility will implement the following .for abuse prevention and investigation . Prevention .will provide protection of residents in the case of any allegations of abuse, neglect .conduct any investigations in a timely manner . Investigate .will thoroughly investigate any and all allegations of abuse, neglect .Staff will notify Administrator and Director of Nursing of all allegations .will act immediately when being notified of an allegation .will conduct and/or facilitate interviews of the direct resident(s) involved in the allegation, all other interviewable residents and all staff members, and any visitors that have knowledge or witnessed the allegation will also be interviewed. A written report or statement will be gathered and maintained on all interviews will notify all parties of the outcomes of the investigation and forward all necessary reports to OSDH and any other officials warranted . Protect .will act immediately to protect the resident when being notified of any allegation .will notify and request Local Law Enforcement if the allegation warrants their involvement .will separate any residents as necessary if the allegation is a resident to resident abuse .will take measures as appropriate to protect one resident from another, on a case by case basis . Reporting .will sent a report to all reporting agencies as required by OSDH guidelines .will send a report to the Oklahoma State Department of Health and adult protective services immediately, but not later than 2 hours of being notified of the allegation, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serous bodily injury .will send copies and necessary forms to the Nurse Aide Registry for Certified Nurse Aides, Certified medication aides and nontechnical workers .will forward copies of the reports to the Oklahoma Board of Nursing if a Licensed Nurse is involved in the allegations . 1. Resident #85 had diagnosis to include cerebral infarction, dementia with behavioral disturbance, and cognitive communication deficit. An admission assessment, dated [DATE], documented Resident #85 as follows: ~had clear speech, was understood and understood others; ~moderate cognitive impairment for daily decision making; ~inattentive, disorganized thinking, and altered level of consciousness that did not fluctuate; ~no behaviors; ~required limited assistance for bed mobility, transfers, walking, locomotion, toileting, hygiene and bathing; and ~utilized a w/c for mobility and locomotion The physician orders, dated 08/2022, did not contain medication orders for behavioral issues. The physician orders did not include what behaviors Resident #85 displayed due to dementia with behavioral disturbance. A nurse's note, dated [DATE] at 10:00 p.m., read in parts, .has been observed exhibiting flirtatious and hypersexualized behaviors throughout the weekend with peers to include getting close to individuals, groping peer in .room behind closed doors even after being informed by nurse if [Resident #85] is visiting doors must remain open. Resident was found with hands in the lap of a peer tugging on .pants asking why not. As the weekend progressed it has been stated by another resident that [Resident #85] was present in their room and giving unwanted attention. Redirection attempted by staff bringing up the topic of resident's wife or asking resident if he'd like to go on a walk in the building to go visit the birds. Redirection attempts appeared to work well . A nurse's note, dated [DATE] at 6:47 a.m., documented Resident #85 had expired. The care plan, dated [DATE], did not address behaviors or the history of behaviors. The care plan provided did not include any identified issues or interventions prior to [DATE]. The clinical record contained no other documentation of flirtatious/hypersexualized behaviors. The care plan did not address Resident #85's hypersexuality. The clinical record did not document how the peer/residents were protected when Resident #85 exhibited flirtatious and hypersexualized behaviors. The clinical record did not document the resident to resident behaviors had been reported to supervisors or that an abuse investigation was initiated. The incident was not reported to OSDH or local law enforcement. On [DATE] at 10:56 a.m., in the presence of the administrator and Consultant #3, the DON was asked to review Resident #85's nurse notes dated [DATE]. The DON was asked if the DON was aware of the entry. The DON stated, Eventually. The DON was asked if the allegation was investigated. The DON stated the facility did an investigation and the event did not appear as described in the nurse's documentation. The DON was asked where were the investigative notes and the incident reports. The DON stated the nurse that documented the event should have completed the incident report. The DON stated we talked to other staff that was on the shift the progress note was entered and there were conflicting stories. The DON was asked what residents were identified during their investigations. The DON stated Resident #32 was the first person, but the door was opened. The second resident identified was Resident #25. Resident #25 reported resident #85 had come into Resident #25's room briefly and left. Resident #25 had reported to therapy and paid no concern. The DON stated Resident #85 had a history to wander. The DON was asked what interventions were put into place to protect the residents. The DON did not respond. The DON was asked what the facility's abuse policy documented should be put into place. The DON stated, Investigate. Report it. Notify family, doctor and state. The nurse should have notified the DON immediately. The DON was asked if the facility followed their abuse policy for reporting. No response was provided. The administrator, DON and Consultant #3 were asked when should the event have been reported. Consultant #3 stated the event should have been reported within 24 hour, maybe 2 hours. The DON stated the facility talked to all individuals involved and the families were made aware. At 11:10 a.m., the BOM entered the interview. The DON was asked if Resident #85 had been assessed and care planned for dementia with behaviors. The BOM stated the behavior notes were in hospital records. At 11:35, the administrator, DON and the MDS coordinator were asked when did they become aware of the entry on Resident #85's record. The DON stated on Monday when the records were reviewed for weekend issues. The DON stated the LPN that made the entry on Resident #85 was a new hire to the facility. The DON was asked if new employees receive training at the time of hire regarding the abuse policy. The DON stated, Yes. They were asked if the facility had followed their policy to prevent abuse/neglect. The DON stated, No. They were asked if the facility completed a thorough investigation at the time of the event per their abuse policy. The administrator stated, No. The administrator, DON and Consultant #3 were asked if all staff and residents capable of interview, had been interviewed to identify if other residents had been involved. The DON stated we talked to staff that were here that shift and the resident's family. They were asked if local law enforcement had been notified due to the allegation of an unwanted sexual encounter. The DON and administrator stated the allegation was not substantiated so it was not required to report the incident. The DON stated resident #25 nor the family of resident #32 wanted to press charges and did not feel it needed to be addressed further. The administrator, DON and Consultant #3 were asked, when the allegation was identified, what was put into place to protect all residents during and after the investigation. Consultant #3 stated the nurse note documented the staff redirected Resident #85. They were asked if the staff did continuous monitoring of Resident #85 to ensure the safety of other residents. No response was provided. The administrator, DON and Consultant #3 were asked if all allegation of sexual abuse had been reported within 2 hours as required by guidelines. The administrator stated the facility did not report since their in-house investigation was not substantiated. The records did not document an incident report or a report submitted to OSDH from [DATE] until [DATE], after the surveyor asked about the investigation and reports to the required agencies. Local law enforcement was observed in the administrator's office on [DATE] at 2:45 p.m., as the surveyor exited the building. 2. Resident #25 had diagnoses to include anxiety disorder, depressive disorder, and PTSD. A quarterly assessment, dated [DATE], documented Resident #25 as follows: ~clear speech, usually understood, usually understands; ~cognitively intact for daily decision making; ~is inattentive, had disorganized thinking and altered level of consciousness that does not fluctuate; and ~had delusion. A care plan, dated [DATE], documented as follows: ~ .Depression .orders per my PCP for an antidepressant .observe me for decline in mood, increase in self isolation, depression .Report to Nurse/PCP s/sx of depression, including .verbalizing negative statements, repetitive anxious or health-related complaints . ~ .Antipsychotic .order .for antipsychotic medication brexiprazole .Report to nurse s/sx .confusion, mood change, change in normal behavior, hallucination/delusion . ~ .Delusional .at risk for delusional episodes .history of altered memories of recent events and feelings of being exploited .establish baseline level of functioning .Discuss with me and my family any concerns about delusions .Monitor and address environmental factors recent change in environment, environmental noise and commotion .Monitor and report to MD new onset s/sx of delusional episodes .delusions, hallucinations .Monitor my safety daily .sometimes because of my delusional thinking, I don't feel safe .attempt to remind me of known facts . The care plan did not address specific delusions held by Resident #25. A progress note, dated [DATE], documented Resident #25 was seen by a provider as a routine skilled nursing visit. The progress note documented Resident #25 was to be evaluated by mental health services due to increase of anxiety and taking two medications to improve anxiety. A progress note, dated [DATE], documented Resident #25 was seen by a provider as a routine skilled nursing visit. The progress note read in parts, .talking all about her last couple months of medical problems, but her stories do not make sense .ambulance personnel picked her up on a fire truck along with a lot of dancing girls . A second progress note, dated [DATE], documented Resident #25 was being seen as a routine skilled nursing visit. The progress note read in parts, .states that this last weekend she had a situation that she did not want to talk about it, but she states that she thought this was her safe haven and now she is not sure. She states that this event triggered her PTSD . A nurse note, dated [DATE] at 11:30 a.m., read in parts, .approximately 10:45 [a.m.] resident requested to speak to nurse and ended up confiding in CMA that a peer at this facility entered her room the day prior during the morning and proceded to grope her breasts and other inappropriate behaviors while she was in bed. Resident stated that her peer told her he would return to do more later. Resident verbalized being scared to be viewed as a snitch, and scared of causing trouble because she doesn't want to be kicked out of the facility. Resident reassured her concerns are not being taken lightly. Resident informed that the facility's chain of command has been notified. Resident stated the incident triggered her PTSD to a similar event in her life that occurred in 2005. Resident also later confided in her daughter. Nurse informed the daughter that the DON and administrator have been notified and the situation is on going, but is being taken seriously. Resident has cried several times throughout the day when recounting the event. Resident is also requesting a 'stop sign' in front of her doorway . A nurse note, dated [DATE] at 7:30 a.m., read in parts, .This nurse was informed of an incident that took place on Saturday 8/13 .asked the resident about the incident .stated she was up in wheelchair when the male came into her room .he touched her chest when stating cold hands warm heart .memory of the situation was different than the previous chart entry .like the stop sign reminder placed on her doorway . A nurse note, dated [DATE] at 11:14 p.m., read in parts, .Resident was adamant .did not receive her gabapentin .contacted evening shift charge to confirm if medication was given .Due to uncertainty and the medication being documented as given night shift did not administer the medication . The nurse progress notes contained no other documentation of behaviors or delusions. On [DATE] at 1:15 p.m., Resident #25 was asked if it was okay to discuss an encounter she had briefly mentioned previously the day before regarding a male resident having entered her room. Resident #25 agreed to the interview. Resident #25 was asked if Resident #25 recalled having mentioned a male resident that came into Resident #25's room. Resident #25 stated she did and identified Resident #85. Resident #25 stated Resident #85 had entered the room and at first patted her hand and told her that her hands were cold. Resident #25 stated a reply was made, Cold hands, Warm heart. At that time, Resident #85 grabbed the breast of Resident #25. Resident #25 stated a history of PTSD due to having been raped, beaten and left in an apartment alone to die, so the event was very upsetting. Resident #25 stated she felt comfortable to report to the physical therapist and a certain nurse aide. Resident #25 stated the DON came and visited about the event and Resident #25 had voiced the event was frightening. Resident #25 stated no further information had been shared regarding the incident so was not aware if the facility had taken care of the issue. Resident #25 was asked if there were any other persons at the facility she was afraid of, leery of, or concerned about. Resident #25 stated there had not been a personal encounter or observation but other female residents had warned to watch out for [Resident #27]. Resident #25 stated had not seen anything first hand but have the ability to say no. Resident #25 stated worry/concern for female residents that are unable to have a voice. On [DATE] at 3:15 p.m., the DON was asked to clarify why Resident #25 was seen by a provider for a skilled visit twice on [DATE]. After review of the progress notes and personal e-mails which the notes were sent, the DON stated the second progress note was received via e-mail on [DATE], but would call the provider to clarify. No other information was provided regarding clarification of the provider progress notes. The clinical record contained no documentation how Resident #25 was protected after the allegation of sexual abuse was identified. The clinical record did not document the resident to resident sexual assault had been thoroughly investigated. The records did not document an investigation had been completed; a report submitted to OSDH; or Local Law Enforcement had been notified from [DATE] until [DATE]. The facility did not take action to follow their abuse policy until after the surveyor asked about the investigation and reports to the required agencies. 3. Resident #27 was admitted with diagnoses to include anxiety, history of transient ischemic attack, cerebral infarction, and dementia without behaviors. Physician orders, dated [DATE] and continued to current, documented Resident #27 was to have behavior monitoring every shift for the target behavior of wandering, restlessness, insomnia, sadness, anxiety, and irritation/upset. A physician order, dated [DATE] and continued to current, documented Resident #27 was to receive Donapezil 10 mg at bedtime for dementia without behaviors. An annual assessment, dated [DATE], documented Resident #27 as follows: ~speech is unclear, rarely/never understood, and sometimes understands; ~short/long term memory deficits; ~modified independence for daily decision making; ~independent in walking, locomotion, eating, toileting, and hygiene; ~required supervision for bed mobility, and transfers; ~required limited assistance for dressing and bathing; and ~no behaviors had been observed during the assessment period. A care plan, dated [DATE], read in parts, .staff for reminders, cueing and direction for activities, cognitive stimulation, social interaction r/t cognitive deficits .need assistance of one for many ADLs due to weakness and forgetfulness .enjoys passing out clothing protectors in dining room .Impaired Cognitive function r/t hx CVA and TIAs with problems with decision making .need cueing, reminders and supervision/assistance with all decision making . A care plan, dated [DATE], read in parts, .sexuality .attracted to an alert consensual female. We enjoy private time together occasionally .allow mutually consensual intimacy as desired .wife is aware of my attraction for another resident .respects my rights .only asks that [Resident #27] be reminded that he is married .Provide privacy as requested. Close privacy curtain and door when privacy desired . The care plan regarding sexuality for Resident #27 was not updated from [DATE] until [DATE]. A care plan, dated [DATE], read in parts, .anti-anxiety medication r/t Anxiety disorder .Monitor/document side effects .Mania, Hostility and rage, Aggressive or impulsive behavior, Hallucinations . The clinical record did not document Resident #27 had been assessed to ensure the cognitive capacity was intact to consent in a sexual relationship. The clinical record did not contain documentation to the frequency/extent of the relationship between Resident #27 and Resident #10. No entries were provided to indicate staff were monitoring Resident #27 and/or Resident #10. The facility abuse policy did not address how staff were to identify consensual resident to resident physical contact versus how to identify inappropriate touching/sexuality between residents with impaired cognition. On [DATE] at 3:31 p.m., Resident #29 stated that Resident #10 and Resident #22 wander throughout the facility and do not have cognitive skills to make good choices. Resident #29 stated that Resident #10 lived across hall from a male resident, which only knew the first name of the male resident. Resident #29 stated Resident #10 goes into the male resident room frequently. Resident #10 and the male resident have been observed to kiss and male resident have his hands under Resident #10's blouse. Resident #29 stated she did not feel other residents should have to watch/observe this public display. On [DATE] at 11:35 a.m., the administrator, DON and Consultant #3 were asked if they were aware residents in the facility had concerns of inappropriate sexual touching between residents was occurring without supervision. They were informed only a first name had been identified. The administrator and DON identified the residents as Resident #27 and Resident #10. The administrator stated, Resident #27 and Resident #10 sat in the church service the weekend prior, holding hands through the church services. On [DATE] at 12:55 p.m., Resident #27's wife was asked if Resident #27 required cues/reminders. She stated the resident does have trouble communicating and may say the wrong words than what was meant. Resident #27's wife was asked if there had ever been any concerns with behaviors. Resident #27's wife stated none that she was aware of. Resident #27's wife was asked if she had ever been informed of resident touching other female residents. The wife stated Resident #27 has always been one to pat or give hugs. The wife was asked if the facility had spoken to her about Resident #27 having a female friend which he spend time with, and/or holding hands. The wife stated she had been notified of an indiscretion several years ago, she did not like it but did not feel she had any say in the matter. The wife stated she understood that it had ended, as the female resident involved had passed away. The wife was asked if she had been informed of a current female resident he was fond of. The wife stated she was aware he visited with another female resident but only that they spend time to visit each other. The wife was asked if Resident #27 had the capability to make good choices, what he would think if he thought others believed he was sexually inappropriate with the touch/pats/hugs. The wife stated Resident #27 would be very upset, if Resident #27 thought people believed he was inappropriate with female residents. On [DATE] at 2:40 p.m., the DON, Consultant #1 and Consultant #2 were asked if Resident #27's care plan was initiated on [DATE] for sexuality, why was this portion of the care plan not updated at any time until [DATE]. Consultant #1 reviewed the care plan and stated it appeared the issue had been resolved on the care plan at some time and was recently re-opened and put back into the care plan. The DON, Consultant #1 and #2 were asked if this was the same female as having been discussed on [DATE]. The DON stated there have been two female residents that Resident #27 had been involved with. The DON, Consultant #1 and #2 were asked if Resident #27's family was aware of the current relationship. The DON stated the wife was aware. The DON was asked if the wife had been told the entirety of the relationship due to the wife's belief of the current relationship was verbal exchange only. The DON stated she was not sure why the wife would say that. The DON stated she would have to look in the nurse notes to find the documentation the wife had been made aware of the situation. They were asked if the resident's with cognition impairment had been assessed to ensure they were able to give consent to a physical relationship. No information was provided. The DON was asked if an in-service had been provided to the staff after initiating the discussion of resident to resident physical altercation/relationships on [DATE]. The DON acknowledged staff had been in-serviced on the abuse policy. The DON was asked what information was provided to staff to ensure staff could determine the difference between consensual touching/relationships versus an event that a cognitive impaired resident should be protected from. No response was provided. The DON was asked how Resident #27 was being monitored in his relationship with Resident #10 to ensure the physical relationship remained consensual. No response was provided. The DON was asked if the relationship was consensual, how often did the facility re-evaluate/re-assess both residents to ensure the extent of the physical relationship and if it continued to be consensual for both residents. No response was provided. A policy was not provided regarding determination of consensual sexual relationships between residents that reside in the facility. 4. Resident #10 had diagnoses to include depressive disorder and dementia without behaviors. An activity care plan, dated [DATE], documented Resident #10 liked to sit outside and visit with fellow residents. The physician orders, dated [DATE], documented Resident #10 was to be monitored for behaviors due to medication side effects of a hypnotic and anti-depressant, to include sadness and crying. A care plan, dated [DATE], read in parts, .Cognitive Loss .forgetful .make my own decisions but please intervene if indicated .Keep My routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion . A significant change of status/five day skilled assessment, dated [DATE], documented the resident as follows: ~clear speech, understands and is understood; ~moderately impaired for daily decision making; ~is inattentive, has disorganized thinking, and altered level of consciousness that does not fluctuate; and ~required supervision with one person assist for bed mobility, transfers, dressing, and toileting. A care plan, dated [DATE], read in parts, .Sexuality .am attracted to an alert consensual male. We enjoy private time together .Allow mutually consensual intimacy as desired .Physician is aware of my desire for mutually consensual intimacy with another resident .Provide privacy as requested. Close privacy curtain and door when privacy is desired . The care plan did not address a consensual sexual relationship with a male resident prior to [DATE]. The clinical record did not contain documentation regarding when the relationship began between Resident #10 and resident #27. The clinical record did not contain documentation Resident #10 was assessed to ensure cognitive skills were intact to consent to a sexual relationship. The clinical records of Resident #10 and #27 did not contain documentation the residents had been monitored do ensure the relationship was/continued to be consensual. The facility's abuse policy did not address how residents would be determined to enter into a consensual sexual relationship, or to provide guidance to the staff in determining consensual sexual relationship versus resident to resident altercation that would require protection, investigation and reporting. On [DATE] at 3:31 p.m., Resident #29 stated Resident #10 and Resident #22 wander throughout the facility and do not have cognitive skills to make good choices. Resident #29 stated that Resident #10 lived across hall from a male resident, which only knew the first name of the male resident. Resident #29 stated Resident #10 goes into the male resident room frequently. Resident #10 and the male resident have been observed to kiss and male resident have his hands under Resident #10's blouse. Resident #29 stated she did not feel other residents should have to watch/observe this public display. On [DATE] at 11:35 a.m., the administrator, DON and Consultant #3 were asked if they were aware residents in the facility had concerns of inappropriate sexual touching between residents was occurring without supervision. They were informed only a first name had been identified. The administrator and DON identified the residents as Resident #27 and Resident #10. The administrator stated, Resident #27 and Resident #10 sat in the church service the weekend prior, holding hands through the church services. On [DATE] at 2:45 p.m., the DON, Consultant #1 and Consultant #2 were asked when did the sexual relationship begin between Resident #10 and Resident #27. The DON stated, Not sure. The DON, Consultant #1 and #2 were asked if Resident #10 had documentation of the relationship in the clinical record. No response was provided. They were asked if the care plan had addressed the sexual relationship between Resident #10 and Resident #27, prior to the initial discussion on [DATE]. Consultant #2 stated it does not look like it by looking at the current care plan. The DON and Consultant #1 and #2 were asked if the situation was being monitored by the facility, where would the encounters between the residents be documented. No response was provided. The DON and Consultant #1 and #2 were asked what intervention/consents were placed prior to [DATE]. The DON stated the families knew. No documentation of family awareness prior to [DATE] was provided. The DON and Consultant #1 and #2 were asked if the facility had at any time considered an investigation and/or incident report to ensure Resident #10 and Resident #27 had in fact began as a consensual sexual relationship. No information was provided. The DON a[TRUNCATED]