Every finding on record at Shawn Manor Nursing Home

Based on record review and interview, the facility failed to ensure the food service supervisor completed certification as a certified dietary manager within three years of beginning employment per State requirement. The administrator identified 26 residents resided in the facility and 23 residents received services from the kitchen. Findings: The Food Services Manager policy, revised 10/08, read in part, The Food Services Manager is a qualified supervisor licensed by this state. The DM was hired on 11/13/2015. There was no documentation the DM had completed certification as a certified dietary manager. On 11/18/24 at 1:07 p.m., the DM stated they had been in the dietary manager role for 9 years. They stated they completed the dietary manager training, but had not taken the exam for the certification. On 11/19/24 at 10:35 a.m., the administrator stated the DM had been in their role since 2015. They stated the DM did not have their certification.

Based on observation, record review, and interview, the facility failed to adhere to enhanced barrier precautions for: a. one (#9) of one sampled resident reviewed for a urinary catheter; and b. one (#14) of one sampled resident observed for medication administration via peg tube. The administrator identified 26 residents resided in the facility and 11 residents were on enhanced barrier precautions. Findings: An undated ENHANCED BARRIER PRECAUTIONS facility policy, read in part, Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: Device care or use .urinary catheter, feeding tube. 1. Resident #9 had diagnoses which included benign prostatic hyperplasia with lower urinary tract symptoms. A physician's order, dated 05/31/24, documented enhanced barrier precautions for an indwelling medical device three times a day for infection control. Resident #9's care plan for EBP, revised 07/22/24 documented the resident was on EBP related to their suprapubic catheter. It documented staff only had to wear gowns and gloves when touching the resident or body fluids in the resident's room. On 11/19/24 at 8:51 a.m., CNA #1 and CNA #2 entered Resident #9's room. They provided privacy. Both CNAs donned gloves and changed the resident's shirt. CNA #1 and CNA #2 transferred the resident to their bed using a lift. On 11/19/24 at 8:56 a.m., CNA #1 provided peri care with the assistance of CNA #2. LPN #1 put cream on the resident's buttocks. CNA #1 and LPN #1 changed gloves. A new brief was put on the resident. Resident #9 was repositioned in bed. All three staff removed gloves and exited room. Trash was removed. LPN #1 stated they would be back to complete catheter care. CNA #1, CNA #2, and LPN #1 did not wear a gown during the provision of care. Resident #9 had a suprapubic catheter. There was a wood dresser inside the resident's room by the door with a sticker on top labeled enhanced barrier precautions. The drawer had face masks, sanitizer, and gowns. A box of large gloves hung above the dresser on the wall in the room. A box of medium gloves hung on the wall outside resident's door. On 11/19/24 at 9:02 a.m., LPN #1 went into Resident #9's room to complete catheter care. Privacy was provided. On 11/19/24 at 9:04 a.m., LPN #1 flushed Resident #9's catheter with 60 ml of uric acid. They changed their gloves and removed the old split gauze from the pubic catheter site. LPN #1 cleansed the site and catheter tubing with cleanser and changed their gloves. They applied a new split gauze and tape. They removed their gloves, adjusted the resident, and took the trash out. LPN #1 did not wear a gown during catheter care. On 11/19/24 at 10:12 a.m., CNA #1 stated the facility process for EBP was to wash hands, wear a gown, gloves, and a face mask. On 11/19/24 at 10:13 a.m., CNA #1 stated EBP signs were posted on resident doors and carts were placed outside of resident rooms. They stated Resident #9 was on EBP. On 11/19/24 at 10:14 a.m., CNA #1 stated they did not wear a gown during the provision of care for Resident #9. They stated they should had worn a gown. On 11/19/24 at 10:15 a.m., LPN #1 stated the resident was on EBP for the suprapubic catheter. They stated they were to use gloves and hand sanitizer during care of the resident. On 11/19/24 at 10:16 a.m., LPN #1 stated they did not wear a gown during the provision of care for the resident. They stated a gown was worn for Covid-19, influenza, and airborne precautions. On 11/19/24 at 10:18 a.m., LPN #1 read the EBP sign on Resident #9's dresser. They stated they should have worn a gown. 2. Resident #14 had diagnoses which included gastrostomy status. A Physician Order, dated 05/31/24, documented the resident was on EBP for an indwelling medical device. The Care Plan, dated 06/19/24, documented the resident was on EBP for the presence of a feeding tube. On 11/19/24 at 8:53 a.m., a nightstand inside the door of Resident #14's room was observed to contain PPE and had signage which indicated the resident was on EBP. On 11/19/24 at 9:28 a.m., LPN #1 was observed to administer medications via peg tube to Resident #14. LPN #1 was observed to don gloves, but was not observed to utilize a gown. On 11/19/24 at 9:46 a.m., LPN #1 was observed to perform peg tube care for Resident #14. LPN #1 was observed to don gloves but was not observed to utilize a gown. On 11/19/24 at 10:19 a.m., LPN #1 stated they were supposed to wear a gown and gloves when residents were on EBP. They stated they had only utilized gloves, but should have donned a gown as well when they had provided medications and peg tube care for Resident #14. On 11/19/24 at 10:22 a.m., the DON/IP stated any resident who had an indwelling medical device were on EBP. The DON stated staff were to utilize gowns, gloves, and eye protection if there was a risk of splash, for residents who were on EBP. 35474

Based on record review and interview, the facility failed to ensure assessments were accurately coded for two (#3 and #5) of 13 sampled residents whose assessments were reviewed. The DON identified four residents who were ordered antiplatelet medications and five residents who were ordered anticoagulant medications. Findings: 1. Resident #3 had diagnoses which included heart failure and long term use of anticoagulant medication. Review of the October 2024 medication administration record did not reveal the resident had received an anticoagulant medication. A physician's order, dated 10/11/24, documented the resident was ordered clopidogrel (an antiplatelet medication) 75mg daily. The admission assessment, dated 10/17/24, documented the resident received an anticoagulant medication. The assessment did not indicate an antiplatelet medication had been received. 2. Resident #5 had diagnoses which included atherosclerotic heart disease. A physician's order, dated 06/23/23, documented the resident was ordered clopidogrel 75mg daily. Review of the September 2024 medication administration record did not reveal the resident had received an anticoagulant medication. The quarterly assessment, dated 09/29/24, documented the resident received an anticoagulant medication. The assessment did not indicate an antiplatelet medication had been received. On 11/19/24 at 10:55 a.m., the MDS coordinator reviewed the assessments for Resident #3 and Resident #5 and stated they had coded the residents were on anticoagulant medications because they thought clopidogrel was an anticoagulant. On 11/19/24 at 11:00 a.m., the DON stated clopidogrel should be coded as an antiplatelet on the assessments for Resident #3 and Resident #5.

Based on record review and interview, the facility failed ensure the co-pay charged to a resident account did not exceed the Medicaid payment limit for one (Resident #5) of four resident whose monies were held in the resident trust. The Administrator identified 20 residents who received Medicaid and 17 residents whose monies were held in the facility trust. Findings: Resident #5 had diagnoses which included bipolar disorder and schizophrenia. On 10/31/23 at 3:07 p.m., Resident #5 stated they received $50.00 a month for personal funds. The trust transaction history, dated 11/02/23, documented the resident received $1854.00 per month and paid $112.00 a month for a medical supplement and $1677.00 to the facility as their vendor payment for a total of $1789.00 in payments, leaving the resident with $65.00 per month for their personal funds. On 11/02/23 at 11:50 a.m., the administrator stated residents' who received Medicare and Medicaid would have $75.00 in personal funds after supplement payment and vendor payment. The administrator stated they did not know why Resident #5 only received $65.00 in personal funds but would review the account with the business office manager. On 11/02/23 at 1:15 p.m., the administrator stated the resident's funds were garnished for life by Medicare for overpayment. The administrator was asked to provide legal documentation of the lifetime garnishment. No documentation of garnishment was provided by the end of the survey.

Based on observation, record review, and interview, the facility failed to perform range of motion and positioning for one (#12) of one resident whose clinical records were reviewed for range of motion and positioning. The DON identified two residents with orders for range of motion and positioning. Findings: On 10/31/23 at 2:30 p.m., Resident #12 was observed in bed. The resident's left hand was observed with fingers drawn in. There was no positioning device or hand roll positioned within the left hand. On 11/01/23 at 9:04 a.m., Resident #12 was observed in their room. The resident's fingers of their left hand were drawn in. The resident denied the facility provided range of motion and denied the facility used a hand roll or other positioning device to position the fingers of the left hand. On 11/01/23 at 11:15 a.m., Resident #12 was observed in their room. The resident's fingers of their left hand were drawn in and there was no hand roll or other positioning device to position the fingers of the left hand. On 11/01/23 at 2:55 p.m., Resident #12 was observed in their room. The resident's fingers of their left hand were drawn in and there was no hand roll or other positioning device to position the fingers of the left hand. On 11/02/23 at 8:35 a.m., Resident #12 was observed in their room. The resident's fingers of their left hand were drawn in and there was no hand roll or other positioning device to position the fingers of the left hand. On 11/02/23 at 12:55 p.m., Resident #12 was observed in their room. The resident's fingers of their left hand were drawn in and there was no hand roll or other positioning device to position the fingers of the left hand. The order summary, dated 11/02/23 at 2:26 p.m., read in part, .cleanse bilateral hands with warm water and soap, dry thoroughly, place and maintain [positioning device] or hand roll in Left Hand only with gentle ROM including extension to fingers and wrist of both hands as tolerated, every 6 hours as needed for prevention . On 11/02/23 at 3:10 p.m., LPN #1 was asked if Resident #5 received range of motion and positioning aides for their left hand. The LPN stated the resident was not receiving therapy and there was no order for nursing to do it. On 11/02/23 at 3:25 p.m., LPN #2 was asked if Resident #5 received range of motion and positioning aides for their left arm. The LPN stated the resident was not currently receiving therapy and there was no order for nursing to provide range of motion and positioning for Resident #5 since the resident had moved halls more than a year ago. On 11/02/23 at 3:38 p.m., the DON was asked if the facility had a restorative program. The DON stated no. The DON was asked if nursing provided range of motion and positioning for residents. The DON stated the nurse aides provided some range of motion. The DON was asked if Resident #5 received the warm water washes and positioning aide for their left hand. The DON reviewed the orders and treatment sheets and stated no. The DON stated the order for range of motion and positioning was not entered as a routine order so did not come up on the computer for nursing to provide. The DON stated to prevent contractures, any order for range of motion and positioning needed to be routine.

Based on record review and interview, the facility failed to create a water management plan for the prevention of waterborne pathogens for the facility. The Administrator stated 29 residents resided at the facility. Findings: A Legionella Surveillance and Detection policy, revised date 09/23 read in part .Legionellosis outbreaks are generally linked to locations where water is held or accumulates and pathogens can reproduce . On 11/02/23 at 10:20 a.m., the Administrator stated they knew of the requirement for a water management plan and had attended a seminar on the subject, but had not yet begun to develop the plan.

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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 ,d+[DATE], did not contain MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [CONDITION(S)] . 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 [CONDITION(S)] 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 ,d+[DATE] .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 [MEDICATION(S)] .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 [CONDITION(S)] 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 [MEDICATION(S)] to follow their abuse policy until after the surveyor asked about the investigation and reports to the required agencies. 3. Resident #22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 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, [CONDITION(S)], 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. 4. Resident #32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 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, 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [CONDITION(S)] . 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 [CONDITION(S)] 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 ,d+[DATE] .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 [MEDICATION(S)] .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 [CONDITION(S)] 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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, [CONDITION(S)], 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 [MEDICATION(S)] 125 mg daily for history of other mental and behavioral disorders. On [DATE], the [MEDICATION(S)] was increased to administer 125 mg two times a day. On [DATE], the [MEDICATION(S)] 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. 4. Resident #32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 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, 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 ,d+[DATE], 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [CONDITION(S)] 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 [CONDITION(S)] . 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 [CONDITION(S)] 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 ,d+[DATE] .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 [MEDICATION(S)] .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 [CONDITION(S)] 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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, [CONDITION(S)], 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 [CONDITION(S)] 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 .[CONDITION(S)], 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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, [CONDITION(S)], 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 [MEDICATION(S)] 125 mg daily for history of other mental and behavioral disorders. On [DATE], the [MEDICATION(S)] was increased to administer 125 mg two times a day. On [DATE], the [MEDICATION(S)] 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 were initiated/completed regarding resident to resident altercations for Resident #22 to ensure the events had been investigated and residents protected. 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, and interventions to protect other residents put into place as required. No response was provided. 6. Resident #32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 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], th [TRUNCATED]

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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 ,d+[DATE], did not contain MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [CONDITION(S)] . 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 [CONDITION(S)] 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 ,d+[DATE] .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 [MEDICATION(S)] .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 [CONDITION(S)] 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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, [CONDITION(S)], 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 [CONDITION(S)] 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 .[CONDITION(S)], 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . An activity care plan, dated [DATE], documented Resident #10 liked to sit outside and visit with fell ow 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 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, protect and report. 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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, [CONDITION(S)], 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 [MEDICATION(S)] 125 mg daily for history of other mental and behavioral disorders. On [DATE], the [MEDICATION(S)] was increased to administer 125 mg two times a day. On [DATE], the [MEDICATION(S)] 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 deter [TRUNCATED]

Based on record review and interviews, the facility failed to ensure residents were offered an opportunity to up-date an advanced directive for two (#1 and #27) of three sampled residents reviewed for advanced directives. The Resident Census and Condition of Residents documented 34 residents resided in the facility with four residents having formulated an advanced directive. Findings: 1. The admission packet, dated 12/01/20, documented Resident #1 did not have an advance directive or living will. The form documented information was offered to formulate an advance directive. The admission packet and information was signed by the resident's representative. The clinical record contained no further information an advance directive was re-assessed/re-offered to ensure Resident #1's wishes were followed at end of life. 2. An admission packet, dated 08/21/19, documented Resident #27 did not have a DNR or advance directive. The form documented information was offered to formulate an advance directive. The admission packet and information was signed by the resident's representative. The clinical record contained no further information an advance directive was re-assessed/re-offered to ensure Resident #27's wishes were followed at end of life. On 09/08/22 at 1:30 p.m., the DON was asked when were residents offered information to formulate an advance directive. The DON stated the admission packet contained the information to assess for advance directives and ensure information was provided to formulate an advance directive if the resident did not have an advance directive in place. The DON was asked what the facility had in place to periodically re-assess/re-offer information for a resident to formulate/update an advance directive. The DON stated the facility did not have a practice in place to ensure a follow-up was completed to formulate advance directives.

Based on record review and interview, the facility failed to ensure assessment accurately reflected the residents status for two (#1 and #24) of 14 sampled residents. The Resident Census and Condition of Residents identified 34 residents resided in the facility. Findings: A P&P, titled Comprehensive Assessment and the Care Delivery Process, revised December 2016, read in parts, .Comprehensive assessments will be conducted to assist in developing person-centered care plans .Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating intervention, and then monitoring results and adjusting interventions . 1. Resident #1 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A fall care plan, last updated 02/21/22, read in parts, .at risk for falls r/t dementia .cue me routinely for safety while transferring self .assistance as needed .prompt response to all requests for assistance .wearing appropriate footwear . A progress note, dated 04/13/22 at 6:42 p.m., read in parts, .observed resident fall from w/c onto floor . A progress note, dated 04/15/22 at 7:09 p.m., read in parts, .observed resident lying on floor in her room .resident stated got up by herself without help . A quarterly assessment, dated 06/02/22, documented Resident #1 had severe cognitive impairment for daily decision making, required supervision of staff for transfers, supervision with two staff assistance for walking, utilized a walker and/or wheelchair for mobility/ambulation and had not had any falls since the prior assessment dated [DATE]. On 09/08/22 at 2:18 p.m., the MDS coordinator was asked if the assessment completed on 06/02/22 was accurate. After review of the progress notes and the assessment, the MDS coordinator stated the assessment did not accurately reflect falls. 2. Resident #24 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 05/27/22, read in part, .Admit to [name] Hospice Service .DNR . A significant change assessment, dated 06/08/22, did not document Resident #24 was receiving hospice services. An annual assessment, dated 08/07/22, did not document Resident #24 was receiving hospice services. On 09/08/22 at 2:09 p.m., the MDS coordinator was asked if the significant change assessment on 06/08/22 documented Resident #24 was receiving hospice services. They stated, I didn't get it, so there are some things I missed. The MDS coordinator was asked if Resident #24's annual assessment, dated 08/07/22 documented the resident was receiving hospice services. They stated, No, I didn't catch it on the first one.

Based on record review and interview, the facility failed to ensure monitoring was completed for the effectiveness of a hypnotic medication for one (#25) of one resident reviewed for the administration of a hypnotic medication. The Resident Census and Condition of Residents documented two residents had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Resident #25 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 07/25/22, documented Resident #25 was to be administered [MEDICATION(S)] 8 mg every night at bedtime for [CONDITION(S)]. The clinical record did not contain documentation the effectiveness of the hypnotic medication had been monitored. On 09/08/22 at 3:37 p.m., the DON was asked if Resident #25 had been monitored for the effectiveness of [MEDICATION(S)] that had been administered for [CONDITION(S)]. After review of the record, the DON stated a behavior monitoring order should have been put in place to prompt the monitoring of the effectiveness of the hypnotic medication, but had not been.

Based on record review and interview the facility failed to respond in a timely manner to a pharmacists recommendations for a GDR of a [CONDITION(S)] medication for one (#16) of five sampled residents reviewed for pharmacy recommended GDR's. The Resident Census and Condition of Residents, documented 21 residents received [CONDITION(S)] medications. Findings: A P&P titled, Tapering Medications and Gradual Dose Reduction, revised 2007, read in parts, .After medications are ordered for the resident, the staff and practitioner shall seek an appropriate dose and duration for each medication .Resident who use antipsychotic drugs shall receive a gradual dose reduction .unless clinically contraindicated .The Physician will review periodically whether current medications are still necessary in their current dose . Resident #16 had diagnoses which included, [CONDITION(S)] and depressive disorder, recurrent, severe with psychotic symptoms. A physician medication review report, read in parts, .[MEDICATION(S)] Tablet 50 MG Give 0.5 tablet [25 mg] by mouth at bedtime for [CONDITION(S)] .start date 04/28/21 .[MEDICATION(S)] Tablet 100MG .Give 100mg by mouth two times a day related to MAJOR DEPRESSIVE DISORDER,RECURRENT,SEVERE WITH PSYCHOTIC SYMPTOMS .start date 05/30/20 . A Pharmaceutical Consultant Report, dated 02/12/22, read in parts, .Trazadone 25 mg HS started 4/28/21 .[MEDICATION(S)] 100mg BID started 5/30/20 . The report documented a request to evaluate the routine use of the medications and consider a dose reduction. The report did not have a physician response or signature. On 09/08/22 at 1:55 p.m., the DON was asked if a GDR had been attempted for Resident #16 for the use of [MEDICATION(S)] and/or Trazadone. No response was provided at this time. On 09/08/22 at 2:40 p.m., the DON stated there was one GDR on 02/10/22, and provided a signed copy of an undated GDR. The DON was asked what the date was on the GDR form. The DON left the room with the undated GDR. On 09/09/22 at 11:49 a.m., the DON approached this surveyor and provided a copy of Resident #16's pharmaceutical consultant report for [MEDICATION(S)] and Trazadone, dated 02/10/22. The DON stated, The doctor came in and signed it yesterday and dated it today for yesterday.

Based on observation and interview the facility failed to ensure a. staff wore an N-95 while assigned in the COVID-19 isolation unit; and, b. unvaccinated staff wore an N-95 while in the facility per facility policy. The DON reported 34 residents resided in the facility. Findings: A P&P titled, COVID-19 VACCINE IMMUNIZATION REQUIREMENTS FOR STAFF MEMBERS WHO REQUEST AN EXEMPTION FROM VACCINATION, EFFECTIVE 02/14/22, read in part, .Those staff who are not fully vaccinated, or who have been granted an exemption .will adhere to additional precautions .Additional precautions include the use of a well fitted NIOSH approved N-95 mask for source control at all times while in the building . On 09/06/22 at 4:18 p.m., a PPE bin was observed outside of the double doors to enter the COVID isolation unit. Upon entry to the unit CNA #1 was observed sitting at the nurse's desk. CNA #1 was observed to be wearing only a yellow surgical mask. Three residents were housed in the COVID unit, all resident doors were observed to be open to the hallways. PPE bins were located outside the resident's rooms. On 09/08/22 at 7:49 a.m., LPN #4 was the charge nurse for the night shift. LPN #4 was observed at the nurse's desk (outside of the covid unit) and was wearing a surgical mask. On 09/09/22 at 5:39 a.m., CNA #1 was asked what had they been told about wearing PPE in the COVID unit. CNA #1 stated, if we're not in the resident's rooms, can wear a normal mask. On 09/09/22 at 6:13 a.m., LPN #4 who had worked the night shift, was interviewed and was observed wearing a yellow surgical mask. They were asked if they had been vaccinated for COVID. They stated, no. LPN #4 was asked how often are you tested . LPN #4 stated, daily. LPN #4 was asked if there were any other special precautions in place. They stated, None that I have been made aware of. LPN #4 was asked what should be worn while working in the COVID unit. LPN #4 stated, If you are providing personal care its full PPE, gown, gloves, booties, hairnet, N-95 and face shield/goggles. LPN #4 was asked what if someone is just sitting in the unit. They stated, You should be wearing an N-95. On 09/09/22 at 7:42 a.m., the DON was asked if there any special precautions in place for unvaccinated staff. The DON stated, Yes they should be wearing an N-95 when they are at work. Unless documentation for medical reasons. They were asked if any unvaccinated staff have documentation that they cannot wear an N-95? The DON stated, Not that I am aware of. On 09/09/22 at 8:03 a.m., the DON was asked are your staff that are not vaccinated wearing an N-95 mask, while in the facility? The DON stated, There is one that is not. The DON was asked what PPE should be worn by staff in the COVID unit. The DON stated, when the residents are in their rooms, they (staff) can wear the surgical mask when they go in the unit. When they go into the resident room staff should don full PPE. The DON was asked again if that was the policy to allow staff to wear a surgical mask while in the COVID unit. The DON stated, I believe it was just verbal. They were asked if that would be an infection control issue. The DON stated, Yes.

Based on record review and interview the facility failed to implement/use a SBAR tool for the use of antibiotics for one (#14) of five sampled residents reviewed for the use of antibiotics. The DON reported 34 residents resided in the facility. Findings: Resident #14 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 08/31/22, read in part, .[MEDICATION(S)] Packet Give 1 tablet by mouth one time a day for Cough/sputum for 5 days . On 09/09/22 at 1:40 p.m., the DON was asked what criteria was used for the use of antibiotics. The DON stated, the SBAR, and documentation should be in the EHR. On 09/09/22 at 2:37 p.m., LPN #2 was asked if an SBAR had been completed for Resident #14 for the antibiotic ordered on 08/31/22. LPN #2 stated, No. LPN #2 stated, the SBAR is used for respiratory and urinary tract infections. LPN #2 was asked for the antibiotic stewardship P&P. LPN #2 stated, they were unable to locate the P&P.

Based on record review and interview, the facility failed to ensure consent forms were completed for: a. pneumococcal vaccines were offered to two (#20 and #22) of five sampled residents reviewed for pneumococcal vaccines; and b. influenza vaccines were offered for one (#20) of five sampled residents reviewed for influenza vaccines. The Resident Census and Condition of Residents, documented five residents had received pneumococcal vaccines, and 20 residents had received influenza vaccines. The Resident Census and Condition of Residents documented 34 residents resided in the facility. Findings: A P&P, titled Influenza Vaccine, revised March 2022, read in parts, .Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees .For those who receive the vaccine .will be documented in the resident's .medical record .A residents's refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record . A P&P titled, Pneumococcal Vaccine revised March 2022, read in parts, .Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission .If refused .information is documented in the resident's medical record .For each resident who received the vaccine .are documented in the resident's medical record . 1. Resident #20 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/09/22 at 6:54 a.m., Resident #20's EHR was reviewed for immunizations. There was no documentation Resident #20 had received or refused the flu or pneumo vaccination. Resident #20's flu and pneumo consent form, dated 10/13/21, documented . Educational materials provided . The consent form was not completed to reflect Resident #20's consent/decline for the flu or pneumo vaccination. Resident #20's flu and pneumo consent form, dated 06/15/22, documented, Resident #20 had consented to receive the pneumo vaccination. A physician order, dated 06/16/22, read in part .flu or pneumonia vaccine . Resident #20's MAR, dated June 2022, read in part, .[MEDICATION(S)] Inject 0.5 ml intramuscularly one time . On 06/18/22 the MAR, documented the pneumo vaccination had not been administered. A medication administration note, dated 06/18/22, read in part, .waiting on pharmacy . On 09/09/22 at 8:16 Resident #20's admission flu and pneumo consent form was reviewed with the DON. The DON was asked was Resident #20 admitted during the time of flu season. The DON stated, yes. The DON was asked if the resident had been offered the flu vaccine at that time. The DON stated, The paperwork is just marked education provided. The DON was asked if the physician had ordered the pneumo vaccination since Resident #20 had admitted ? The DON stated, Looks like it was ordered June 16th. The DON was asked if the pneumo vaccination was administered as ordered. The DON stated, there was no documentation the pneumo immunization had been administered. 2. Resident #22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/09/22 at 6:54 a.m., Resident #22's EHR was reviewed for immunizations. There was no documentation Resident #22 had received or refused the pneumo vaccination. On 09/09/22 at 8:07 a.m., Resident #22's flu and pneumo consent form was reviewed with the DON. The DON, was asked if Resident #22 was offered the pneumo vaccine at the time of admission. The DON stated, Yes, it appears so .Educational materials provided, it is not marked whether [the resident] would like [to receive] it or not. The DON was asked if the admission paperwork had been completed on the vaccinations offered. The DON stated, no.

Based on record review and interview the facility failed to ensure unvaccinated staff tested daily per facility protocol for two (LPN #4 and CMA #1) of three unvaccinated staff reviewed for COVID-19 testing. The DON reported three staff who had COVID-19 vaccination exempt status. The Resident Census and Condition of Residents documented 34 residents resided in the facility. Findings: A P&P titled, COVID-19 VACCINE IMMUNIZATION REQUIREMENTS FOR STAFF MEMBERS WHO REQUEST AN EXEMPTION FROM VACCINATION, EFFECTIVE 02/14/22, read in part, .Those staff who are not fully vaccinated, or who have been granted an exemption .will adhere to additional precautions .Additional precautions .daily testing prior to shift . On 09/09/22 at 1:34 p.m., COVID-19 staff testing logs for the month of August 2022 and September 2022 was reviewed. On 09/09/22 at 7:22 a.m., the DON was asked how often COVID-19 testing was being completed. The DON stated, During outbreak, testing all staff and residents every 3-7 days when a positive is identified, with the exception of unvaccinated [staff] who are tested prior to every shift. On 09/09/22 at 2:51 p.m., the BOM was asked to confirm testing documentation for LPN #4 on 08/10/22 ,and CMA #1 on 09/03/22 and 09/04/22. The BOM confirmed there was no documentation for testing on those dates. On 09/09/22 at 3:50 p.m., the DON was asked for documentation to confirm LPN #4 had tested on [DATE], and CMA #1 had tested on [DATE] and 09/04/22. The DON was unable to provide any documentation testing had been completed for LPN #4 on 08/10/22, and CMA #1 on 09/03/22 and 09/04/22.

Based on record review and interview the facility failed to develop and implement a base line care plan for one (#31) of one newly admitted residents reviewed for base line care plans. The DON reported 34 residents resided in the facility. The Resident Matrix for newly admitted residents, documented three new admissions in the past 30 days. Findings: A P&P titled, Care Plans-Baseline, revised December 2016, read in parts, .To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. Resident #31 admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical records for Resident #31 did not contain a baseline care plan completed within 48 hours of admission to the facility. On 09/07/22 at 3:25 p.m., the MDS coordinator was asked if there was a baseline care plan for Resident #31. The MDS coordinator stated, [Resident #31] came in when I was off of work and was unsure if it had been completed. The MDS coordinator was asked to review the EHR for the baseline care plan. The MDS coordinator stated, It didn't get done.

Based on record review and interview the facility failed to ensure the comprehensive care plan was updated for one (#24) of 14 sampled residents. The Resident Census and Condition of Residents documented 34 residents resided in the facility. Findings: A P&P, titled Comprehensive Assessment and the Care Delivery Process, revised December 2016, read in parts, Comprehensive assessments will be conducted to assist in developing person-centered care plans .Monitoring results and adjusting interventions includes .Periodically reviewing progress and adjusting treatments . Resident #24 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #24's care plan, date initiated 06/21/2021, read in part, CODE STATUS: I am a FULL CODE .END OF LIFE CARES [sic]: DNR .Revision on: 05/27/22 . On 09/08/22 at 1:57 p.m., the DON was asked to review the care plan that documented Resident #24 was a full code as well as a DNR. The DON was asked if the care plan was accurate and up to date to reflect the residents code status. The DON stated, I would say not, being it has conflicting information The MDS Coordinator was asked to review Resident #24's focus code status and end of life care plan. The MDS coordinator was asked what was Residents #24's code status. They stated, a full code. They were asked what the end of life care plan documented. They stated, resident is a DNR. They were asked if that was an accurate care plan, they stated I might have just not seen the code status. The MDS coordinator was asked if the residents code status is correct on the care plan. They stated, no.

Based on observation, interview and record review it was determined the facility failed to ensure a resident was free from mental abuse for one (#1) of three sampled residents who were reviewed for abuse, neglect and exploitation. The resident had been photographed with a cell phone, by a staff member. The face of the resident, named in the allegation, was swapped with the face of a staff member. The photo had a caption which read, omg omg I look lk (sic) a gorilla. The photo was then posted to a social media site. This resulted in a past non-compliance harm. This had the potential to affect the 28 residents, identified by the administrator, who resided in the the facility. Findings: A facility policy, titled Abuse and Neglect-Administrative Protocol, documented, .It is a policy of this facility that the residents of this facility will be free of abuse, neglect, mistreatment .the facility will thoroughly investigate any and all allegations of abuse, neglect or misappropriation of property .the facility will act immediately when being notified of an allegation. Any staff member(s) that is part of the allegation will be immediately suspended and remain suspended throughout the investigation .the facility will act immediately to protect the Resident when being notified of an allegation . A staff inservice, titled Cell Phone Policy, in effect 07/23/15, documented, .the facility conducted a staff inservice which included CNA's and CMA's are not allowed to use a cell phone for any reason while clocked in .R.N's and L.P.N's are only allowed to use their cell phones for facility related issues not person (sic) use . An undated facility form, titled Abuse, was located in each employees personal file signed with their initials. Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A quarterly assessment, dated 11/15/16, documented the resident was severely impaired in cognitive skills for daily decision making and required extensive assistance with transfers and ADLs. The resident was unable to be interviewed due to her cognitive status. The other certified nursing assistant, involved in the incident, resigned before the investigation of the incident was initiated. The certified nursing assistant involved in the incident was terminated by administration on 11/29/16. The DON was terminated by the administration on 11/29/16. The facility owner conducted phone interviews with current and former employees who had knowledge of the incident on 11/29/16. A staff inservice record, dated 11/30/16, documented the facility conducted a staff inservice which included Resident's rights to privacy and confidentiality and abuse prohibition. Ten cognitive resident questionnaires, dated 11/30/16, documented the facility conducted interviews to see if residents felt safe and knew who they could talk to if they felt they had endured abuse. On 12/01/16 a report had been sent to the Nurse Aide Registry and Board of Nursing in regard to the incident. A staff inservice form, dated 12/01/16, documented the facility conducted an inservice for the social media policy to all staff members. The corporate nurse and nurse consultant #1 stated they met with the resident's husband, on 12/01/16, and notified him of the incident. On 12/01/16 the facility owner met with the resident's husband and his pastor to follow up with him regarding the incident. A facility document, titled INVESTIGATION OF RESIDENT ABUSE, documented, .On November 29th, 2016 the corporate nurse for Shawn Manor, (name deleted) LPN, was made aware of a (social media name deleted) photo which had been taken of a resident and employee which was demeaning and disrespectful in nature. The reporting party told the (name deleted) LPN she was aware that the photo had been sent to the Director of Nurses, (name deleted), on November 20th, 2016 by a concerned LPN, (named deleted); however, no action had been taken .The (social media name deleted) photo identified a female, (name deleted), and (name deleted), CNA. The ladies' faces had been swapped and a caption underneath the photo read, omg omg I look lk (sic) a gorilla. On 12/14/16 at 11:45 a.m., nurse consultant #1 stated a social media policy was put into place on 12/01/16. She stated staff had been trained on the new policy and it was now included in the new employee orientation packet. She stated that at the time of the incident there was not a social media policy at the facility. At 1:53 p.m., the administrator was asked if she was aware of the photos of the resident. She stated, No, not until I received a call from the owner. At 2:00 p.m., the LPN #1 stated she received the information from CNA #1. As soon as she received the information she contacted nurse consultant #1 and notified her that a photo had been taken which was demeaning and disrespectful in nature. At 2:20 p.m., nurse consultant #2 was asked if there was a social media policy prior to the incident. She stated, No. At 3:00 p.m., nurse consultant #1 was asked how did the resident's husband respond when the facility notified him about the photo of his wife. She stated, he was told his wife's face had been swapped with an employee's face and it was a demeaning and disrespectful photo. She stated he responded well when he was told. At 3:08 p.m., the administrator was asked if the staff were told they could not take photos of the residents. She stated, No, not that she could recall. The administrator was asked, at the time of the incident, who was the abuse coordinator for the facility. She stated, The DON. At 3:10 p.m., the resident's husband was called. He was asked how his wife would feel about the photo if she had seen it. He stated he had received numerous phone calls from friends who had seen the photo on social media. He stated, This would have humiliated my wife. His friends had told him about the caption under the photo. He stated this was such a hurtful act for someone to do to his wife and she never did anything to hurt others. He stated that she could not speak but she was aware of what was going on around her. He stated that he could not understand why the director of nursing had not taken action when she had been told and shown the photo of his wife. On 12/15/16 at 11:30 a.m., CNA #1 was asked who told her about the resident's photo on social media. She stated, LPN #1 notified her on 11/24/16. She stated, LPN #1 told her she had notified the DON on 11/20/16. CNA #1 stated she had notified the corporate nurse on 11/29/16. The CNA was asked if she had received social media training prior to the incident. She stated, No, not to my knowledge. At 2:10 p.m., LPN #1 was asked how did she learn of the photo of the resident on social media. She stated she saw it on another employee's phone. She stated, it was on 11/19/16 and she reported the incident to the DON on 11/20/16. She stated there were no further discussions with the DON regarding the photo and nothing seemed to be happening. She stated she confided in CNA #1 on 11/24/16. She was asked if she had received social media training prior to the incident. She stated, No. She was asked if she had received social media training since the incident. She stated, Yes.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident's privacy was not violated for one(#1) of three sampled residents who were reviewed for privacy. The resident had been photographed with a cell phone, by a staff member. The face of the resident, named in the allegation, was swapped with the face of a staff member. The photo had a caption which read, omg omg I look lk (sic) a gorilla. The photo was then posted to a social media site. This resulted in a past non-compliance harm. This had the potential to affect the 28 residents, identified by the administrator, who resided in the the facility. Findings: A facility policy, titled Abuse and Neglect-Administrative Protocol, documented, .It is a policy of this facility that the residents of this facility will be free of abuse, neglect, mistreatment .the facility will thoroughly investigate any and all allegations of abuse, neglect or misappropriation of property .the facility will act immediately when being notified of an allegation. Any staff member(s) that is part of the allegation will be immediately suspended and remain suspended throughout the investigation .the facility will act immediately to protect the Resident when being notified of an allegation . A staff inservice, titled Cell Phone Policy, in effect 07/23/15, documented, .the facility conducted a staff inservice which included CNA's and CMA's are not allowed to use a cell phone for any reason while clocked in .R.N's and L.P.N's are only allowed to use their cell phones for facility related issues not person (sic) use . All staff attended the inservice. An undated facility form, titled Abuse, was located in each employees personal file signed with their initials. Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A quarterly assessment, dated 11/15/16, documented the resident was severely impaired in cognitive skills for daily decision making and required extensive assistance with transfers and ADLs. The resident was unable to be interviewed due to her cognitive status. The other certified nursing assistant, involved in the incident, resigned before the investigation of the incident was initiated. The certified nursing assistant involved in the incident was terminated by administration on 11/29/16. The DON was terminated by the administration on 11/29/16. The facility owner conducted phone interviews with current and former employees who had knowledge of the incident on 11/29/16. A staff inservice record, dated 11/30/16, documented the facility conducted a staff inservice which included Resident's rights to privacy and confidentiality and abuse prohibition. All staff attended the inservice. Ten cognitive resident questionnaires, dated 11/30/16, documented the facility conducted interviews to see if residents felt safe and knew who they could talk to if they felt they had endured abuse. On 12/01/16 a report had been sent to the Nurse Aide Registry and Board of Nursing in regard to the incident. A staff inservice form, dated 12/01/16, documented the facility conducted an inservice for the social media policy to all staff members. The corporate nurse and nurse consultant #1 stated they met with the resident's husband, on 12/01/16, and notified him of the incident. On 12/01/16 the facility owner met with the resident's husband and his pastor to follow up with him regarding the incident. A facility document, titled INVESTIGATION OF RESIDENT ABUSE, documented, .On November 29th, 2016 the corporate nurse for Shawn Manor, (name deleted) LPN, was made aware of a (social media name deleted) photo which had been taken of a resident and employee which was demeaning and disrespectful in nature. The reporting party told the (name deleted) LPN she was aware that the photo had been sent to the Director of Nurses, (name deleted), on November 20th, 2016 by a concerned LPN, (named deleted); however, no action had been taken .The (social media name deleted) photo identified a female, (name deleted), and (name deleted), CNA. The ladies' faces had been swapped and a caption underneath the photo read, omg omg I look lk (sic) a gorilla. On 12/14/16 at 11:45 a.m., nurse consultant #1 stated a social media policy was put into place on 12/01/16. She stated staff had been trained on the new policy and it was now included in the new employee orientation packet. She stated that at the time of the incident there was not a social media policy at the facility. At 1:53 p.m., the administrator was asked if she was aware of the photos of the resident. She stated, No, not until I received a call from the owner. At 2:00 p.m., the LPN #1 stated she received the information from CNA #1. As soon as she received the information she contacted nurse consultant #1 and notified her that a photo had been taken which was demeaning and disrespectful in nature. At 2:20 p.m., nurse consultant #2 was asked if there was a social media policy prior to the incident. She stated, No. At 3:00 p.m., nurse consultant #1 was asked how did the resident's husband respond when the facility notified him about the photo of his wife. She stated, he was told his wife's face had been swapped with an employee's face and it was a demeaning and disrespectful photo. She stated he responded well when he was told. At 3:08 p.m., the administrator was asked if the staff were told they could not take photos of the residents. She stated, No, not that she could recall. The administrator was asked, at the time of the incident, who was the abuse coordinator for the facility. She stated, The DON. At 3:10 p.m., the resident's husband was called. He was asked how his wife would feel about the photo if she had seen it. He stated he had received numerous phone calls from friends who had seen the photo on social media. He stated, This would have humiliated my wife. His friends had told him about the caption under the photo. He stated this was such a hurtful act for someone to do to his wife and she never did anything to hurt others. He stated that she could not speak but she was aware of what was going on around her. He stated that he could not understand why the director of nursing had not taken action when she had been told and shown the photo of his wife. On 12/15/16 at 11:30 a.m., CNA #1 was asked who told her about the resident's photo on social media. She stated, LPN #1 notified her on 11/24/16. She stated, LPN #1 told her she had notified the DON on 11/20/16. CNA #1 stated she had notified the corporate nurse on 11/29/16. The CNA was asked if she had received social media training prior to the incident. She stated, No, not to my knowledge. At 2:10 p.m., LPN #1 was asked how did she learn of the photo of the resident on social media. She stated she saw it on another employee's phone. She stated, it was on 11/19/16 and she reported the incident to the DON on 11/20/16. She stated there were no further discussions with the DON regarding the photo and nothing seemed to be happening. She stated she confided in CNA #1 on 11/24/16. She was asked if she had received social media training prior to the incident. She stated, No. She was asked if she had received social media training since the incident. She stated, Yes.

Based on observation, interview and record review it was determined the facility failed to ensure a resident was free from mental abuse for one (#1) of three sampled residents who were reviewed for abuse, neglect and exploitation. The resident had been photographed with a cell phone, by a staff member. The face of the resident, named in the allegation, was swapped with the face of a staff member. The photo had a caption which read, omg omg I look lk (sic) a gorilla. The photo was then posted to a social media site. This resulted in a past non-compliance harm. This had the potential to affect the 28 residents, identified by the administrator, who resided in the the facility. Findings: A facility policy, titled Abuse and Neglect-Administrative Protocol, documented, .It is a policy of this facility that the residents of this facility will be free of abuse, neglect, mistreatment .the facility will thoroughly investigate any and all allegations of abuse, neglect or misappropriation of property .the facility will act immediately when being notified of an allegation. Any staff member(s) that is part of the allegation will be immediately suspended and remain suspended throughout the investigation .the facility will act immediately to protect the Resident when being notified of an allegation . A staff inservice, titled Cell Phone Policy, in effect 07/23/15, documented, .the facility conducted a staff inservice which included CNA's and CMA's are not allowed to use a cell phone for any reason while clocked in .R.N's and L.P.N's are only allowed to use their cell phones for facility related issues not person (sic) use . All staff attended the inservice. An undated facility form, titled Abuse, was located in each employees personal file signed with their initials. Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A quarterly assessment, dated 11/15/16, documented the resident was severely impaired in cognitive skills for daily decision making and required extensive assistance with transfers and ADLs. The resident was unable to be interviewed due to her cognitive status. The other certified nursing assistant, involved in the incident, resigned before the investigation of the incident was initiated. The certified nursing assistant involved in the incident was terminated by administration on 11/29/16. The DON was terminated by the administration on 11/29/16. The facility owner conducted phone interviews with current and former employees who had knowledge of the incident on 11/29/16. A staff inservice record, dated 11/30/16, documented the facility conducted a staff inservice which included Resident's rights to privacy and confidentiality and abuse prohibition. All staff attended the inservice. Ten cognitive resident questionnaires, dated 11/30/16, documented the facility conducted interviews to see if residents felt safe and knew who they could talk to if they felt they had endured abuse. On 12/01/16 a report had been sent to the Nurse Aide Registry and Board of Nursing in regard to the incident. A staff inservice form, dated 12/01/16, documented the facility conducted an inservice for the social media policy to all staff members. The corporate nurse and nurse consultant #1 stated they met with the resident's husband, on 12/01/16, and notified him of the incident. On 12/01/16 the facility owner met with the resident's husband and his pastor to follow up with him regarding the incident. A facility document, titled INVESTIGATION OF RESIDENT ABUSE, documented, .On November 29th, 2016 the corporate nurse for Shawn Manor, (name deleted) LPN, was made aware of a (social media name deleted) photo which had been taken of a resident and employee which was demeaning and disrespectful in nature. The reporting party told the (name deleted) LPN she was aware that the photo had been sent to the Director of Nurses, (name deleted), on November 20th, 2016 by a concerned LPN, (named deleted); however, no action had been taken .The (social media name deleted) photo identified a female, (name deleted), and (name deleted), CNA. The ladies' faces had been swapped and a caption underneath the photo read, omg omg I look lk (sic) a gorilla. On 12/14/16 at 11:45 a.m., nurse consultant #1 stated a social media policy was put into place on 12/01/16. She stated staff had been trained on the new policy and it was now included in the new employee orientation packet. She stated that at the time of the incident there was not a social media policy at the facility. At 1:53 p.m., the administrator was asked if she was aware of the photos of the resident. She stated, No, not until I received a call from the owner. At 2:00 p.m., the LPN #1 stated she received the information from CNA #1. As soon as she received the information she contacted nurse consultant #1 and notified her that a photo had been taken which was demeaning and disrespectful in nature. At 2:20 p.m., nurse consultant #2 was asked if there was a social media policy prior to the incident. She stated, No. At 3:00 p.m., nurse consultant #1 was asked how did the resident's husband respond when the facility notified him about the photo of his wife. She stated, he was told his wife's face had been swapped with an employee's face and it was a demeaning and disrespectful photo. She stated he responded well when he was told. At 3:08 p.m., the administrator was asked if the staff were told they could not take photos of the residents. She stated, No, not that she could recall. The administrator was asked, at the time of the incident, who was the abuse coordinator for the facility. She stated, The DON. At 3:10 p.m., the resident's husband was called. He was asked how his wife would feel about the photo if she had seen it. He stated he had received numerous phone calls from friends who had seen the photo on social media. He stated, This would have humiliated my wife. His friends had told him about the caption under the photo. He stated this was such a hurtful act for someone to do to his wife and she never did anything to hurt others. He stated that she could not speak but she was aware of what was going on around her. He stated that he could not understand why the director of nursing had not taken action when she had been told and shown the photo of his wife. On 12/15/16 at 11:30 a.m., CNA #1 was asked who told her about the resident's photo on social media. She stated, LPN #1 notified her on 11/24/16. She stated, LPN #1 told her she had notified the DON on 11/20/16. CNA #1 stated she had notified the corporate nurse on 11/29/16. The CNA was asked if she had received social media training prior to the incident. She stated, No, not to my knowledge. At 2:10 p.m., LPN #1 was asked how did she learn of the photo of the resident on social media. She stated she saw it on another employee's phone. She stated, it was on 11/19/16 and she reported the incident to the DON on 11/20/16. She stated there were no further discussions with the DON regarding the photo and nothing seemed to be happening. She stated she confided in CNA #1 on 11/24/16. She was asked if she had received social media training prior to the incident. She stated, No. She was asked if she had received social media training since the incident. She stated, Yes.

Based on observation, interview and record review it was determined the facility failed to ensure a resident was free from mental abuse for one (#1) of three sampled residents who were reviewed for abuse, neglect and exploitation. The resident had been photographed with a cell phone, by a staff member. The face of the resident, named in the allegation, was swapped with the face of a staff member. The photo had a caption which read, omg omg I look lk (sic) a gorilla. The photo was then posted to a social media site. This resulted in a past non-compliance harm. This had the potential to affect the 28 residents, identified by the administrator, who resided in the the facility. Findings: A facility policy, titled Abuse and Neglect-Administrative Protocol, documented, .It is a policy of this facility that the residents of this facility will be free of abuse, neglect, mistreatment .the facility will thoroughly investigate any and all allegations of abuse, neglect or misappropriation of property .the facility will act immediately when being notified of an allegation. Any staff member(s) that is part of the allegation will be immediately suspended and remain suspended throughout the investigation .the facility will act immediately to protect the Resident when being notified of an allegation . A staff inservice, titled Cell Phone Policy, in effect 07/23/15, documented, .the facility conducted a staff inservice which included CNA's and CMA's are not allowed to use a cell phone for any reason while clocked in .R.N's and L.P.N's are only allowed to use their cell phones for facility related issues not person (sic) use . An undated facility form, titled Abuse, was located in each employees personal file signed with their initials. Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A quarterly assessment, dated 11/15/16, documented the resident was severely impaired in cognitive skills for daily decision making and required extensive assistance with transfers and ADLs. The resident was unable to be interviewed due to her cognitive status. The other certified nursing assistant, involved in the incident, resigned before the investigation of the incident was initiated. The certified nursing assistant involved in the incident was terminated by administration on 11/29/16. The DON was terminated by the administration on 11/29/16. The facility owner conducted phone interviews with current and former employees who had knowledge of the incident on 11/29/16. A staff inservice record, dated 11/30/16, documented the facility conducted a staff inservice which included Resident's rights to privacy and confidentiality and abuse prohibition. Ten cognitive resident questionnaires, dated 11/30/16, documented the facility conducted interviews to see if residents felt safe and knew who they could talk to if they felt they had endured abuse. On 12/01/16 a report had been sent to the Nurse Aide Registry and Board of Nursing in regard to the incident. A staff inservice form, dated 12/01/16, documented the facility conducted an inservice for the social media policy to all staff members. The corporate nurse and nurse consultant #1 stated they met with the resident's husband, on 12/01/16, and notified him of the incident. On 12/01/16 the facility owner met with the resident's husband and his pastor to follow up with him regarding the incident. A facility document, titled INVESTIGATION OF RESIDENT ABUSE, documented, .On November 29th, 2016 the corporate nurse for Shawn Manor, (name deleted) LPN, was made aware of a (social media name deleted) photo which had been taken of a resident and employee which was demeaning and disrespectful in nature. The reporting party told the (name deleted) LPN she was aware that the photo had been sent to the Director of Nurses, (name deleted), on November 20th, 2016 by a concerned LPN, (named deleted); however, no action had been taken .The (social media name deleted) photo identified a female, (name deleted), and (name deleted), CNA. The ladies' faces had been swapped and a caption underneath the photo read, omg omg I look lk (sic) a gorilla. On 12/14/16 at 11:45 a.m., nurse consultant #1 stated a social media policy was put into place on 12/01/16. She stated staff had been trained on the new policy and it was now included in the new employee orientation packet. She stated that at the time of the incident there was not a social media policy at the facility. At 1:53 p.m., the administrator was asked if she was aware of the photos of the resident. She stated, No, not until I received a call from the owner. At 2:00 p.m., the LPN #1 stated she received the information from CNA #1. As soon as she received the information she contacted nurse consultant #1 and notified her that a photo had been taken which was demeaning and disrespectful in nature. At 2:20 p.m., nurse consultant #2 was asked if there was a social media policy prior to the incident. She stated, No. At 3:00 p.m., nurse consultant #1 was asked how did the resident's husband respond when the facility notified him about the photo of his wife. She stated, he was told his wife's face had been swapped with an employee's face and it was a demeaning and disrespectful photo. She stated he responded well when he was told. At 3:08 p.m., the administrator was asked if the staff were told they could not take photos of the residents. She stated, No, not that she could recall. The administrator was asked, at the time of the incident, who was the abuse coordinator for the facility. She stated, The DON. At 3:10 p.m., the resident's husband was called. He was asked how his wife would feel about the photo if she had seen it. He stated he had received numerous phone calls from friends who had seen the photo on social media. He stated, This would have humiliated my wife. His friends had told him about the caption under the photo. He stated this was such a hurtful act for someone to do to his wife and she never did anything to hurt others. He stated that she could not speak but she was aware of what was going on around her. He stated that he could not understand why the director of nursing had not taken action when she had been told and shown the photo of his wife. On 12/15/16 at 11:30 a.m., CNA #1 was asked who told her about the resident's photo on social media. She stated, LPN #1 notified her on 11/24/16. She stated, LPN #1 told her she had notified the DON on 11/20/16. CNA #1 stated she had notified the corporate nurse on 11/29/16. The CNA was asked if she had received social media training prior to the incident. She stated, No, not to my knowledge. At 2:10 p.m., LPN #1 was asked how did she learn of the photo of the resident on social media. She stated she saw it on another employee's phone. She stated, it was on 11/19/16 and she reported the incident to the DON on 11/20/16. She stated there were no further discussions with the DON regarding the photo and nothing seemed to be happening. She stated she confided in CNA #1 on 11/24/16. She was asked if she had received social media training prior to the incident. She stated, No. She was asked if she had received social media training since the incident. She stated, Yes.

On 10/18/12, an Immediate Jeopardy (IJ) situation was determined to exist for resident #13, who developed a pressure ulcer to her left heel, due to the facility's failure to provide routine skin and/or wound assessments, promptly notify the physician of changes in a wound, and ensure appointments were made and kept with the wound care clinic and the surgeon. The resident developed a gangrenous ulceration with necrosis of the left heel with acute and chronic osteo[DIAGNOSES REDACTED] of the calcaneus bone. The resident required a [MEDICAL CONDITION] of her left leg. The Oklahoma State Department of Health was notified and verified the Immediate Jeopardy situation. At 12:03 p.m., the Corporate Director of Clinical Operations and Administrator were notified of the IJ situation. At 2:20 p.m., an acceptable plan of removal was presented to the survey team. The plan of removal documented: "Assessment- Facility wide skin assessment today, in progress at this time, October 18, 2012. This is being completed by (ADON with CMA #4 and LPN #2 with CNA #10). This will be completed by 5pm. Prevention and assessment- All residents will have a Braden Scale done on admit and quarterly beginning October 18, 2012. Braden scales will be done with any significant change, per MDS significant change criteria. This will be reviewed by the DON or ADON and/or Director of Clinical Operations, within 24 hours of admit. Any resident shown to be at risk will have immediate interventions put into place and documented on the care plan. This review starts October 18, 2012 at 5 pm. New Transportation protocol, effective October 18, 2012 by 5 pm- all nurses will notify (name deleted) SSD if there is a transportation need. If (SSD) is unavailable, Nurses will notify (name deleted) Administrator. In-servicing-Calling all Nursing Department employees for an in-service today, October 18, 2012, at 2pm on the protocols for skin assessment, skin breakdown prevention and identification, notifying nurses of reddened and/or open areas, using Tasks/ADLs in Point Click, transportation set-up. A list of employees not attending the in-service today is being documented and they will not be allowed to work on the floor until they are in-serviced. A separate meeting will be held today, October 18, 2012 at 2:30pm with the charge nurses today and they will be specifically trained on assessing skin, calling the physician as needed for skin breakdown, skin documentation, and notifying administration and/or the Director of Clinical Operations when there is a skin problem. Monitoring-The Director of Clinical Operations will train and supervise the Director of Nursing through direct and indirect supervision and evaluate her progress daily. If there is a deficit in her abilities, she will be terminated and a new DON will be sought. This starts October 18, 2012. Monitoring-The Director of Clinical Operations will commit as much time as necessary up to 7 days a week to supervise, train and maintain the clinical operations of this facility starting October 18, 2012 by 5pm. Wound care consulting is done by a RN, CWS from (wound care company) and she comes monthly on a routine basis. If there is a need between their visits, a physician order [REDACTED]. This will be effective October 18, 2012 by 5 pm." On 10/18/12 at 2:45 p.m., and 3:20 p.m., nursing staff from all shifts who had attended the inservices were interviewed. They were knowledgeable in regard to the reporting of residents' condition changes. All staff were knowledgeable concerning notifying the physician of changes in condition and proper documentation. All staff were knowledgeable in regards to new transportation protocol. Staff were knowledgeable in regards to initial and ongoing assessment of wounds and interventions to prevent pressure sores or worsening of pressure sores. At 4:45 p.m., the facility wide skin assessments were completed. The assessment documentation was provided to the survey team for review. At 5:00 p.m., the Immediate Jeopardy was removed after the staff had been in-serviced, a new transportation protocol was implemented and facility wide skin assessments were completed. The deficient practice remained at a pattern level of actual harm. Based on observation, record review, interviews, and review of facility policy and procedure, it was determined the facility failed to: provide routine skin and/or wound assessments; promptly notify the physician of changes in a wound; ensure appointments were made and kept with the wound care clinic and the surgeon for one (#13) of three sampled residents with pressure sores. The resident developed a gangrenous ulceration with necrosis of the left heel with acute and chronic osteo[DIAGNOSES REDACTED] of the calcaneus bone. The resident required a [MEDICAL CONDITION] of her left leg. This resulted in an Immediate Jeopardy Situation. This had the potential to affect three residents identified by the facility with pressure ulcers. Findings: A policy, titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, documented: "Assessment and Recognition: 1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall assess and document/report the following: b. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue e. Resident's mobility status f. Current treatments, including support surfaces..." A policy, titled Pressure Ulcer Risk Assessment, documented: "Purpose: The purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers. 1. Review the resident's care plan to assess for any special needs of the resident. General Guidelines: 1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area, which destroys the tissues. 2. The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes... 4. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often become infected. 5. Pressure ulcers are often made worse by continual pressure... 10. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor. Assessment: 1. Risk Assessment. A pressure ulcer risk assessment will be completed upon admission, with each additional assessment, quarterly, annually and with significant changes. 2. Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. 3. Monitoring: a. Staff will maintain a "skin alert," performing routine skin inspections daily or every other day as needed. b. Nurses are to be notified to inspect the skin if skin changes are identified. c. Nurses will conduct skin assessments at least weekly to identify changes. 4. Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers..." A policy, titled Prevention of Pressure Ulcers, documented: "Interventions and Preventive Measures: General:... 2. For a person in bed: a. Change position at least every two hours or more frequently if needed..." Resident #13 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 01/12/12, documented, "...Problem: (Resident) has potential for skin breakdown related to decreased mobility and incontinent of bowel and bladder. Approach:... (2) With each incontinent episode, check skin for redness, discoloration and open areas. If noted inform charge nurse for notification of physician for treatment. (3) Turn and reposition (resident) when in bed q 2 hours. (4) Check pressure areas (bony prominences) for redness, discoloration or open areas. If noted inform nurse for notification to physician for treatment..." A Physician Notification, dated 04/24/12, documented, "...Res legs are weeping." A nurse's note, dated 08/01/12, documented, "...Legs are [MEDICAL CONDITION] and weeping. Awaiting further order." No other skin assessments were documented for the resident prior to 09/05/12. A Physician Notification, dated 09/05/12, documented, "Res has a blood blister to L heel measures 9cm x 9cm. May we have an order for [REDACTED]. A nurse's note, dated 09/06/12, documented, "LE on 9/5/12 found 9x9cm open area on lt heel. Fax to (physician) received order for hydrogel bid. Fax sent 9/6/12 requesting antibiotic as wound has a smell. Awaiting reply." A Physician Notification, dated 09/06/12, documented, "Problem: Res has open area on foot. Today it has a smell. May we start antibiotics? And lower leg is warm to touch. Response: [MEDICATION NAME] 100mg BID #20." A Skin/Wound QI Log, dated 09/06/12, documented, "Skin/wound type or stage: Stage II. Skin/wound site: lt heel. L x W (cm): 9 x 9. Intervention: hydrogel NS." A quarterly assessment, dated 09/08/12, documented the resident was severely impaired in cognitive skills for daily decision making. The assessment documented a 9cm x 9cm pressure ulcer with necrotic tissue. No additional skin or wound assessments were documented until 09/20/12. A Wound Care/Skin Integrity/Evaluation, dated 09/20/12, documented: "Wound: heel, left. Thickness: Full thickness. Etiology: Pressure/Unstageable. Size (L x W cm): 5.00 x 5.50. Acquisition: Facility Acquired. Wound bed: 95% brown-black adhered necrotic tissue and 5% yellow slough. Rationale/wound comments: Antibiotic script completed...Santyl ordered daily by physician for removal of nonviable tissue. Treatment Intervention: Cleanse wound with NS and pat dry. Apply santyl to wound bed. Apply hydrogel to wound. Cover with nonbordered foam. Wrap stretch gauze and tape secure. Change QD." There was no documentation to show the physician had been contacted regarding the necrotic tissue and yellow slough in the wound bed, or to indicate that Santyl had been ordered for the resident. A nurse's note, dated 09/20/12, documented, "Wound to left heel continues to heal. Wound care was here this am and assessed wound." A Physician Notification, dated 09/24/12, documented, "Requesting permission to use Santyl gel c hydrogel on L heel to rid of nacrotic (sic) tissue and promote better healing." A Physician response, dated 09/24/12 documented, "Ok." The September 2012 TAR documented Santyl was started on 09/25/12. A Physician Notification, dated 09/25/12, documented: "Problem: L heel wound seems to better (sic) getting worse it measures at 6cm x 5 cm c nacrotic (sic) tissue, large amounts of purulent drainage has a gangrene odor to it, also has [DIAGNOSES REDACTED] all the way to mid shin. I am very concerned with this wound and of her possibly losing this extremity. What would you like to do? Tx. that we have don't seem to be working. Response: Send to (wound care) at Hosp (hospital)." A nurse's note, dated 09/25/12, documented, "Received order to send to (wound care) at hospital for wound care. Appointment Friday 09/28/12 at 1030. Needs to be there at 1015. Arrangements fortransit (sic) to be made..." There was no documentation to show the resident was sent to the wound care clinic on 09/28/12. A nurse's note, dated 09/29/12, documented, "Left foot drsng (dressing) intact with foul odo (sic) noted." A nurse's note, dated 09/30/12, documented, "Dsg to lt heel clean dry and intact. Foul odor noted." A PT Wound Care Note, dated 10/01/12, documented, "Noted large wound on medial and posterior L heel. Measured 9 x 8cm. Black, moist, odorous tissue on wound bed c moderate foul smelling serosanguinous drainage. Contour of calcaneous bone palpable. [MEDICAL CONDITION] noted around the heel and dorsum of foot and up the posterior ankle to calf. 1+ [MEDICAL CONDITION] on LLE. Cleansed wound c cleanser, dressed c 4x4s, kerlix bandnet. Spoke c (named physician), v/o for podiatry surgical consult with (named physician) asap." A Wound Care Eval-Outpatient, dated 10/01/12, documented, "According to NH (nursing home) staff present w/ (with) patient, wound has been present since at least early September...(named physician) ordered wound care on 9/25, but d/t transportation problems, pt's (patient's) appt has been canceled twice and was rescheduled today... Other findings: [DIAGNOSES REDACTED] extends from periwound skin around to the lateral and medial aspects of the ankle, superior to the calf to just below the knee... Assessment: Stage 4 pressure ulcer L heel, w/ necrotic, foul-smelling wound... Rehab potential: Poor. Comment: Palpable bone clinically correlated w/ osteo[DIAGNOSES REDACTED]. Other procedures: Spoke w/ (physician name deleted) on the phone and was updated on findings, recommendations for surgical consult asap...(physician name deleted) has opening for 1 pm today, (physician name deleted) has opening tomorrow; (SSD) at (facility) re appt w/ (physician) today, states they can't get a ride for that appt; (physician) office updated on all developments today..." A nurse's note, dated 10/02/12 at 11:17 p.m., documented, "...Foot contins (sic) to have oul (sic) odor and VS taken bp 89/63, (physician) called with progress report. (Physician) on call and orders received to sent (sic) to ER for evaluation at 1740 (5:40 p.m.)" An ER note, dated 10/02/12, documented, "...Stage 4 decubiti to the left heel is brought via EMS for evaluation of [MEDICAL CONDITION]. The nursing staff has noted she is not active and harder to arouse over the last 2-3 days and are concerned that her decubiti is evolving [MEDICAL CONDITION] is due to have left heel debrided tomorrow in (physicians) office in the morning...Case discussed with (physician)...feels patient may be appropriately discharged with office follow up. Start the patient on [MEDICATION NAME] and he will see her in the office." A Patient History and Physical, dated 10/03/12, documented, "The patient...presented to my office as a consultation for left heel wound. The patient suffers from severe dementia and is unable to give me any history on how long the wound has been there...There is no documentation sent with the patient at the time of my exam... Physical examination:... The left lower extremity has a large necrotic wound overlying the left heel, it is malodorous, and appears to have at least an anaerobic infection. She has some mild surrounding [MEDICAL CONDITION] to the periwound area... Assessment: Left necrotic heel wound... Plan: The patient will be admitted for surgery..." A radiology exam note, dated 10/03/12, documented, "Indications: Necrotic foot. Impression: Loss of soft tissue over the calcaneus. Possible osteo[DIAGNOSES REDACTED] of the dorsum of the calcaneus." A Patient Operative Report, dated 10/05/12, documented: "...Preoperative Diagnosis: [REDACTED]. Postoperative Diagnosis: [REDACTED]. Procedure: Left below-the-knee amputation." A Surgical Pathology Report, dated 10/05/12, documented: "Diagnosis: [REDACTED]. Calcific [MEDICAL CONDITION] of anterior and posterior tibial arteries with patent lumens. Acute and chronic osteo[DIAGNOSES REDACTED] of calcaneus bone." On 10/18/12 at 11:30 a.m., the Corporate Director of Clinical Operations was asked why transportation was not available for the resident's appointment on 09/28/12 and 10/01/12. She stated that transportation didn't show up to get her and that the nurse had called the physician and let him know, but she didn't document the call. She was asked if there were any skin assessments prior to identification of the wound to the heel and any skin assessments between 09/06/12 and 09/20/12. She stated, "They should be doing weekly skin assessments." No further skin measurements or assessments were provided to the survey team. She was asked when the resident received the low air loss mattress. She stated, "When hospice readmitted her on 10/11/12 they requested it. She was on a pressure reduction mattress prior to then. It's standard for residents with skin issues so there is no order or documentation." She was asked for any documentation that heel protectors were in place. She stated, "Ok, let me do some research on that." There was no documentation provided for heel protectors. She was asked if she could provide turning and repositioning documentation from January 2012 through September 2012. She stated, "Let me see what I can find" Documentation was provided for September but no prior documentation was provided. The Corporate Director of Clinical Operations was notified that wound care documented necrotic tissue on 09/20/12 and no physician notification was documented until 09/24/12. She stated, "I will look." No documentation was provided.

An immediate jeopardy (IJ) situation was determined to exist due to the facility's failure to identify side rails as an accident hazard and the potential for injury to residents who have climbed over and/or around side rails. The Oklahoma State Department of Health (OSDH) was notified on 07/28/11 at 5:00 p.m. and verified the existence of an immediate jeopardy (IJ) situation. At 5:15 p.m., the administrator and the ADON were informed of the IJ situation existing in regards to accident hazards related to the use of side rails. On 07/28/11 at 7:45 p.m., the facility's plan of removal was accepted. The plan of removal for accident hazards documented: "...All residents will be assessed to determine medical necessity and appropriate [DIAGNOSES REDACTED]. Contact physicians for all residents whose beds currently have 1/4 side rails and request orders discontinuing the use of the 1/4 side rails and to use, where appropriate, bolster pads or other resident specific interventions and who have medical symptoms to support the use of bed rails. Remove all 1/4 side rails except those that are specifically ordered, by a physician, to remain on the resident's bed and except those where cognitive residents express an educated and informed decision to keep their side rails. All staff currently in the building shall immediately be in-serviced and all remaining staff shall be inserviced by 10:00 a.m. on July 29, 2011 and those who cannot attend will be inserviced by phone concerning the risks, assessment of risk, hazards of bed rails and on duty staff shall monitor all residents currently using side rails until the side rails are removed. Any staff that cannot be inserviced in person or telephonically by 10:00 a.m. on July 29, 2011 will be removed from the schedule until they are inserviced. All residents with side rails shall be checked at least every two hours, side rails lowered and resident repositioned. All residents and family shall be educated on the risks and hazards of the use of side rails. Education shall start immediately and shall be the duty of the DON, the ADON and all Charge Nurses upon contact with Residents and family members. All education will be completed 9:00 p.m. on July 28, 2011 in person or telephonically. With respect to those residents whose physicians order that the resident's bed be fitted with 1/4 side rails the Administrator and DON shall immediately, upon the making of such order and before the installation of the side rails, in-service all staff on the risks and hazards of side rails and direct appropriate monitoring devices to assure that bed rail accidents do not occur. All incident reports of any kind, but especially those involving doctor ordered side rails, shall be immediately presented to the DON and to the Administrator who shall immediately assess all 1/4 side rail risks, consult the resident's physician, family and develop a plan specific to the resident. The issue has been QA'd (quality assured) and will be monitored continuously. MEASURES TAKEN TO IMMEDIATELY PROTECT RESIDENTS All staff present was in-serviced concerning the risks and hazards of side rails. Monitoring of those residents who have side rails immediately commenced. All residents with side rails are being checked at a minimum of every two hours, the rails are being lowered and the residents repositioned. The (sic) shall continue indefinitely. The Subject Resident's 1/4 rails were DC'd and removed from her bed at no later than 5:50 p.m. and bolster pads were put in place." On 07/29/11 at 1:30 p.m., the facility's IJ was removed when all components of the plan of removal had been completed. The deficiency remained at an isolated level with a potential for more than minimal harm. Based on observation, clinical record review, review of policy and procedures, and staff interviews, it was determined the facility failed to ensure side rails were not an accident hazard and residents were not at risk for injury by crawling over and/or around side rails for one (#15) of seven sampled residents who utilized side rails. This had the potential to affect seven residents identified by the facility with side rails. An undated facility policy titled "Restraints/Positioning Devices" documented, "Objective: 1. to promote the resident's safety and comfort in bed or wheelchair. 2. To help prevent the resident from scratching, pulling out tubes, or interfering with medical procedures. Restraints are designed primarily for the resident's safety and comfort in bed or wheelchair. These products are not intended to replace appropriate nursing care and common sense...Whenever possible, non-restrictive devices should be used. In all cases, restrictive devices should be removed at the first possible opportunity..." Resident #15 had [DIAGNOSES REDACTED]. An annual assessment, dated 02/23/11, documented, "Resident was severely impaired in cognitive skills for daily decision making and required extensive to total assistance with ADL's. A care plan, dated 03/04/11, documented: "...Problem... ...Potential for falls r/t severe impaired vision, cognitive loss... ...Goal... ...She will have no falls by next review... ...Approach... ...when in bed put siderails (sic) up for safety r/t fear of falling from bed d/t blindness..." A side rail assessment, dated 05/22/11, documented, "...2. Does the resident have a history of falls, problem with balance or poor trunk control?...Yes...3. Does the resident have any visual deficits?...Yes...5. Does the resident have fluctuations in levels of consciousness, a cognitive deficit, involuntary movement disorder, history of seizures?...Yes...7. Is there a risk to the resident if side rails are used? (ex: climbing over rails)...No... ...Alternatives/Interventions...Interventions...Frequent monitoring...Put to bed when fatigued...Meaningful/pleasurable activities...Reminders to use call light...Regular toileting..." A nurse's note, dated 06/27/11 at 1:40 a.m., documented, "...Staff hears res hollar 'help me' upon entry to res rm res found hanging off the R side of her bed. L arm caught in bed rail, head leaning against bed rail, lower extremities under bed, res alert, unable to recall nature of fall, [DIAGNOSES REDACTED] noted L forehead, [DIAGNOSES REDACTED] to R ankle + both arms, swelling to R arm, ROM to lower extremities WNL, ROM to R arm WNL, L arm + hand contracted, res c/o pain 'everywhere' + indicates pain in both arms..." An incident/accident report form, dated 06/27/11 at 1:40 a.m., documented, "...res found hanging off the R side of bed, L arm caught in bed rail, head leaning against bed rail, lower extremities under bed, [DIAGNOSES REDACTED] to L forehead, [DIAGNOSES REDACTED] to R ankle + both arms, swelling to R arm...Dr...fax notification sent...moved to lobby for observation. TX for pain. Out to ER for eval..." A nurse's note, dated 06/27/11 at 2:05 a.m., documented, "...@ 140 heard (Resident #15) say very quietly help me went to her and found her w/ left arm in bed rail head leaning agaist (sic) it and lower extrimities (sic) under the bed then the nurse came in and took over..." A facility document, dated 06/27/11, titled, Follow up report on Fall 6/26/11, documented, "...Plan to continue using the 1/4 side rails to ensure sense of security for (Resident #15). Staff to ensure she is positioned for comfort after bed checks to ensure (Resident #15) does not attempt to reposition self in a unsafe manner..." A nurse's note dated 06/30/11 at 5:10 a.m., documented, "...Res again tries to climb out of bed was unsuccessful..." A July 2011 monthly physician's orders [REDACTED]...1/4 rails QS to aid in reposition body in bed d/t blindness r/t fear of falling from bed..." A Fall Risk Assessment, dated 07/16/11, documented, "...Total score...A resident who scores a 10 or higher is at risk. Consider ENVIRONMENTAL RISK factors in resident's interventions..." The resident's total score for the assessment completed on 07/16/11 was 24. On 07/28/11 at 12:00 p.m., CNA #1 was asked why Resident #15 had side rails. She stated, "I'm guessing so she won't roll out of bed..." At 12:10 p.m., the DON was asked about the reason Resident #15 had side rails. She stated, "She has had side rails for years. She wants them because she is afraid of falling out of bed." The DON was asked about the side rail incident for the resident. She stated, "...We did two hour position checks for four days straight. During that time she did not move in bed..." The DON was asked what interventions had been tried for reduction in side rails after the side rail accident. She stated, "We used bolsters but after assessing her decided she didn't move around in bed so we began to use rails again..." The DON was asked if the resident had a [DIAGNOSES REDACTED]. She stated, "She is blind and she is afraid." At 12:20 p.m., LPN #3 was asked why resident #15 had side rails. She stated, "I know she doesn't use them for positioning. I think it is so if she were to roll over she won't fall out of bed." At 4:30 p.m., the ADON was asked if they had assessed the side rails for this resident as an accident hazard. She stated, "No, If I had known about the 2nd attempt we would have used bolsters or something." She further stated, "We monitored her at night and used bolsters temporarily. It didn't seem to be a problem. We thought it was a positioning issue." The ADON was asked if they had done anything differently after the temporary interventions she had already mentioned. She stated, "No, besides making sure staff place her bed in a flat position when putting her bed." The ADON was asked why they stopped using the bolsters and put the rails back up. She stated, "I'm unsure why we did that." At 4:45 p.m., CNA #2 was asked if resident #15 was able to get up or reposition in bed. She stated, "She can take off her briefs..." At 4:50 p.m., LPN #4 was asked to tell me about what happened with resident #15 the second time she attempted to get out of bed. She stated, "She had her arm through the rail and her leg around the bottom of the rail so I noted it." She further stated, "It was a behavior that hadn't been there before and now it is happening and I put it in the notes to let them know the behavior wasn't going away so they would address it...."

Based on observation, clinical record review and staff interview, it was determined the facility failed to: a. provide pain management for one (#2) of nine sampled residents who required pain management. This resulted in actual harm for resident #2. This had the potential to affect 52 residents identified by the administrator who required pain management, b. provide treatment and services as ordered for an injury of unknown origin and pain management for one (#11) of one sampled residents with injury of unknown source. The facility identified five residents with injuries of unknown sources and 52 residents who required pain management, c. provide care and services to diabetic residents to ensure insulin was administered as ordered by the physician and the physician was notified of abnormal FSBS results for one (#1) of four sampled residents with diabetes mellitus. The facility identified ten residents with diabetes mellitus who received FSBS testing. Findings: 1. An undated facility policy titled, "Pain" documented: "...Monitor residents for pain, some things to look for are: verbals, body language, facial expressions...anger... ...How do you know someone might be in pain?...Observe how they function or move...Are they cranky, moaning...Resistant to care... ...Emphasize how important it is for all staff to report signs and symptoms of pain to Supervisor, Charge Nurse or DON..." An undated facility policy titled, "Pain Management" documented: "...Older adults are at risk of inadequate pain management, with age related factors affecting pain management...59% to 80% of nursing home residents experience persistent pain..." An undated facility document titled, "Pain Management, documented: "...Pain may be inadequately assessed or inappropriately treated in the older population, and not always documented in their medical charts. Assessment may be complicated by concurrent illness, under-reporting of symptoms, and cognitive decline..." The 23rd Edition 2010 Mosby's Nursing Drug Reference documented, "[MEDICATION NAME] ...Topical route...Use only on normal, intact skin..." Resident #2 had [DIAGNOSES REDACTED]. A significant change assessment, dated 08/18/10, documented the resident was moderately impaired in cognitive skills for daily decision-making, sometimes understood others, had deteriorated in her ability to express, understand and hear information and required limited to extensive assistance with ADLs. A care plan, dated 08/18/10, documented: "Problem...potential for pain r/t arthropathy of left hand... Goal...resident will be comfortable with minimal degree of pain by next review in 90 days... Approach...give pain medications as ordered...observe and record effectiveness of medication. Nurse to inform physician if not effective...staff to help with ADLs, turning and repositioning when in bed as needed to help minimize discomfort... Comment...09/07/10 monitor for pain...11/24/10 no changes cont c (with) current approaches...02/22/11 no (changes) cont c (with) current approaches...05/24/11 pain meds are given as ordered. No c/o pain voiced..." A monthly physician's order, dated February 2011, documented, "[MEDICATION NAME] Gel two times daily apply to left hand..." Nurse's notes documented the following: 03/13/11 at 3:20 p.m., "...Area on 4th digit of left hand, approx 1cm x 1cm pressure ulcer. Appears to be through to the bone, hard to measure or stage appropriately due to contracture of left hand. Cleaned area c (with) NS (normal saline) and applied foam between fingers..." 03/19/11 at 8:00 a.m., "...Cleaned wound to 4th digit of left hand c NS. Applied foam between fingers covered c coban. Res very combative c tx and care..." 03/20/11 at 9:45 a.m., "...Tx provided to 4th finger L hand, cleaned c NS, foam pad c coban, res resist care..." 03/21/11 at 7:25 p.m., "...Dressing to L hand intact. Res yells out when [MEDICATION NAME] is applied to L hand. (No) c/o pain @ this time..." 03/22/11 at 8:00 a.m., "...Tx provided to 4th digit on L hand, cleaned c NS, foam dressing c coban, drainage noted to foam, res very resistant to care, screaming and trying to bite nurse..." At 7:30 p.m., "...(no) dressing to L hand. [MEDICATION NAME] applied. Res screaming its cold. (No) c/o pain voiced @ this time..." 03/23/11 at 8:15 a.m., "...Tx provided to 4th digit on L hand, cleaned c NS, foam dressing c coban, 4th finger wound red with yellow drainage, res very resistant to care, screaming and trying to hit nurse... At 9:00 a.m., "... Dr faxed concerning finger on L hand..." 03/25/11 at 1:00 a.m., "...Res started on ABT [MEDICATION NAME] 875 mg for infection to wound on L hand..." At 7:30 p.m., "[MEDICATION NAME] applied to L hand..." 03/26/11 at 8:30 a.m., "...Res in recliner. [MEDICATION NAME] applied to L hand res screaming out..." At 4:00 p.m., "...Area reddened c yellow drainage noted. Res c/o pain while cleaning site. (No) complaints once hand wrapped. Continues ABT for infection to site..." A behavior report record for March 2011 documented, "...03/28 Screams and yells when you do tx to hand and pulls away..." A medication record for March 2011 documented the resident did not receive any pain medication during the month of March. The resident did not have physician's orders for any pain medications other than [MEDICATION NAME] during the month of March. Nurse's notes documented the following: 04/02/11 at 9:20 a.m., "...continues ABT for wound infection, tx provided to L hand, sm amt drainage noted to dressing, res uncooperative with care..." 04/04/11 at 9:15 a.m., "...Tx provided to L hand, drainage noted to 4th digit, L hand, cleaned c NS and dressed ...res uncooperative c care..." 04/07/11 at 9:00 a.m., "...uncooperative with tx, drainage noted to dressing..." 04/08/11 at 7:45 a.m., "...Tx provided to L hand (no) redness noted, red drainage to dressing, res uncooperative with care..." 04/09/11 at 10:00 a.m., "...Tx provided to L hand...res uncooperative with care..." 04/10/11 at 9:00 a.m., "...Tx provided to 4th digit L hand...res. uncooperative c care..." 04/11/11 at 12:30 a.m., "...drsg (dressing) to L hand CDI, (clean dry and intact) res protective c hand, hollars 'no, leave it alone'..." 04/12/11 at 1:00 p.m., "...area to finger soft, moist and stage four noted. Foul smell present c bandage change..." 04/14/11 at 7:25 p.m., "...Res won't let L hand be touched. L hand red and swollen to fingers..." 04/15/11 at 9:20 a.m., "...Res refused tx to L hand, continuous screaming to stop, dressing left off @ this time..." At 7:30 p.m., "...Res pinching and trying to hit during tx care. Res calm after tx completed..." 04/16/11 at 9:30 a.m., "...Tx provided to L hand, res uncooperative with care assist of CNA to (change) dressing ..." 04/18/11 at 11:00 p.m., "...4th digit left hand discolored. Approx 1-2 inch bone exposed. Notified hospice nurse...Dr..." 04/19/11 at 8:00 p.m., "...Res refuses tx or for hand to be examined..." 04/20/11 at 9:20 a.m., "...tx provided to L hand as ordered, res uncooperative c care assist of CNA needed to provide tx, res yelling and slapping @ nurse..." A physician's telephone order, dated 04/22/11, documented, "...DC Volteran Gel due to inability to use c (with) dressing change..." A nurse's note, dated 04/23/11 at 9:20 a.m., documented, "...attempt to tx L hand, res refusing, will attempt another time..." The April 2011 medication record documented the resident did not receive any pain medication during the month of April. The resident did not have physician's orders for any pain medication during the month of April, other than the [MEDICATION NAME]. Nurse's notes documented the following: 05/02/11 at 11:00 a.m., "...Tx provided to L hand as ordered, res yelling and screaming during tx..." 05/04/11 at 8:30 a.m., "...Tx provided to L hand as ordered, res yelling out during tx, assist x 1 CNA to complete tx..." 05/05/11 at 9:30 a.m., "...Tx provided to L hand as ordered, res yelling out during tx, assist x 1 CNA to complete tx..." 05/07/11 at 7:45 p.m., "...Dressing to L hand (changed). Res combative hitting, punching, and digging fingernails into arm @ this nurse. Blood noted between 4th and 5th digits...Res yelling during tx..." 05/18/11 at 1:30 p.m., "...Tx provided to L hand, res yelling and screaming CNA assist with tx, res calmer after tx..." At 11:30 p.m., "...res protective c L hand..." The May 2011 medication record documented the resident did not receive any pain medication during the month of May. The resident did not have physician's orders for any pain medications during the month of May. On 07/26/11 at 2:15 p.m., the ADON was asked how should a resident be treated who potentially has pain during a stage four wound treatment. She stated, "You should give them pain medication." The ADON was asked if the resident was medicated for pain prior to wound care. She stated, "No." At 2:30 p.m., the DON was asked what best practice would be for wound care treatment and pain control. She stated, "It would be to treat with pain medication 30 minutes prior to wound care." At 3:50 p.m., LPN #1 was asked if she had applied Volteran gel to the resident's hand after the wound was discovered. She stated, "Yes, but the wound was on the side of her finger. I put the gel on the top of her hand." LPN #1 was asked if she thought the gel might have gotten on the resident's wound. She stated, "Yes." At 4:30 p.m., Resident #2 was asked if she had pain in her hands. The resident stated, "My arms and my legs hurt..." At 4:35 p.m., the DON was asked how a resident with cognitive impairment should be assessed for pain. She stated, "We look for signs, signals, grimacing, pulling away, tears and frowning. Anything that would indicate pain." The DON was asked if a resident screamed or yelled during wound care would that be an indicator of pain. She stated, "Yes." At 4:43 p.m., CMA #1 was asked if she had noticed Resident #2 having pain with her hand. She stated, "When you touch her hand she is in pain. She says Mama stop." On 07/27/11 at 8:40 a.m., the Restorative Aide was asked if she thought Resident #2 had pain in her hand. She stated, "Yes, when I try to do restorative she pulls way and yells out." She further stated, "She pulls the blanket over her hand and says leave me alone or don't do that." The resident did not currently have any physician's orders for pain medication. 2. Resident #11 had [DIAGNOSES REDACTED]. The initial assessment dated [DATE], and the quarterly assessment, dated 06/18/11, documented the resident had long term and short term memory problems. The resident required limited to extensive assistance with activities of daily living. Nurses' notes documented the following: "5/24/11 11:00 L arm would not extend, resident grimaced in pain and pulled arm towards her. Eccymosis noted above and below elbow. Res States, 'It hurts above.' Which was upper portion of arm posterior to shoulder. Res extended arm slightly." At 11:10 (a.m.), "Call to Dr. (name deleted) office... ordered x-ray to L arm. (Name deleted) called... stated 'I'll be there this afternoon.'" At 11:30 (a.m.), "Call to Dr. (name deleted) to notify him of L arm xray and possible injury to L arm..." At 2:30 p.m., "X Ray to L arm completed..." At 10:50 p.m., "Bruising and swelling continue to L arm. C/o of pain c movement. X Ray results pending..." 05/25/11 at 6:55 a.m., "...Bruising and swelling continues ...Res grimacing c touch. Waiting on results of X-Ray." At 1:45 p.m., "X Ray results faxed ..." 05/27/11 at 3:15 a.m., "Bruising and swelling to L arm above & below elbow Guarded movements of L arm X-Ray neg for FX." At 9:15 a.m., "Arm hurts. Will continue to monitor." 05/29/11 at 12:30 a.m., "Swelling and bruising to L arm... continues fluctuating between improvement & getting worse..." At 1:15 (p.m.), "Res lethargic this am..." 05/30/11 at 8:00 a.m., "...Swelling noted continues to L arm & swelling to L hand c (with) bruising. Grimaces when touched. Fax sent to Dr. (name deleted)." 9:00 p.m., "...L hand still continues c swelling & bruising to hand & arm L ...Res does grimace when arm & hand is touched..." 05/31/11 at 12:20 a.m., "Bruising & swelling continues to L arm & L hand, res protective c arm & grimaces to touch..." At 8:00 a.m., "...Res still continues to grimace when touched, very protective of arm. Fax sent to (name deleted)." At 4:00 p.m., "N.O. recd (received): xray L wrist, [MEDICATION NAME] 5 mg PO (by mouth) q 4 (hours) prn pain." At 4:10 (p.m.), "...Grimacing noted when L arm touched..." At 11:00 p.m., "(Name deleted) informed via telephone need for xray to L wrist. (Name deleted) says he should be here Thursday (06/02/11- in two days) ...L arm, L hand & L wrist continues to remain swollen c generalized bruising, res protective c arm..." 06/01/11 at 12:20 (p.m.), "(Name deleted) from xray here, xray to L wrist. Bruising and swelling continues... continues to be protective of hand. Grimacing noted." At 2:30 p.m., "... Grimacing to touch..." 06/02/11 10:00 (p.m.)- 6:00( a.m.), "W/C (wheelchair) propelled by self for mobility L arm swelling continues x-ray of wrist pending results..." 6:00 (a.m.) - 2:00 (p.m.), "Swelling continues to L arm and wrist. X Ray results pending on L wrist. Waiting on reply from Dr. (name deleted)." An x-ray report for the left wrist, completed on 06/01/11, was noted by facility staff on 06/02/11 at 1:20 p.m. The report documented, "IMPRESSION: ...Irregularity of the trapezium bone at the wrist, perhaps due to a fracture of indeterminate age. Recommend clinical correlation..." A nurse's note, dated 06/02/11 for the 2:00 (p.m.) - 10:00 (p.m.) shift, documented, "...Swelling and discoloration remains to LUE (left upper extremeties)." A nurse's note, dated 06/03/11 for the 10:00 (p.m.) - 6:00 (a.m.) shift, documented, "...W/C propelled by self for mobility... L arm still swollen..." A physician's order, dated 06/03/11, documented, "wrist splint x (times) four weeks - OT eval (evaluation) for splint 06/06/11 - part B." On 06/03/11, the care plan documented, "wrist splint x four weeks. OT eval for splint 06/06/11." No goals or approaches were documented. A nurse's note, dated 06/03/11 at 5:00 p.m., documented, "N.O. (New order) rec'd(received) wrist splint (times) 4 wks (weeks), OT eval on 6-6-11 for splint. TARS (treatment records) updated." The treatment record for June-2011 documented: a. "6/3/11 wrist splint x 4 wks (weeks) when rec'd (received)" and b. "OT eval for splint 6/3/11" Nurses' notes documented the following: 06/04/11 10:00 (p.m.)- 6:00( a.m.), "... OT to eval on 6/6/11 for splint for L arm." At 1:45 p.m., "Bruising et (and) swelling to upper L arm et on chest..." 10:00 (p.m.) - 6:00 (a.m.), "...L arm elevated continues to remain swollen c generalized bruising res protective c L arm..." 06/05/11 2:00 (p.m.) - 10:00 (p.m.), "L arm guarded- slightly swollen c some bruising..." 10:00 (p.m.) - 6:00 (a.m.), "...Does not answer to questions asked... resistive to care @ noc (night)...does not express needs, protective c L arm, pending splint arrival for L wrist..." 06/06/11 6:00 (a.m.) - 2:00 (p.m.), "...Unable to answer questions appropriately... Does not express needs. Splint pending." 2:00 (p.m.) - 10:00 (p.m.), "...Unable to answer questions... Pt (patient) continues to guard. Splint pending." 06/06/11 10:00 p.m. - 6:00 a.m., "...Does not answer to questions asked, does not express needs... res protective (with) L arm, splint for L wrist (not) yet avail..." 06/07/11 6:00 (a.m.) - 2:00 (p.m.), "...Unable to answer questions asked... Protective of L arm continues... Pending OT eval c splint..." 2:00 (p.m.) - 10:00 (p.m.), "...Unable to properly answer questions when asked... OT eval will be here 6/8/11 to eval for splint..." 10:00 (p.m). - 6:00 (a.m.), "...Does not answer to questions asked, does not voice needs, ...Protective c L arm, swelling continues to L arm..." 06/18/11 (no time documented), "...some swelling continues. (No) splint available @ this time." 2 (p.m.) - 10:00 (p.m.), "...some swelling to L arm- still (no) splint available @ this x." 06/21/11 at 10:45 p.m., "Slight swelling noted to L arm, (no) visible bruising, res (resident) continues to be protective c arm, splint not available..." 06/25/11 at 4:45 a.m., "...(No) wrist splint has been received to this date." 06/25/11 at 8:00a.m., "...(No) wrist splint available." The nurse'e treatment notes for June 2011 documented the following: ~ "6-4-11 Have not received splint" ~ "6-5-11 No (appointment with) OT as of today" ~ "6/7/11 6-2 waiting on OT eval for splint" ~ "6/8/11 6-2 Splint eval today, waiting on splint" ~ "6/12/11 (No) splint available" ~ "6/18/11 2-10 (No) splint available" ~ "6/23/11 10-6 Splint not available yet" ~ "6/29/11 (No) splint received" ~ "6/30/11 6-2 PT applied splint" A nurse's note, dated 07/01/11 at 12:00, documented, "Dr. (name deleted) making rounds N.O. (new order) DC OT interventions. Short arm sling on/off daily as tolerated." On 07/01/11, the care plan documented, "DC (discontinue) OT intervention short arm splint elevate." There was no documentation to show the physician had been notified of the delay in obtaining the splint when ordered for the resident. The splint was applied to the resident's wrist 27 days after it had been ordered by the physician. On 07/28/11 at 11:00 a.m., when asked to explain the delay in providing interventions when ordered for the resident, the DON stated, "We had problems getting the splint. PT said to call the company and I tried to call without results. It took several days for PT to get back and tell us what kind of splint; we finally ordered it ourselves." The facility provided no documentation to show the physician had been notified of the delay in obtaining the splint as ordered for the resident. Pain Management On 05/24/11 at 11:00 a.m., it was determined the resident had injury with pain and bruising, On 05/31/11 at 4:00 p.m., an order was received for [MEDICATION NAME] 5 mg every four hours as needed. ~ Prior to the order for [MEDICATION NAME], it was documented the resident exhibited pain nine times. There was no documentation to show the resident was assessed for the extent and/or frequency of her pain. ~ After the order for the [MEDICATION NAME], it was documented the resident exhibited pain ten times. There was no documentation to show the resident was assessed for the extent and/or frequency of her pain. It was not documented the resident was offered pain medication when the licensed nurses identified the resident was suffering with pain. On 07/28/11 at 12:30 p.m., the DON was asked to explain the delay in treatment and services for the resident. She stated this is where she had all the [MEDICAL CONDITION] in that arm. It was brought to my attention she had some bruising in that arm, before that, "I don't know." 3. A facility policy/procedure titled "[DIAGNOSES REDACTED], Adult", effective 07/10/07, documented: "...GUIDELINES FOR NOTIFYING PHYSICIAN: ? Severe Reaction ? Blood sugar less than 70 mg/dl after 3 treatments or FSBS > 300 ? [DIAGNOSES REDACTED] episode before Humalog, [MEDICATION NAME], or [MEDICATION NAME] or oral hypoglycemic agent (excluding) [MEDICATION NAME], Actos, [MEDICATION NAME] or [MEDICATION NAME] is to be given..." Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The June 2011, monthly physician orders documented: ~ "...12/24/10 (original order date) FSBS two times daily before breakfast/dinner...", and ~ "...04/01/11 (original order date), [MEDICATION NAME] 100 U/ml before breakfast/dinner take FSBS (subtract) 120 (divide by) 30 (equals) amt (amount) (to be) given..." A telephone order, dated 06/02/11, documented [MEDICATION NAME] 20 units hs. The June 2011, injection sheet documented: ~ On 06/02/11 at 4:30 p.m., the FSBS result was 339. There was no documentation the physician was notified of the elevated FSBS. ~ On 06/03/11 at 4:30 p.m., the FSBS result was 400. There was no documentation the physician was notified of the elevated FSBS. ~ On 06/04/11 at 4:30 p.m., the FSBS result was 432. There was no documentation the physician was notified of the elevated FSBS. ~ On 06/05/11 at 4:30 p.m., the FSBS result was 356. There was no documentation the physician was notified of the elevated FSBS. ~ On 06/06/11 at 4:30 p.m., the FSBS result was 313. There was no documentation the physician was notified of the elevated FSBS. ~ On 06/07/11 at 4:30 p.m., the FSBS result was 308. There was no documentation the physician was notified of the elevated FSBS. ~ On 06/08/11 at 4:30 p.m., the FSBS result was 326. There was no documentation the physician was notified of the elevated FSBS. ~ On 06/11/11 at 4:30 p.m., the FSBS result was initialed by the nurse but no result was written in. Two units of sliding scale insulin was given. Not enough information was documented to know if the amount of sliding scale insulin given was correct or not. ~ On 06/12/11 at 4:30 p.m., the FSBS result was initialed by the nurse but no result was written in. Four units of sliding scale insulin was given. Not enough information was documented to know if the amount of sliding scale insulin given was correct or not. ~ On 06/15/11 at 4:30 p.m., the FSBS result was 182. Regular insulin five units was given. According to physician's orders, she should have received two units. ~ On 06/19/11 at 4:30 p.m., the FSBS result was 344. There was no documentation the physician was notified of the elevated FSBS. ~ On 06/20/11 at 4:30 p.m., the FSBS result was 334. There was no documentation the physician was notified of the elevated FSBS. ~ On 06/26/11 at 4:30 p.m., the FSBS result was 240. Regular insulin three units was given. According to physician's orders, she should have received four units. The July 2011, monthly physician orders documented: ~ "...FSBS two times daily before breakfast/dinner...", ~ "[MEDICATION NAME] 100 U/ml before breakfast/dinner take FSBS (subtract) 120 (divide by) 30 (equals) amt (amount) (to be) given...", and ~ "...Lavemir ([MEDICATION NAME]) hs...20 units..." The July 2011, injection sheet documented: ~ On 07/03/11 at 6:30 a.m., the FSBS result was 319. There was no documentation the physician was notified of the elevated FSBS. ~ On 07/03/11 at 4:30 p.m., the FSBS result space was left blank. The space for the amount of sliding scale insulin given was left blank. There was no documentation indicating why the FSBS had not been performed. There was no documentation indicating the resident was out of the facility. ~ On 07/04/11 at 6:30 a.m., the FSBS result was 315. There was no documentation the physician was notified of the elevated FSBS. ~ On 07/07/11 at 6:30 a.m., the FSBS result was 392. There was no documentation the physician was notified of the elevated FSBS. ~ On 07/08/11 at 6:30 a.m., the FSBS result was 370. There was no documentation the physician was notified of the elevated FSBS. ~ On 07/08/11 at 4:30 p.m., the FSBS result was 437. There was no documentation the physician was notified of the elevated FSBS. ~ On 07/09/11 at 4:30 p.m., the FSBS result was 301. There was no documentation the physician was notified of the elevated FSBS. ~ On 07/10/11 at 6:30 a.m., the FSBS result was 416. There was no documentation the physician was notified of the elevated FSBS. ~ On 07/11/11 at 6:30 a.m., the FSBS result was 428. There was no documentation the physician was notified of the elevated FSBS. A telephone order, dated 07/12/11, documented, "Increase [MEDICATION NAME] to 40 units @ HS." The July 2011, injection sheet documented: ~ On 07/13/11 at 6:30 a.m., the FSBS result was 436. There was no documentation the physician was notified of the elevated FSBS. ~ On 07/15/11 at 6:30 a.m., the FSBS result was 452. There was no documentation the physician was notified of the elevated FSBS. ~ On 07/16/11 at 6:30 a.m., the FSBS result was 507. There was no documentation the physician was notified of the elevated FSBS. ~ On 07/16/11 at 4:30 p.m., the FSBS result was 569. There was no documentation the physician was notified of the elevated FSBS. ~ On 07/18/11 at 6:30 a.m., the FSBS result was 462. Regular insulin 8 units was given. According to physician's orders, she should have received 11 units. There was no documentation the physician was notified of the elevated FSBS. A telephone order, dated 07/19/11, documented, "add regular insulin 15U sub Q (subcutaneous) TID." The July 2011, injection sheet documented: ~ On 07/19/11 at 6:30 a.m., the FSBS result was 513. There was no documentation the physician was notified of the elevated FSBS. ~ On 07/19/11 at 4:30 p.m., the FSBS result was 477. There was no documentation the physician was notified of the elevated FSBS. ~ On 07/20/11 at 4:30 a.m., the FSBS result was 499. There was no documentation the physician was notified of the elevated FSBS. ~ On 07/22/11 at 6:30 a.m., the FSBS result was 497. Regular insulin 11 units was given. According to physician's orders, she should have received 12 units. ~ On 07/23/11 at 4:30 p.m., the FSBS result was 486. There was no documentation the physician was notified of the elevated FSBS. ~ On 07/24/11 at 6:30 a.m., the FSBS result was 447. There was no documentation the physician was notified of the elevated FSBS. ~ On 07/25/11 at 6:30 a.m., the FSBS result was 457. There was no documentation the physician was notified of the elevated FSBS. On 07/27/11 at 10:10 a.m., the DON was asked to explain the calculation of the sliding scale order. She stated, "You take the FSBS result, subtract 120, then divide by 30. The result you get is the amount of insulin to be given." On 07/27/11 at 3:30 p.m., the DON was asked if there was an order from the resident's physician to notify him at a different FSBS result than the policy stated. After looking through the clinical record the DON stated there was no physician order "contrary" to what was stated in the policy. The DON then stated, "I know during this time we contacted him (the physician) frequently, I hope." The DON was asked if she knew how many times the resident had a FSBS result greater than 300. She stated, "There were probably quite a few..." The DON then stated she had QA'd it on 05/02/11 as ineffective documentation to show the physician was notified. She then stated, "It is an ongoing problem. I continue to work on it." On 07/27/11 at 7:20 p.m., the DON was asked if and when the the result received when calculating the sliding scale dose is rounded up or down. She stated they are never to round up or down. She was asked if she was aware of miscalculations in the sliding scale dosage for the resident. She stated she was unaware.