Every finding on record at Fernwood Supportive Living at Madrona Grove

Based on interview and record review it was determined the facility failed to have the Infection Preventionist attend the quality assessment and assurance (QAA) committee meetings for 3 of 3 months reviewed for QAA. This placed residents at risk for unidentified and unmet needs. Findings include: Documentation of QAA/QAPI meeting minutes were requested from 3/2026 through 5/2026 which revealed a qualified Infection Preventionist did not attend any of the QAA/QAPI meetings.On 6/4/26 at 3:32 PM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged a qualified Infection Preventionist did not attend the QAA/QAPI meetings.

Based on interview and record review it was determined the facility failed to have a qualified and trained Infection Preventionist in place for 1 of 1 facility reviewed for infection prevention and control. This placed residents at risk for inadequate infection control. Findings include: A Staff List provided on 6/1/26 did not identify an Infection Preventionist.On 6/2/26 at 9:30 AM, Staff 1 (Administrator) stated Staff 12 (RNCM) was the facility's designated Infection Preventionist.Staff 12 was out of the facility and unable to be interviewed.A review of documents provided by Staff 1 (Administrator) revealed Staff 12 completed 11 of 24 modules of training from CDC Train's program and no indication the modules were completed and no evidence of a completed certification.Additional information regarding completion of the training and certification was requested from Staff 1 (Administrator) and no additional information was provided.On 6/4/26 at 12:43 PM, Staff 1 confirmed there was no documentation verifying Staff 12 completed the appropriate certification to serve as the designated qualified Infection Preventionist.

Based on observation and interview it was determined the facility failed to ensure staff wore Personal Protective Equipment for 1 of 1 sampled residents (#2) reviewed for Transmission Based Precautions. This placed resident at risk for infections. Findings include: Resident 2 was admitted to facility in 12/2024 with a diagnosis of parkinsonism (an umbrella term for a group of conditions that cause movement problems, such as tremors, slowness, stiffness, and balance issues).Resident 14's 3/5/26 Quarterly MDS revealed the resident was cognitively intact.On 6/1/26 at 10:46 AM, Resident 2's door was observed to have a contact precaution sign with a storage container of PPE outside the door. The signage did not include information regarding what to put on before entering the room and where to doff PPE prior to exiting the room. Instructions on the sequence of donning and doffing PPE were inside of the drawer of the PPE bin. On 6/1/26 at 10:46 AM, Staff 10 (LPN) stated Resident 2 was on contact precautions due to vomiting, loose stools and stomach cramps and everyone was required to don PPE prior to entering the resident's room.On 6/1/26 at 12:15 PM, Staff 10 (Housekeeper) was observed inside of Resident 2's room, approximately two feet from the resident without a gown or mask. Staff 10 was observed exiting the room, then entering the room to take out the trash inside of the resident's room. Staff 10 exited the room and entered again to put a liner in the trash can. On 6/1/26 at 12:19 PM, Staff 10 was observed exiting the resident's room without a gown or mask. Staff 10 stated she just completed cleaning the resident's toilet and bathroom. Staff 10 stated she did not know what the contact precautions sign meant on the resident's door, was unsure who to ask, and unaware of what to do when the sign was on the door.On 6/4/26 at 10:44 AM, Staff 5 (Environmental Services Manager) stated she expected housekeeping staff to refer and follow the signage for PPE when residents had precaution signs on their doors. On 6/4/26 at 11:50 AM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Staff 10 did not don PPE prior to entering Resident 2's room. Staff 2 stated she expected all staff and visitors to don PPE prior to entering Resident 2's room.

Based on interview and record review it was determined the facility failed to act upon and implement pharmacy recommendations for 1 of 5 sampled residents (#12) reviewed for medications. This placed residents at risk for unnecessary medications. Findings include: The facility's 11/2025 Pharmacy Recommendations and Medication Regimen Review Policy & Procedure Manual specified pharmacy recommendations are reviewed within five business days, follow up actions and implementation dates should be documented, and the MAR should be updated. Resident 12 was admitted to the facility in 5/2023 with diagnoses including dementia with behavioral disturbances. Resident 12's 3/2026 Physician Orders included diclofenac arthritis pain external gel 1% (pain relief gel) topical, apply to knees topically in the morning for pain. Resident 12's 3/17/26 Pharmacist's Recommendation to Prescriber specified to update the 3/2026 diclofenac order to include the missing dosage in grams as follows: diclofenac arthritis pain external gel 1%, apply 4 grams to knees topically in the morning for pain. There was no evidence the Pharmacist Recommendation was forwarded to the provider and there was no evidence the Recommendation was acted upon. Resident 12's 3/2026, 4/2026, 5/2026 and 6/2026 TARs revealed the Pharmacist Recommendation was not acted upon and implemented until 6/2/26. On 6/3/26 at 12:30 PM Staff 2 (DNS) stated pharmacy reviews occurred monthly, and any recommendations should be followed through with the provider and promptly implemented by nursing staff. Staff 2 acknowledged Resident 12's 3/2026 Pharmacist Recommendations were not acted on by the provider and not implemented until 6/2/26.

Based on interview and record review it was determined the facility failed to have a process in place to ensure resident rights to execute an advance directive, obtain copies for the medical record and periodically follow up on preferences for 2 of 3 sampled residents (#s 1 and 14) reviewed for advance directives. Findings include: The facility's advance care planning and end of life policy and procedure manual dated 12/2025 included the following: - The Licensed Social Worker will determine or review the POLST and advance directive choices of each resident on admission, quarterly, and with each change of status.- If resident chooses not to execute an advance directive, the Licensed Social Worker will document accordingly.1. Resident 1 was admitted to facility in 1/2024 with a diagnosis of alcohol dependence. Resident 1's 1/30/26 Annual MDS revealed the resident was cognitively intact.A review of Resident 1's progress notes revealed advance directives were discussed on 5/29/24, 8/22/24, and 9/4/24 with Resident 1 and she/he declined each time.On 6/2/26 at 2:38 PM, Resident 1 stated she did not have an advance directive and the facility did not regularly discuss it with her/him.On 6/3/26 at 12:58 PM, Staff 4 (Social Worker) stated she only asked about advance directives at admission, but did not follow up periodically with residents who did not have one. Staff 4 stated she unaware if she was required to periodically offer or talk about advance directives with residents.On 6/4/26 at 9:15 AM, Staff 1 (Administrator) acknowledged advance directives were not being discussed with residents on a regular basis. Staff 1 stated he expected Staff 4 to discuss advance directives upon admission, during quarterly care conferences and as needed. 2. Resident 14 was admitted to facility in 11/20/24 with a diagnosis of type two diabetes. Resident 14's 3/5/26 Quarterly MDS revealed the resident was cognitively intact.A review of Resident 14's progress notes revealed the following:- On 11/27/24, Resident 14 stated she/he had an advance directive.- On 1/14/26, Resident 14 stated she/he had old copies of an advance directive, but wanted to fill out a new one. A review of Resident 14's clinical record revealed copies of Resident 14's advance directive were not obtained. On 6/3/26 at 12:58 PM, Staff 4 (Social Worker) stated she only asked about advance directives at admission and would request copies, but did not follow up periodically. Staff 4 acknowledged Resident 14 said she/he had an advance directive and confirmed she had not followed up.On 6/4/26 at 9:15 AM, Staff 1 (Administrator) acknowledged advance directives were not being discussed with residents on a regular basis. Staff 1 stated he expected Staff 4 (Social Worker) to discuss advance directives upon admission and during quarterly care conferences.

Based on interview and record review it was determined the facility failed to ensure to review the infection control policies annually and failed to transport clean laundry in a manner to prevent cross contamination for 1 of 1 facility. This placed residents at risk for ineffective infection control program and cross contamination of laundry. Findings include: 1. Review of the facility Policy and Procedure Manual revealed:-Influenza and Pneumococcal Immunizations policy was last reviewed on 1/2020. Information in the policy did not include the latest CDC guidelines on pneumococcal vaccines (Pneumococcal conjugate vaccines 15, 20, and 21). -Antibiotic Stewardship policy was last reviewed on 5/2024.-Infection Prevention and Control Program policy was last reviewed on 10/2023. On 8/5/25 at 9:34 AM Staff 2 (DNS) stated the infection control policies were not reviewed yearly and Staff 10 (Assistant Director of Health Services) might have additional information. On 8/7/25 at 10:51 AM Staff 10 stated the DNS was to review all the policies and update as needed. When the policies were reviewed the review date was updated on the policy. Staff 10 stated the facility had multiple people fill the DNS position in the last few years. 2. The facility's undated Laundry Safety Sheet specified staff were to use plastic coverings on carts when transporting clean laundry to prevent dust and contamination. On 8/6/25 at 3:18 PM Staff 5 (CNA) was observed to wheel a laundry rack containing hanging dress shirts, folded shirts and socks through the living room and dining room adjacent to the kitchen to room [ROOM NUMBER]. The rack was not covered and the clothing was exposed as she transported the clothing. Staff 5 stated this was the only cart staff used to deliver clean laundry and she was unaware of a covered laundry cart. On 8/6/25 at 3:33 PM Staff 4 (Laundry Manager) stated residents' laundry was often washed and dried in the laundry room on the main floor by the shared living room and occasionally in the basement laundry room. She stated staff only use the uncovered laundry racks to collect residents' clean laundry and delivered the clothing items to their rooms. On 8/6/25 at 5:00 PM Staff 2 (DNS) stated she was aware staff delivered residents' laundry to their rooms using the uncovered laundry racks. She acknowledged delivering clean laundry using an uncovered rack exposed clean laundry to dust and cross contamination. Staff 2 stated it was necessary to use covered racks to ensure clean laundry remained uncontaminated during the delivery process.

Based on observation, interview and record review it was determined the facility failed to ensure a system was in place to resolve resident grievances including a lack of an identified Grievance Official and a lack of information available to residents on how to file a grievance for 1 of 1 facility reviewed for Resident Council. This placed residents at risk for unresolved grievances. Findings include:The facility's Resident Grievance Policy & Procedure, dated 1/2024, included the following:-A resident and/or her/his legal representative may voice a grievance to any staff in person, by telephone, email, or in writing.-Complete details of the grievance are documented so the grievance can be resolved within thirty (30) calendar days.-All information related to the resident's grievance would be held in strict confidence and not be disclosed to staff or contract providers, except when appropriate to process the grievance.The policy did not specify how long the facility was required to retain grievance forms.On 8/6/25 at 3:15 PM Staff 2 (DNS) stated the facility did not have a process for providing residents or their representatives grievance forms. Staff 2 was unaware of how the grievances were tracked, who the grievance official was, how the grievances were followed up on or the amount of time the facility kept the forms.On 8/7/25 at 10:07 AM Resident 5 and at 10:21 AM Resident 8 stated they attended Resident Council occasionally and they were unaware of how to file a grievance.On 8/7/25 at 11:37 AM Staff 7 (CNA) and Staff 8 (CNA) reported they were not aware of a grievance form, the formal process for submitting grievances, or the process resolving resident concerns.On 8/7/25 at 11:42 AM Staff 10 (Assistant Director of Health Services) stated residents, or their representatives typically verbalized concerns or sent emails when expressing a grievance. Staff 10 reported grievance documentation was kept in residents' charts and indicated she was unaware of who the designated staff member responsible for tracking and addressing grievances. On 8/7/25 at 3:18 PM Staff 1 (Administrator) acknowledged there was not a specific form used to document grievances and no formal process in place for collecting, reviewing, or tracking grievances to ensure their resolution. Staff 1 confirmed there was no process in place for maintaining grievance records for the required three years.

Based on interview and record review it was determined the facility failed to maintain records of consent for covid vaccines for 5 of 5 sampled residents (#s 5, 6, 7, 12, and 15) reviewed for immunizations. This placed residents at risk for uniformed decisions. Findings include: 1. Resident 5 was admitted to the facility in 1/2023 with a diagnosis of a fracture. Resident 5's 8/2024 Quarterly MDS revealed she/he was cognitively intact. Resident 5's 9/30/24 Covid -19 vaccination form revealed no education was provided prior to administration.On 8/6/25 at 5:05 PM Resident 5 stated she/he did not recall if staff provided education regarding the risk and benefits of the vaccine prior to administration. Resident 5 stated she/he wanted the vaccine and just remembered staff came around, she/he said yep, and did not remember signing any documents. On 8/5/25 at 10:51 AM Staff 2 (DNS) stated a local pharmacy had come to the facility to administer the flu vaccines. Staff 2 also stated the facility did not make any copies of the paperwork for the residents' clinical records, and the pharmacy was not able to provide copies of the consents.2. Resident 6 was admitted to the facility in 9/2024 with a diagnosis of cancer.Resident 6's 6/20/25 Quarterly MDS revealed she/he was cognitively intact. Resident 6's 4/30/25 Covid-19 vaccine form revealed she/he was provided education prior to administration. On 8/5/25 at 10:51 AM Staff 2 (DNS) stated a local pharmacy had come to the facility to administer the flu vaccines. Staff 2 also stated the facility did not make any copies of the paperwork for the residents' clinical records, and the pharmacy was not able to provide copies of the consents.On 8/6/25 at 3:52 PM Resident 6 stated she/he did not remember if the facility reviewed the risk or benefits of the vaccine or if she/he signed a consent.3. Resident 7 was admitted to the facility in 6/2016 with a diagnosis of Huntington's disease (genetic nerve disease causing motor and sensory deficits which worsen over time). Resident 7's 5/23/25 Quarterly MDS revealed she/he was moderately cognitively impaired. Resident 7's clinical record revealed she/he received a Covid-19 vaccine on 9/30/24 and education was not provided. Resident 7's clinical record did not reveal a Covid-19 signed consent form.On 8/5/25 at 10:51 AM Staff 2 (DNS) stated a local pharmacy had come to the facility to administer the flu vaccines. Staff 2 also stated the facility did not make any copies of the paperwork for the residents' clinical records, and the pharmacy was not able to provide copies of the consents.On 8/6/25 at 3:25 PM Resident 7 stated she/he did not remember if she/he signed anything for the vaccine, but thought she/he was provided the risk and benefits.4. Resident 12 was admitted to the facility in 12/2024 with a diagnosis of Parkinson's disease.Resident 12's 7/14/25 Quarterly MDS revealed she/he was cognitively impaired.Resident 12's Covid-19 vaccine form revealed she/he was provided education prior to vaccine administration. Resident 12's clinical record did not reveal a Covid-19 signed consent form.On 8/5/25 at 10:51 AM Staff 2 (DNS) stated a local pharmacy came to the facility to administer the Covid-19 vaccines. Staff 2 stated if the facility did not make copies of the paperwork for the resident's clinical records and the pharmacy was not able to provide copies for the resident's record.5. Resident 15 was admitted to the facility in 11/2024 with a diagnosis of diabetes. Resident 15's 4/15/25 Covid-19 vaccine form revealed she/he was provided education prior to administration. Resident 15's 6/5/25 Quarterly MDS revealed she/he was cognitively intact.On 8/5/25 at 10:51 AM Staff 2 (DNS) stated a local pharmacy had come to the facility to administer the flu vaccines. Staff 2 also stated the facility did not make any copies of the paperwork for the residents' clinical records, and the pharmacy was not able to provide copies of the consents.On 8/6/25 at 5:26 PM Resident 15 stated she/he remembered being administer the Covid -19 vaccine but did not recall the details of the paperwork or if she/he did any paperwork.

Based on observation interview and record review it was determined the facility failed to maintain a homelike environment for 1 of 1 facility and 4 of 4 sampled residents (#s 1, 3, 7, and 8) reviewed for environment. This placed residents at risk for an unhomelike environment. Findings include:1. On 8/6/25 at 8:11 AM the following observations were made of the facility handrails: -Near the corner where two rails meet by room [ROOM NUMBER] there was missing wood creating a rough area which was approximately one inch by one half inch.-Near the corner where two handrails meet across from room [ROOM NUMBER] there was missing wood creating a rough area which was approximately one inch by one half inch.-Across the hall from room [ROOM NUMBER] there was a deep one inch by one half inch gouge. -By room [ROOM NUMBER] there was missing wood creating a rough area which was approximately one inch by one half inch.-By room [ROOM NUMBER] near the corner where two handrails meet there was missing wood creating a rough area which was approximately one-half inch. -By room [ROOM NUMBER] there was missing wood creating a rough area missing wood which was approximately one and one inch long and one-half inch deep. On 8/6/25 at 10:22 AM Staff 16 (Maintenance Preventative Lead) stated he was not aware of the handrail gouges, and if he was not notified of the issue, he could not fix the damage. On 8/6/25 12:14 PM Staff 2 (DNS) stated she was not aware of concerns related to the facility handrails.2. Resident 1 was admitted to the facility in 11/2019 with a diagnosis of chronic lung disease.Resident 1's 6/27/25 Annual MDS revealed she/he was cognitively intact. Resident 1's 7/16/25 Care Conference Review Notes revealed her/his spouse wanted the resident's carpet replaced and the bathroom wall fixed and painted. The note indicated a work order was in progress. On 8/4/25 at 1:50 PM in the center of Resident 1's carpet was a soiled area which was approximately three feet in diameter. On 8/6/25 at 8:21 AM Staff 8 (CNA) stated Resident 1's carpet was cleaned in the past but the stain could not be removed, and would likely need to be replaced. Staff 8 stated the stain was from Resident 1's wheelchair because she/he was able to go outside and her/his wheelchair tires were dirty from the community outings. On 8/6/25 at 12:14 PM Staff 2 (DNS) stated on 7/16/25 Resident 1's spouse requested the carpet be replaced. In order for the carpet to be replaced Resident 1 would need to vacate her/his room for at least 24 hours. E-mails were sent to management but there were no concrete decisions made on how to facilitate the carpet replacement. Staff 2 acknowledged the bathroom wall could have been repaired but a work order was not submitted until 8/6/25. On 8/7/25 at 9:03 AM Resident 1 stated no one offered to replace the carpet and change rooms prior to 8/7/25. On 8/7/2025 10:51 AM Staff 10 (Assistant Director of Health Services) stated she was aware Resident 1's carpet needed to be replaced and the wall needed to be repaired. Staff 10 stated the facility staff may not have been aware of how to facilitate the process. 3. Resident 3 was admitted to the facility in 11/2017 with a diagnosis of dementia. Resident 3's 6/19/25 quarterly MDS revealed she/he was cognitively impaired. On 8/6/25 at 10:22 AM with Staff 16 (Maintenance Preventative Lead) nine gouges were observed on the wall behind Resident 3's head of the bed ranging from one inch in length to six inches in length. Three of nine gouges were deeper and were approximately one-half inch deep. Damage to the paint and drywall was also observed on the lower wall next to the bathroom sink which was approximately four inches long and one inch wide. Staff 16 indicated if he was not notified of the damage, he was not able to fix the issues. On 8/6/25 12:14 PM Staff 2 (DNS) stated she was not aware of concerns related to Resident 3's walls. 4. Resident 7 was admitted to the facility in 6/2016 with a diagnosis of Huntington's disease (genetic nerve disease causing motor and sensory deficits which worsen over time).On 8/6/25 at 12:55 PM Resident 1's carpet was observed to have a stained area which was approximately three feet in diameter.On 8/6/25 9:47 AM Staff 16 (Maintenance Preventative Lead) stated if a carpet was stained and the carpet tiles needed to be replaced, he was notified. He was not notified there were any residents in the facility who needed carpet tiles replaced, including Resident 7's carpet. On 8/6/25 at 12:14 PM Staff 2 (DNS) stated Resident 7's carpet was stained for at least six months. Resident 7 did not walk so it would be possible to replace the carpet tiles without needing to relocate her/him to another room. 5. Resident 8 was admitted to the facility in 5/2018 with a diagnosis of diabetes.Resident 8's 11/13/24 annual MDS revealed she/he was forgetful, but able to engage in conversation. On 8/4/25 at 10:59 AM Resident 8 was observed sitting in her/his recliner chair. Behind the recliner there were significant gouges in the wall behind the chair where the chair head rest corners hit the wall. On 8/6/25 at 10:22 AM Staff 16 (Maintenance Preventative Lead) verified the gouges and stated he was not aware of the gouges, and if he was not notified of the issue, he could not fix the concern. On 8/6/25 12:14 PM Staff 2 (DNS) stated she was not aware of concerns related to Resident 3's walls, staff informed her it occurred on 8/6/25.

Based on observation, interview and record review it was determined the facility failed to ensure residents received trauma informed care for 1 of 1 sampled resident (#5) reviewed for behavioral-emotional care and abuse. This placed residents at risk for re-traumatization. Findings include:The facility's Trauma-Informed Care Policy & Procedure date 11/2019, indicated the following:-Each resident will have a preliminary screening for trauma upon admission.-The facility will account for residents' experiences, preferences, and cultural differences in order to mitigate triggers that may cause re-traumatization of the resident. Potential causes of re-traumatization by staff may include, but are not limited to:a. Being unaware of the resident's traumatic history.b. Failing to screen resident for trauma history prior to treatment planning.c. Challenging or discounting reports of traumatic events.d. Endorsing a confrontational approach in counseling.e. Labeling behaviors/feelings as pathological.f. Failing to provide adequate safety.g. Minimizing, discrediting or ignoring resident responses.Resident 5 was admitted to the facility in 1/2024 with diagnoses including alcohol dependance and PTSD (Post-Traumatic Stress Disorder).Resident 5's 8/1/25 Quarterly MDS revealed the resident was cognitively intact and able to make herself/himself understood and understood others without difficulty.On 8/5/25 at 1:37 PM and on 8/6/25 at 12:37 PM, Resident 5 was observed in her/his room in bed facing the door without the lights on. Resident 5 stated she/he suffered from PTSD as a result of childhood trauma. Resident 5 stated no one at the facility discussed the cause of her/his PTSD or potential triggers for re-traumatization.No evidence was found in Resident 5's clinical record to indicate an assessment of the resident's trauma was completed or a care plan was developed to address the resident's potential trauma triggers.On 8/5/25 at 3:17 PM, Staff 12 (CNA) stated she was unaware if Resident 5 had PTSD and indicated it was not listed on the resident's Kardex (reference for resident care needs).On 8/6/25 at 9:19 AM, Staff 3 (RN) stated she was aware Resident 5 had trauma from her/his past but unaware if the resident had any triggers or a diagnosis of PTSD.On 8/6/25 at 11:13 AM, Staff 11 (Social Worker) stated trauma screenings were not completed at the time of admission for residents and confirmed she did not develop a care plan related to Resident 5's history of trauma or potential triggers.On 8/6/25 at 3:15 PM, Staff 2 (DNS) acknowledged Resident 5's trauma and stated nothing was implemented related to Resident 5's trauma triggers.

Based on observation, interview, and record review it was determined the facility failed to ensure residents were free from accidents for 2 of 5 sampled residents reviewed for accidents (#s 7 and 14). This placed residents at risk for adverse medication reactions. Findings include: 1. Resident 7 was admitted to the facility in 6/2016 with a diagnosis of Huntington's disease (genetic nerve disease causing motor and sensory deficits which worsen over time). Resident 7's 2/21/25 Annual MDS revealed she/he required extensive assistance with her/his ADLs and was expected to decline, was incontinent, and did not transfer. Resident 7's 8/2025 MAR revealed staff were to administer an antifungal powder two times a day. On 8/4/25 at 11:41 AM a medicine cup with a white powder was observed on the bathroom sink counter. On 8/4/25 at 1:16 PM Staff 13 (CNA) stated the powder in Resident 7's room was an antifungal powder, and she applied it to the resident's rash. On 8/6/25 at 8:04 AM Staff 3 (RN) stated on 8/4/25 she put the antifungal powder in the resident's room and the CNA staff were to page her when the resident was in bed to be applied. On 8/7/25 at 9:28 AM Staff 2 (DNS) stated staff should not leave medications in residents' bathrooms to ensure adverse medication reactions did not occur. 2. Resident 14 was admitted to the facility in 2/2023 with a diagnosis of heart disease. Resident 14's 3/27/25 Annual MDS revealed she/he required assistance with ADLs and incontinence care. Resident 14's 8/2025 MAR revealed staff were to administer an antifungal powder two times a day. On 8/4/25 at 1:18 PM a medicine cup with a white powder was observed on the bathroom sink. Staff 13 (CNA) stated it was an antifungal powder for Resident 14's rash and she assisted the resident to apply the powder. On 8/6/25 at 8:04 AM Staff 3 (RN) stated on 8/4/25 she put the antifungal powder in the resident's room and the CNA staff were to page her when the resident was in bed to be applied. On 8/7/25 at 9:28 AM Staff 2 (DNS) stated staff should not leave medications in residents' bathrooms to ensure adverse medication reactions did not occur.

Based on interview and record review it was determined the facility failed to monitor a resident for a change of condition for 1 of 1 sampled resident (#13) reviewed for change of condition. This placed residents at risk for delayed care. Findings include: Resident 13 was admitted to the facility in 5/2023 with a diagnosis of dementia. Resident 13's Progress Notes revealed the following:-6/27/25 Resident 13 called Staff 14 (RN) to the room and reported she/he thought she/he had pneumonia. Staff 14 assessed Resident 13 to have an unstoppable coughing fit, a runny nose, clear lungs, and Resident 13 was provided tea, honey, and PRN allergy medication. The note indicated Resident 13 would be monitored. Resident 13's Progress Notes did not reveal there were any additional assessments of Resident 13's respiratory status after 6/27/25.Resident 13's clinical record did not indicate her/his temperatures, cough, or oxygen saturation levels were monitored on 6/27/28, 6/28/25, or 6/29/25.On 8/5/25 at 1:24 PM Staff 15 (RN) stated if a resident had a change of condition staff made a note on the clinical dashboard which created an alert. The alert then notified staff to assess and document on a resident. Usually, staff documented on a resident for 72 hours after a change of condition. Staff 15 stated at times a resident was monitored on the TAR and not in progress notes.On 8/7/25 at 7:21 AM Staff 14 stated in 6/2025 some residents in the facility had colds. Staff 14 stated Resident 13 had a diagnosis of allergies, and she was not sure if the resident's cough was related to allergies or if she/he was ill so she thought it would be best to monitor Resident 13 for a few shifts to ensure the cough was just allergies. Staff 14 stated she notified the oncoming shift. On 8/7/25 at 9:31 AM Staff 2 (DNS) stated Resident 13 had a history of allergies. In 6/2025 residents in the facility had colds and Resident 13 should have been monitored for a change to condition to ensure her/his symptoms were related to allergies versus an illness.

Based on interview and record review it was determined the facility failed to ensure psychotropic medications were not increased without indication and failed to perform a GDR (gradual dose reduction) for 1 of 5 sampled residents (#10) reviewed for unnecessary medications. This placed residents at risk for sedation. Findings include:Resident 10 was admitted to the facility in 3/2023 with a diagnosis Lewy body dementia (progressive decline in cognition with symptoms including hallucinations which can occur throughout the disease's progression.)Resident 10's 4/11/25 Annual MDS revealed she/he had Lewy body dementia with significant cognitive impairment, experienced hallucinations, and was administered antipsychotic and antidepressant medications. a. Resident 10's 5/2025 MAR revealed she/he was administered Seroquel (antipsychotic) 50 mg in the morning, 100 mg midday and 150 mg at bedtime. Progress Notes Revealed the following:-5/20/25 An order was received to discontinue Resident 10's AM dose of Seroquel. -5/21/25 and 5/22/23 Resident 10 did not exhibit behaviors.-5/23/25 Resident 10 started to hallucinate at 6:00 PM, refused medications, and was combative when the CNAs attempted to provide care. -5/25/25 through 6/5/25 Resident 10 did not have behaviors. -6/6/25 Resident 10 started to hallucinate at approximately 11:30 AM, behaviors escalated into shouting and screaming until approximately 2:15 PM. Later into the evening the resident continued to hallucinate, screaming and shouting and at approximately 7:30 PM fell asleep. -6/7/25 Resident 10 yelled and was combative during cares. Staff reapproached the resident, provided 1:1 interventions, music therapy and she/he eventually calmed down. It was noted Resident 10 yelled for approximately two hours in the afternoon, hallucinated and interventions attempted were not successful. Resident 10 stated Go away i [sic] will kill you. -6/9/25 a request to restart the AM dose of Seroquel due to a failed dose reduction. -6/10/25 An order was obtained to restart the Seroquel 50 mg AM dose. Resident 10's 6/2025 Documentation Survey Report (CNA documentation) revealed staff were to monitor behavior symptoms. From 6/10/25 to though 6/30/25 there were no behaviors documented. Resident 10's 6/2025 TAR revealed the nurses were to document behaviors. From 6/10/25 through 6/30/25 Resident 10 had agitation and aggression on 6/14/25 and 6/20/25.Resident 10's 7/2025 Documentation Survey Report revealed staff were to monitor behavior symptoms. From 7/1/25 through 7/8/25 there were no behaviors documented. Resident 10's 7/2025 TAR revealed the nurses were to document behaviors. From 7/1/25 through 7/8/25 there were no behaviors documented. Progress Notes revealed the following:-6/14/25 Resident 10 yelled out three times, was not able to be redirected and hallucinated. Resident 10 continued to hallucinate until approximately 4:00 PM, ate dinner and then went to sleep. -6/15/25 Resident 10 called out for short periods only lasting no more than 15 to 30 seconds. No additional behaviors noted. -6/16/25 Resident 10 was restless, staff assisted her/him to her/his room and soon she/he was sleeping. -6/17/25 through 6/19/25 Resident 10 did not have behaviors. -6/20/25 Resident 10 started to hallucinate at 4:30 PM, staff took her/him to her/his room and interventions offered were not effective. Resident 10 fell asleep at 7:00 PM-6/26/25 Resident 10's outburst and behaviors lessened with the restart of her/his medications. -6/27/25 through 7/7/25 no notes related to Resident 10's behaviors.-7/8/25 a new order was obtained for an increase to Resident 10's midday Seroquel dose. Resident 10's 7/2025 MAR revealed starting 7/9/25 she/he was to be administered Seroquel 50 mg in the morning, the Seroquel midday dose was to be increased to 150 mg (was 100 mg), and the Seroquel at bedtime dose remained at 150 mg. On 8/5/25 at 2:47 PM Staff 7 (CNA) stated at times Resident 10 became agitated when there was too much noise and stimulation. When there was too much stimulation Resident 10 hallucinated and yelled. At times she/he seemed scared, but other days she/he slept all day. On 8/6/25 at 9:15 AM Staff 8 (CNA) stated at times Resident 10 was up late and then the next day she/he slept more. If Resident 10 had behaviors the CNAs notified the nurse and the CNAs documented the behavior in the CNA documentation. On 8/6/25 at 5:44 PM Staff 9 (RN) stated Resident 10's behavior varied. Once they tried to decrease Resident 10's medication and her/his behaviors worsened. If Resident 10 exhibited behaviors the nurses were to document in the Progress Notes and TAR. On 8/6/25 at 4:12 PM Staff 2 stated staff were to document Resident 10's behaviors in the clinical record. Staff 2 acknowledged there were only two days of behaviors documented after Resident 10's Seroquel was restarted on 6/10/25 until it was increased on 7/9/25. Staff 2 stated Resident 10's physician increased the Seroquel on 7/9/25 when she informed the physician Resident 10 continued to have hallucinations. Staff 2 acknowledged Resident's 10 clinical record did not support the increase in dosage. b. Resident 10's 6/28/25 Order Summary Revealed she/he was to prescribed fluoxetine (antidepressant) with a start date of 5/13/2023.A 4/16/25 Quarterly Review of Psychotropic Medications revealed Resident 10 was on fluoxetine since 5/16/23 with no gradual dose reduction. A handwritten note indicated a need for the physician to provide a letter indicating this was the lowest effective dose. No information was found in Resident 10's clinical record to indicate this was the lowest effective dose or a failed gradual dose reduction was attempted and failed. On 8/6/25 at 4:12 PM Staff 2 (DNS) stated Resident 10 was on the same dose of fluoxetine since admission and a request was sent to Resident 10's physician to address the concern, but a response was not received. Staff 2 stated she did not request involvement from the medical director to step in to assist with obtaining the letter from Resident 10's physician.

Based on interview and record review it was determined the facility failed to ensure a pharmacy recommendation was acted upon timely for 1 of 5 sampled residents (#10) reviewed for unnecessary medications. This placed residents at risk for inaccurate diagnoses. Findings include:Resident 10 was admitted to the facility in 3/2025 with a diagnosis of dementia. A Medical Director Report Medication Regimen Review performed between 5/19/25 and 5/21/25 revealed Resident 10 was administered fluoxetine (antidepressant) with a indication for use NEUROCOGNITIVE DISORDER WITH LEWY BODIES [abnormal deposit of proteins in the brain which can lead to problems with thinking, movement, and behavior]. The review indicated it was not an appropriate diagnosis for the use of fluoxetine. A handwritten note on the form indicated on 6/9/25 a request was made to Resident 10's Geriatric Psychiatrist to address the concern.Resident 10's 8/2025 MAR revealed her/his fluoxetine indication for use was neurocognitive disorder with Lewy bodies. On 8/6/25 at 4:12 PM Staff 2 (DNS) stated she expected physicians to respond to the pharmacy recommendations within one to two weeks. Resident 10's physician did not respond to the request to change the diagnosis, and Staff 2 did not involve the medical director to intervene.

Based on interview and record review it was determined the facility failed follow antibiotic stewardship for 1 of 1 sampled resident (#13) reviewed for antibiotics. This placed residents at risk for drug resistant organisms. Findings include:Resident 1 was admitted to the facility in 11/2019 with a diagnosis of bladder disorder. A 6/27/25 Annual MDS revealed Resident 1 had urinary retention and staff assisted with the resident with intermittent catheterization (inserting a sterile catheter into the urethra [tube that allows urine to pass outside the body] to drain the bladder of urine). Resident 1's 10/27/24 UA Dipstick Only form revealed her/his only negative finding was a trace of leukocyte esterase (detects white blood cells which could indicate a UTI).Progress Notes revealed the following:-10/27/24 Resident 1 reported she/he did not feel well and was required to be catheterized multiple times. Resident 1's spouse requested a UA be collected, a urine specimen was obtained and sent to the laboratory. -10/28/24 A fax was received from the pharmacy with orders for cephalexin (antibiotic) to be administered for 14 days.Resident 1's 10/2024 and 11/2024 MARs revealed she/he was administered cephalexin (antibiotic) from 10/28/24 through 11/10/24.Resident 10's clinical record did not have her/his 10/27/24 UA or culture results and progress notes to indicate the facility communicated with the physician's office for the culture to ensure the antibiotic was indicated.Resident 1's 10/31/24 McGeer Criteria for Infection Surveillance Checklist revealed UTI criteria NOT met. On 8/7/25 at 12:26 PM Staff 2 stated she did the McGeer's Surveillance form, and it indicated Resident 1 did not meet the criteria for an UTI. Resident 1's physician ordered the antibiotics and the facility did not receive the culture to ensure the antibiotics were appropriate.

Based on interview and record review it was determined the facility failed to maintain records of consent for vaccinations for 2 of 5 sampled residents (#s 5 and 7). This placed residents at risk for uninformed decisions. Findings include: 1.Resident 5 was admitted to the facility in 1/2023 with a diagnosis of a fracture. Resident 5's clinical record revealed on 9/30/24 she/he received a flu vaccine and education was not provided. Resident 5's clinical record did not reveal a signed consent form.Resident 5's 8/2025 Quarterly MDS revealed she/he was cognitively intact. On 8/5/25 at 10:51 AM Staff 2 (DNS) stated a local pharmacy came to the facility to administer the flu vaccines. Staff 2 stated the facility did not make copies of the paperwork for the residents' clinical records and the pharmacy was not able to provide copies of the consents.On 8/6/25 at 5:05 PM Resident 5 stated she/he did not recall if staff provided education of the vaccine prior to administration. Resident 5 stated she/he wanted the vaccine and just remembered the staff came around, she/he said yep and did not remember signing any documents. 2. Resident 7 was admitted to the facility in 6/2016 with a diagnosis of Huntington's disease (genetic nerve disease causing motor and sensory deficits which worsen over time). Resident 7's 5/23/25 Quarterly MDS revealed she/he was moderately cognitively impaired. a. Resident 7's clinical Record revealed on 9/30/24 she/he received a flu vaccine and education was not provided. Resident 5's clinical record did not reveal a signed consent form.On 8/5/25 at 10:51 AM Staff 2 (DNS) stated a local pharmacy came to the facility to administer the flu vaccines. Staff 2 stated the facility did not make copies of the paperwork for the residents' clinical records and the pharmacy was not able to provide copies of the consents.On 8/6/25 at 3:25 PM Resident 7 stated she/he did not remember if she/he signed anything for the vaccine, but thought she/he was provided the risk and benefits form. b. Resident 7's clinical record revealed she/he received two pneumonia vaccines but was eligible to receive an additional vaccine. Resident 7's clinical record did not have documentation to indicate an additional pneumonia vaccine was offered. On 8/5/25 at 10:51 AM Staff 2 (DNS) stated the facility just ordered the pneumonia vaccine. Staff 2 stated she was not sure the reason Resident 7 was not offered the vaccine in prior years.

Based on observation, interview and record review it was determined the facility failed to protect the resident's right to be free from verbal abuse from a staff member for 1 of 1 sampled resident (#1) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 1 admitted to the facility in 1/2024 with diagnoses including alcohol dependence and Parkinsonism. A 5/2/24 Quarterly MDS indicated Resident 1 had a BIMS of 12 which indicated she/he had moderate cognitive impairments. A 5/3/24 FRI indicated Staff 8 (Agency RN) entered Resident 1's room, who was intoxicated and had been pressing the call light excessively throughout the evening. Staff 8 spoke to her/him harshly regarding her/his intoxicated state and behavior. As a result of Staff 8's harsh language, Resident 1 was crying and sought comfort from the CNA staff. The 8/6/24 care plan indicated Resident 1 was known to consume alcohol as a coping mechanism for her/his trauma, and interventions included behavior monitoring, and creating a safe space for the resident when intoxicated to prevent injury and falls. On 8/6/24 at 10:14 AM Resident 1 stated she/he did not recall the incident and felt safe in the facility. On 8/6/24 at 11:31 AM Staff 5 (CNA) stated the night of the incident Resident 1 was pressing her/his call light constantly. When staff answered the light the resident could not recall why the light was pressed or wanted staff for companionship. Staff 5 stated Resident 1 was redirectable and understanding that staff was assisting with dinner and assisting other residents back to bed. Staff 5 stated Resident 1 was in her/his usual behavior when the incident occurred with Staff 8. Staff 5 stated Resident 1 was tearful and upset after the incident with Staff 8. On 8/6/24 at 12:08 PM Staff 7 (CNA) stated she was walking towards Resident 1's room and heard Staff 8 yelling harsh words at Resident 1 about being intoxicated. Staff 7 stated when she entered Resident 1's room the resident was upset and crying, and had to be consoled. On 8/6/24 at 12:51 PM Staff 8 stated she received report from the outgoing nursing that Resident 1 was intoxicated and consumed more than her/his usual amount. Staff 8 stated Resident 1 was on her/his call light constantly, was not redirectable and was demanding. Staff 8 stated she did not recall speaking harshly to Resident 1, but was sent home early from her shift. On 8/6/24 at 3:02 PM Staff 2 (Interim DNS) stated it was her expectation that all staff, permanent and agency, treated residents with dignity and respect and residents would be free from abuse of any kind in their home. On 5/6/24, the Past Non-Compliance was corrected when the facility completed a root cause analysis of the incident and determined there was abuse. The Plan of Correction included: 1. Staff 8 was terminated on 5/3/24. 2. Resident 1 was placed on alert charting, evaluated and provided with psychosocial support. 3. All staff were educated for abuse and neglect including reporting abuse and neglect.

Based on interview and record review it was determined the facility failed to ensure current copies of residents' advance directives were obtained and accessible in the health record for 1 of 7 sampled residents (#16) reviewed for medications and advance directives. This placed residents at risk for receiving medical treatments and life sustaining interventions against their wishes. Findings include: Resident 16 was admitted to the facility in ,d+[DATE] with diagnoses including Alzheimer's disease (a brain disease causing gradual decline in memory and cognitive function). Resident 16's Face Sheet revealed the section titled, Code Status was blank. Review of Resident 16's health record revealed no advance directive and no instructions regarding medical treatments and life-sustaining interventions the resident wanted in the event of a medical emergency. On [DATE] at 10:23 AM Staff 3 (RNCM) stated Resident 16 did not have an advance directive on file or instructions regarding medical treatments and life sustaining interventions which specified the resident's wishes in the event of a medical emergency. Staff 3 stated without specific instructions in the health record, Resident 16 was considered full code (a medical term meaning if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures would be provided to keep them alive. This process can include chest compressions (hard, aggressive pushing of the chest), intubation (insertion of a tube into the throat), and defibrillation (application of an electric current to the heart). On [DATE] at 10:38 AM Staff 4 (Director of Social Services) stated when residents admitted to the facility, she was responsible to interview the residents and family to find out if the resident had an existing advance directive, obtain the existing advance directive and ensure the documents were stored in the appropriate location in the residents' health records. Staff 4 stated if there was not an advance directive in the resident's health record, then that meant the resident did not have one. On [DATE] at 1:56 PM Staff 5 (LPN) stated in the event of a medical emergency, she referred to Resident 16's face sheet for instructions specific to medical interventions. Staff 5 stated if there were no instructions on the face sheet, she considered the resident a full code and she would administer CPR (cardiopulmonary resuscitation: chest compressions and defibrillation). On [DATE] at 11:26 AM Staff 2 (DNS) and Staff 3 were interviewed regarding the findings of this investigation. Staff 2 stated the residents' health records were the tools used by clinical staff to determine resident preferences and choices related to medical interventions and stated life-sustaining information was to be accessible in the section titled, code status. Staff 2 stated if the code status area was blank, the resident was considered to be a full code. On [DATE] at 11:33 AM Staff 3 located Resident 16's advance directive in a different electronic health record system which was not accessible to the facility's clinical staff. Staff 3 reviewed the advance directive; the advance directive indicated Resident 16 designated her/himself as do not resuscitate, and the document was dated ,d+[DATE]. Staff 2 verified Resident 16's advance directive was not obtained and accessible in the resident's current health record and in the event of a medical emergency, Resident 16's life-sustaining medical intervention preferences would not have been honored.

Based on interview and record review it was determined the facility failed to implement antibiotic stewardship practices for 1 of 5 sampled residents (#16) reviewed for medications. This placed residents at risk for adverse medication effects, inappropriate antibiotic use and potential for development of antibiotic resistance. Findings include: The CDC's 9/7/23 Antibiotic Prescribing and Use, website section titled, Core Elements of Antibiotic Stewardship for Nursing Homes recommended all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections, increased adverse drug events and drug interactions, and colonization and/or infection with antibiotic-resistant organisms. The facility's 6/2018 Antibiotic Stewardship Policy & Procedure specified antibiotics were prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program, in compliance with National Guidelines and the facility assessed all data and requested needed laboratory tests, for example, UA (urinalysis: used to examine urine) and a C&S (culture and sensitivity: test to determine the appropriate antibiotic). Resident 16 was admitted to the facility in 5/2023 with diagnoses including irregular heart beat. A 4/9/24 Physician Order specified the following: - nitrofurantoin monohydrate (antibiotic) 100 mg two times a day for infection for one week. - UA with C&S. Review of Resident 16's health record revealed no UA with C&S was completed before, during or after completion of the antibiotic course. A 4/15/24 Physician Order specified the following: - nitrofurantoin monohydrate (antibiotic) 100 mg two times a day for infection for 14 administrations. Review of Resident 16's health record revealed no UA with C&S was completed before the 4/15/24 antibiotic order was initiated. On 4/17/24 at 2:01 PM Staff 5 (LPN) stated Resident 16's urinary tract infection symptoms continued and the provider extended the course of the antibiotic for an additional seven days. On 4/18/24 at 11:13 AM Staff 2 (DNS) and Staff 3 (RNCM) were notified of the findings of this investigation and reviewed Resident 16's health record. Staff 3 was unable to locate evidence the UA with C&S was completed. Staff 3 stated the importance of the UA with C&S was to ensure the appropriate antibiotic was prescribed. Staff 2 acknowledged the UA with C&S was not completed as ordered.

Based on interview and record review it was determined the facility failed to ensure residents were free from misappropriation of property for 2 of 3 sampled residents (#s 100 and 200) reviewed for misappropriation. This placed residents at risk for stolen property. Findings include: The facility's Abuse, Neglect and Exploitation Reporting policy and procedure manual, revised ,d+[DATE] stated all residents living in the facility would be free from abuse, neglect and exploitation which included misappropriation of resident property. a. Resident 100 admitted to the facility in ,d+[DATE] with diagnoses including Alzheimer's Disease and diabetes mellitus. Resident 100 died on [DATE] and a family member who picked up her/his belongings notified facility staff Resident 100's watch and wedding band were missing. The facility staff completed a thorough search of the resident's room and were unable to find the missing items. The facility made a LEA (Law Enforcment Agency) referral and Witness 1 (Detective/Complainant) was assigned to investigate the theft. In a subsequent theft investigation, Witness 1 identified the alleged perpetrator as Staff 3 (Agency CNA). Staff 3 was not available for interview and the criminal case is ongoing. On [DATE] at 12:40 PM Staff 1 (Administrator) confirmed Staff 3 worked at the facility during the time period Resident 100's watch and ring went missing. She indicated a referral was made to the Board of Nursing regarding Staff 3's conduct. On [DATE] at 10:44 AM Witness 1 stated the resident's ring and watch were not recovered. b. Resident 200 was admitted to the facility in ,d+[DATE] with diagnoses including dementia and dysphagia (inability to swallow). Resident 200's Annual MDS dated ,d+[DATE] revealed a BIMS score of 5, indicating severe cognitive impairment. On [DATE], Resident 200 noticed her/his ring was missing and reported it to facility staff. The facility completed a thorough search and were unable to locate the missing ring. The facility made a LEA referral and Witness 1 (Detective/Complainant) was assigned to investigate the theft. A [DATE] LEA Supplemental Report was submitted by Witness 1 with evidence Staff 3 had taken Resident 200's ring off her/his hand while she/he slept prior to [DATE], then pawned the ring. The ring was identified by family members and the pawn shop identified Staff 3 as the person who sold the ring. On [DATE] at 12:08 PM Resident 200 was observed in her/his room. She/he did not recall any items missing. On [DATE] at 12:40 PM Staff 1 (Administrator) confirmed Staff 3 worked at the facility on NOC shift during the time period Resident 200's ring went missing. She indicated a referral was made to the Board of Nursing regarding Staff 3's conduct. Staff 3 was not available for interview and the criminal case is ongoing. On [DATE] at 10:44 AM Witness 1 confirmed Staff 3 continued to be the primary suspect in the theft case.

Based on interview and record review it was determined the facility failed to have an effective QAPI program which reviewed incidents of physical and sexual abuse for tracking and corrective action. This failure was determined to be an immediate jeopardy situation and continued to place residents at risk for abuse and resulted in two incidents of sexual abuse by Resident 67 against Resident 68. Findings include: The facility's Freedom from Abuse, Neglect and Exploitation revised 2/21 revealed the following: Any Alleged or identified abuse, neglect, exploitation, mistreatment, including injuries or unknown source and misappropriation of resident property is reported, tracked, monitored for trends, patterns, etc. and will be reviewed and discussed via QAPI. Resident 119 was admitted to the facility in 2016 with diagnoses including dementia. A FRI dated 3/6/20 included witness statements and indicated Staff 6 (Former LPN) was verbally aggressive with Resident 119. Three staff members witnessed visually and/or overheard a verbal exchange between Staff 6 and Resident 119 in a hallway near the nurse's station. The facility substantiated the abuse. Staff 6 was taken off of the floor immediately and later fired. On 2/10/23 Staff 1 (Administrator) stated the facility did not review this incident or the findings during QAPI. Resident 118 was admitted to the facility in 7/2020 with diagnoses including Parkinson's disease. She/he passed away in the facility in 9/2020. A 7/29/20 FRI revealed Resident 2 sat in her/his wheelchair in the family room on 7/29/20 at 4:20 PM. Resident 118 stood close to Resident 2. Resident 2 hit Resident 118 on the arm and grabbed her/his hand. The FRI revealed staff were interviewed and the incident was confirmed. The facility was asked to provide any information to demonstrate the incident was reviewed by QAPI. No documentation was provided. Resident 8 was admitted to the facility in 11/2019 with diagnoses including major depressive disorder and mild cognitive impairment. The facility's 11/21/20 FRI revealed Resident 8 and Resident 117 were in a shared room. On 11/21/20 at 4:00 AM Resident 117 was heard by staff yelling, You don't belong here! Get out! Resident 8 reported to the nurse Resident 117 hit her/him on the head several times hard. The FRI revealed both residents' beds were in close proximity to each other separated by a curtain and Resident 117 reached through the curtain to hit Resident 8. It was documented on the FRI Resident 117 had .severe dementia with delusional episodes, this instance also was delusional. The facility was asked to provide any information to demonstrate the incident was reviewed by QAPI. No documentation was provided. On 11/3/21 a FRI was received which indicated Staff 4 (CNA) observed Resident 67 standing next to Resident 68 in a common area. Staff 4 approached the residents and observed Resident 67 was fondling Resident 68's right breast with her/his right hand. Within two hours of the incident Resident 68 was placed on one-on-one care during the hours of 8:00 AM through 10:00 PM. On 7/1/22 a FRI was received which indicated Staff 5 (CNA) observed Resident 68 sitting in the dining room. Resident 67 entered the dining room pushing her/his spouse (Resident 167) in her/his wheelchair. Resident 67 stopped next to Resident 68, put her/his hand down Resident 68's shirt and fondled her/his breasts. No facility investigation was received. A Social Services Note dated 9/14/22 indicated Resident 67 was on the Larkspur unit (A Residential Care Facility located on the building's second floor) for an activity where he attempted to approach Resident 68 but staff intervened and prevented the resident from approaching Resident 68. The note indicated, had staff not been there to intervene, another incident might have occurred. On 2/10/22 at 9:44 AM Staff 1 (Administrator) was asked if the two incidents of sexual abuse involving Resident 67 and Resident 68 were reviewed by the QAPI committee. Staff 1 stated they were not reviewed at the committee level because it would have violated the residents' privacy to discuss it in that group. 12/15/21 QAPI Minutes regarding the 11/3/21 sexual abuse incident included the following: A. Incident Report i. One alleged sexual abuse between residents ii. Interventions included a 1:1 [on the victim Resident 68] iii. Did not report but was documented well iv. The sexual abuse is not of concern at this time On 2/13/23 at 10:35 AM Staff 2 (DNS) confirmed the 7/1/22 incident of sexual abuse was not reviewed at QAPI. On 2/13/23 at 11:02 AM Staff 1 (Administrator) stated the facility did not consistently review resident-to-resident incidents at QAPI. The facility's QAPI Committee's systemic failure to address incidents of resident abuse by tracking the incidents and putting corrective action in place put current and future residents at risk for abuse. There was no evidence the QAPI committee created a formal action plan to monitor, correct and prevent resident abuse. The facility failed to collect relevant data and monitor their system for resident abuse. This resulted in a lack of adequate action to correct the systemic high-risk issue which created a situation where residents were likely to experience abuse. Utilizing the reasonable person concept, Resident 68 would have suffered from agitation, depression and trauma from Resident 67's sexual abuse and continued targeting in her/his new facility where she/he was moved to keep her/him safe from Resident 67. On 2/13/23 at 2:25 PM the facility was notified of the immediate jeopardy (IJ) situation and an IJ removal plan was requested. On 2/13/23 at 2:25 PM an acceptable IJ removal plan was provided by the facility which included: - The QAPI would review a summary of all resident-to-resident incidents and allegations of abuse since the time of the last QAPI meeting. - Resident-to-resident incidents and allegations of abuse will be tracked and reviewed for trends, A performance improvement plan (PIP) will be created for any identified trends. The PIP will be reviewed at each subsequent QAPI meeting until resolved. - A summary of resident-to-resident altercations will be sent to the facility's board of directors at least quarterly. - The facility's QAPI policy and procedure was updated to reflect these changes on 2/13/23. - A QAPI meeting will be held on 2/13/23. On 2/13/23 at 3:41 PM the IJ removal plan was fully implemented and surveyors verified all elements of the IJ removal plan were completed. Refer to F600.

Based on interview and record review it was determined the facility failed to ensure residents were free from physical or sexual abuse for 4 of 5 sampled residents (#s 8, 68, 118 and 119) reviewed for abuse. This failure was determined to be an immediate jeopardy situation. This failure resulted in Resident 68 being sexually abused by Resident 67 and placed residents at risk for physical and sexual abuse. Findings include: The facility's Freedom from Abuse, Neglect and Exploitation Policy and Procedure revised 2/21 revealed Each resident has the right to be free from abuse, neglect, and exploitation. Residents must not be subjected to abuse, neglect, and exploitation by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians or surrogates, friends or any other individual. 1. Resident 68 was readmitted to the facility in 2017 with diagnoses including Alzheimer's disease. The resident was discharged from the facility on 7/4/22. Resident 68's 9/15/21 MDS indicated the resident was rarely or never understood and a BIMS assessment was not completed. Resident 67 was admitted to the facility in 2018 with diagnoses including heart failure. The resident continued to reside at the facility as of 2/13/23. Resident 67's 10/15/21 MDS indicated the resident had a BIMS score of 15 out of 15 (Which indicated the resident was cognitively intact.) On 2/6/22 the facility census included nine female residents. On 11/3/21 a FRI was received which indicated Staff 4 (CNA) observed Resident 67 standing next to Resident 68 in a common area. Staff 4 approached the residents and observed Resident 67 was fondling Resident 68's right breast with her/his right hand. Within two hours of the incident Resident 68 was placed on one-on-one care during the hours of 8:00 AM through 10:00 PM. The FRI did not indicate any interventions were put into place to prevent Resident 67 from sexually abusing other residents. A facility Alleged Abuse incident investigation #2522 dated 11/3/21 indicated a CNA (Staff 4) noticed Resident 68 standing at a table in the family room and Resident 67 went over and stood next to her/him. The CNA approached the residents and saw Resident 67 had her/his hand on Resident 68's breast and was massaging it. When Resident 67 saw the CNA approach she/he pulled her/his hand away from Resident 68's breast and walked away. Resident 68 was placed on one-on-one care during the hours of 8:00 AM through 10:00 PM daily. A facility Alleged Abuse incident investigation #2525 dated 11/3/21 indicated Resident 67 denied touching Resident 68. Resident 67's care plan was updated to include sexual behavior added to quarterly reviews. No other interventions were noted. Resident 67's 1/15/22 Social Services Quarterly Assessment indicated [Resident 67] has had a stable quarter this assessment period. There have been no significant events, issues, or concerns. The assessment did not address sexual behavior. Resident 67's 4/22/22 Social Services Annual Assessment indicated [Resident 67] has had a stable quarter this assessment period. There have been no significant events, issues, or concerns. The assessment did not address sexual behavior. On 7/1/22 a FRI was received which indicated Staff 5 (CNA) observed Resident 68 sitting in the dining room. Resident 67 entered the dining room pushing her/his spouse (Resident 167) in her/his wheelchair. Resident 67 stopped next to Resident 68, put her/his hand down Resident 68's shirt and fondled her/his breasts. A Progress Note dated 7/4/22 indicated Resident 68 was discharged from the facility to a Residential Care Facility on the second floor of the same building as the Nursing Facility. A review of Resident 67's clinical record revealed only four SSD check-ins were completed from 7/25/22 through 2/7/23. A Social Services Note dated 7/25/22 indicated at a bi-weekly meeting Resident 67 stated it was a stupid thing to do, that [she/he] doesn't know why [she/he] did it or what [she/he] was thinking and [she/he] wished it had never happened. [She/he] stated [she/he] was ashamed., it will never happen again. I just wish I never had to hear about it again and men like to touch women's breasts. A Social Services Note dated 9/14/22 indicated Resident 67 was on the Larkspur unit (the facility's second floor) for an activity where she/he attempted to approach Resident 68 but staff intervened and prevented the resident from approaching Resident 68. The note indicated, had staff not been there to intervene, another incident might have occurred. A Social Services Note dated 9/19/22 indicated at a bi-weekly meeting Resident 67 expressed understanding and again stated it would never happen again. A Social Services Note dated 9/19/22 indicated at a bi-monthly meeting (There was no explanation for why the meetings were changed from bi-weekly to bi-monthly.) the resident's inappropriate touching of another resident was not directly addressed and instead focused on the resident's psychosocial well-being. A Social Services Note dated 2/7/23 indicated a regular check in visit was conducted. The note did not mention the resident's sexual behavior. On 2/8/23 at 10:38 AM Staff 5 (CNA) stated on 7/1/22 she brought Resident 68 to the dining room and the resident was seated at a bar stool. Resident 67 came into the dining room, stood over Resident 68, put her/his hand down Resident 67's shirt and was fondling her/his breast. Staff 5 stated she approached the residents and Resident 67 removed her/his hand and took Resident 167 (her/his spouse) to their regular table. Staff 5 stated they started doing 30 minute safety checks on Resident 67 and Resident 68 was moved out of the facility. On 2/8/23 at 10:52 AM Staff 4 (CNA) stated on 11/3/21 Resident 68 was walking around and then stood by a dining room table. Staff 4 saw Resident 67 standing by Resident 68. Resident 67 was rubbing Resident 68's breast. Staff 4 stated she separated the residents, got Resident 68 to a safe place and reported it to Staff 3 (LPN) On 2/8/23 at 1:45 PM Staff 1 (Administrator) confirmed the sexual abuse incidents between Resident 68 and Resident 67 on 11/3/21 and 7/1/22. She stated after the 11/3/21 incident Resident 68 was placed on one-on-one care during waking hours but no interventions were added for the perpetrator Resident 67. Staff 1 stated after the incident on 7/1/22 Resident 67 was placed on 30-minute safety checks and bi-weekly SSD check-ins. Resident 68 was moved out of the facility. A review of Resident 67's 30-minute safety check logs from 7/9/22 through 2/3/23 revealed of the 210 day time span, logs for part or entire days were missing for 122 days. On 2/10/23 at 9:44 AM Staff 1 (Administrator) was asked to provide comprehensive investigations for the sexual abuse incident between Resident 68 and Resident 67 on 7/1/22. At 10:49 AM Staff 1 indicated via e-mail the facility did not complete investigations for the 7/1/22 sexual abuse incident. Utilizing the reasonable person concept Resident 68 would have likely suffered from agitation, depression and trauma from Resident 67's sexual abuse and continued targeting by Resident 67 in her/his new facility where she/he was moved to keep her/him safe from Resident 67. On 2/9/23 at 2:11 PM the facility was notified of the immediate jeopardy (IJ) situation and an IJ removal plan was requested. On 2/9/23 at 4:37 PM an acceptable IJ removal plan was provided by the facility which included: - Resident 67 will not be allowed to the second floor where Resident 68 resides. - Resident 67 will be placed on 30-minute visual safety checks 24-hours per day. - The facility's social worker will conduct bi-weekly visits with Resident 67 to monitor for signs the resident is focused on any co-resident or having sexual thoughts which might be a precursor to sexual abuse of a co-resident. - The facility's IDT (Interdisciplinary Team) team will participate in training related to sexual assault, resultant trauma and appropriate decision making with the victim's holistic well-being as the focal point. On 2/9/23 at 5:22 PM the IJ removal plan was fully implemented and surveyors verified all elements of the IJ removal plan were completed. 38138 2. Resident 2 was admitted to the facility in 7/2012 with diagnoses including dementia with behavioral disturbance. Resident 2's 5/14/20 MDS indicated the resident was rarely or never understood. Resident 2 was assessed to have engaged in physical behaviors directed towards others. Resident 118 was admitted to the facility in 7/2020 with diagnoses including Parkinson's disease. Resident 118's 7/15/20 MDS revealed Resident 118 had a short-term memory problem. Resident 2's 7/2020 care plan revealed she/he became easily agitated and struck out at staff and other residents. The care plan instructed staff to monitor Resident 2 for signs of agitation, anxiety and verbal statements and to assist her/him back to her/his room when agitated. A 7/29/20 FRI revealed Resident 2 sat in her/his wheelchair in the family room on 7/29/20 at 4:20 PM. Resident 118 stood close to Resident 2. Resident 2 hit Resident 118 on the arm and grabbed her/his hand. The FRI revealed staff were interviewed and the incident was confirmed as alleged abuse. The facility's 7/29/20 Incident Audit Report revealed staff responded immediately to the incident and had to physically remove Resident 2's hands off of Resident 118. The summary revealed Resident 2 had a history of combative behaviors, agitation and a tendency to express anger and frustration by striking out. On 2/6/23 at 3:33 PM Witness 1 (Family) stated she/he was notified Resident 118 was hit by Resident 2 on 7/29/20. Witness 1 stated Resident 2 had dementia with behaviors and there were a lot of issues regarding her/his behaviors during that time. On 2/8/23 at 3:44 PM Staff 7 (CNA), who was documented as a witness on the FRI, stated she was familiar with both residents but did not remember the incident on 7/29/20. She stated Resident 2 was to be out of arms reach of others due to past incidents. On 2/8/23 at 4:02 PM Staff 8 (CNA) stated he was familiar with both residents but did not remember the incident on 7/29/20. He stated Resident 2 had a history of striking and pinching others adjacent to her/him in the past. On 2/9/23 at 1:10 PM Staff 9 (CNA) stated she was familiar with Resident 2 and having people around her/him annoyed her/him. She added Resident 2 didn't like people and lashed out. On 2/10/23 at 4:18 PM Staff 10 (RNCM) stated she was familiar with both residents but did not remember the incident on 7/29/20. She stated there were occasions when someone got close to Resident 2 and she/he was upset. Utilizing the reasonable person concept an individual would experience anxiety, agitation and fear from being hit and grabbed in a manner requiring assistance to release another person's grip. On 2/13/23 at 9:56 AM Staff 1 (Administrator) stated she was not familiar with the event between Resident 2 and Resident 118 due to the amount of time which passed. Staff 1 was informed of the findings of this investigation. She indicated she expected residents to be free from abuse and she provided no further information. 3. Resident 8 was admitted to the facility in 11/2019 with diagnoses including major depressive disorder and mild cognitive impairment. Resident 8's 11/22/22 MDS indicated the resident had a BIMS score of 13 out of 15 (which indicated the resident was cognitively intact). Resident 8's mood was assessed and she/he felt down, depressed and felt bad about her/himself. The CAA section of the 11/22/22 MDS indicated Resident 8 had a life long struggle with depression. Resident 117 was admitted to the facility in 3/2018 with diagnoses including Alzheimer's disease. Resident 117's 9/24/20 MDS indicated the resident had a BIMS score of 5 (which indicated the resident was severely cognitively impaired). Resident 117's care plan revealed she/he became frustrated or angry with other residents who went into her/his room, disturbed her/his routine or made messes in her/his space. She/he may lash out at staff or co-residents at these times. The facility's 11/21/20 FRI revealed Resident 8 and Resident 117 were in a shared room. On 11/21/20 at 4:00 AM Resident 117 was heard by staff yelling You don't belong here! Get out! Resident 8 reported Resident 117 hit her/him on the head several times hard. The FRI revealed both resident's beds were in close proximity to each other and separated by a curtain. Resident 117 reached through the curtain to hit Resident 8. Resident 117 had .severe dementia with delusional episodes, this instance also was delusional. The facility's 11/25/20 Investigation Report revealed Resident 8 reported to a nurse Resident 117 hit her/him several times and woke her/him up. It was documented in this report Resident 8 informed staff Resident 117 previously expressed verbal aggression towards her/him. The findings of the investigation revealed there was suspected abuse by Resident 117 towards Resident 8. On 2/6/23 at 12:53 PM Resident 8 stated she/he had dementia and did not remember the incident with Resident 117. On 2/7/23 at 10:37 AM Witness 2 (Family) stated she remembered the incident occurred and was informed Resident 117 hit Resident 8 on the head. On 2/8/23 at 4:02 PM Staff 8 (CNA), who was identified as a witness to the incident, stated he vaguely remembered the incident between Resident 8 and Resident 117. He stated Resident 117 had advanced dementia, was confused, agitated and had delusional behaviors. On 2/10/23 at 4:26 PM Staff 10 (RNCM) stated she remembered both residents and confirmed the incident between Resident 8 and Resident 117. She stated they shared a narrow room and the beds were close together. Staff 10 stated Resident 117 got upset and she/he reached over and hit Resident 8. Utilizing the reasonable person concept an individual would experience anxiety, agitation, depression and fear from being hit on the head while she/he was asleep. On 2/13/23 at 10:12 AM Staff 1 (Administrator) was informed of the findings of this investigation. She indicated she expected residents to be free from abuse and she provided no further information. 43690 4. Resident 119 was admitted to the facility in 1/2016 with diagnoses including vascular dementia with behavioral disturbance and adult failure to thrive. A 3/27/20 Quarterly MDS indicated Resident 119's BIMS score was a 4 indicating severe cognitive impairment. Resident 119's care plan, updated on 1/9/20, included interventions for allowing Resident 119 time to think of what she/he needed to say, for staff to anticipate needs, pay attention to verbal and non-verbal cues and to maintain consistent staff routines as much as possible to minimize confusion. A facility investigation report dated 3/6/20 included witness statements and indicated Resident 119 was muttering and Staff 6 (Former LPN) stated just say what you need to say and bent down in front of the resident and said blah, blah, blah. Three staff members witnessed visually and/or overheard a verbal exchange between Staff 6 and Resident 119 in a hallway near the nurse's station. The facility substantiated the abuse. Staff 6 was taken off of the floor immediately and later fired. On 2/8/23 at 9:56 AM Staff 12 (Former DNS) stated she recalled the incident between Staff 6 and Resident 119. Staff 12 stated once the incident was reported to her, she checked on Resident 119 to make sure she/he was ok and took Staff 6 off of the floor pending the investigation. Staff 12 stated the facility substantiated the abuse allegation through the facility investigation and fired Staff 6. On 2/8/23 at 10:05 AM Staff 6 stated the day of the incident with Resident 119 was the first time she worked with a resident with dementia. Staff 6 stated she recalled Resident 119 was crying and then screaming at her. Staff 6 stated she bent down to ask the resident what she/he needed and did not feel she talked to Resident 119 in an inappropriate way. Staff 6 stated Staff 15 (Former Activities) came out of her office and yanked the resident away from her. Staff 6 stated she was called into the DNS office and asked why she talked to the resident that way and was then told Resident 119 just needed cookies and coffee. Staff 6 stated she was escorted off the premises and later fired. On 2/8/23 at 10:32 AM Staff 14 (Dietary Manager) stated she saw Staff 6 pushing Resident 119 in her/his wheelchair down the hallway when the verbal altercation occurred. Staff 14 stated she heard Resident 119 asking for something, but was unable to recall what it was. Staff 14 stated she heard Staff 6 mock Resident 119 by saying things such as blah, blah, blah in the resident's face. Staff 14 stated she remembered feeling awful hearing the verbal aggression and came out of her office to help Resident 119. Staff 14 stated staff never talked to residents like that, and the incident was shocking. On 2/8/23 at 11:01 AM Staff 16 (Former Health Information Management) stated she witnessed the incident between Staff 6 and Resident 119 from her office. Staff 16 stated Resident 119 was in her/his wheelchair coming down the hall when Staff 6 bent over onto her knees, got in Resident 119's face, was verbally rough and mimicking Resident 119 saying things like blah, blah, blah. Staff 16 stated she got up to intervene and Staff 15 came to help out as well. Staff 16 stated she reported the incident to Staff 12 (Former DNS). On 2/10/23 at 11:42 AM Staff 1 (Administrator) confirmed the staff to resident abuse was substantiated by the facility and provided no further information.

Based on interview and record review it was determined the facility failed to identify, assess and reassess ongoing resident sexual behaviors to ensure residents were free from sexual abuse for 2 of 3 sampled residents (#s 2 and 3) reviewed for abuse. This failure, Resident 1's sexual abuse of Resident 2 and Resident 3, was determined to be an Immediate Jeopardy (IJ) situation. Findings include: Resident 1 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 2 and Resident 3 both admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 8/16/18 Comprehensive Care Plan indicated Resident 1 had behavioral expressions related to dementia with cognitive loss and verbalized sexual comments. On 11/9/18 interventions were revised to notify the nurse for verbal sexual comments during cares and showers. On 8/16/19 Resident 1 was assessed to have short term and long term memory problems, moderately impaired decision making skills, inattention, disorganized thinking and delusions. On 8/21/19 Physician order [REDACTED]. Review of Resident 1's medical record revealed from 8/28/19 through 10/2/19 Resident 1 displayed verbal and sexual behaviors with a focus on the female residents. Resident 1 followed them, touched their arms and shoulders, verbalized inappropriate sexual comments and attempted to place, her/his hand up a female residents shirt. The 10/11/19 Facility Investigation revealed on 10/8/19 Resident 1 rubbed Resident 2's shoulders and then moved her/his hands down Resident 2's chest and grabbed her/his breast. Staff 5 (CNA) intervened and removed Resident 1 from the immediate area. Resident 1 returned to the area and was observed again by Staff 5 to grab Resident 2's left breast. Resident 2 was escorted to her/his room and assessed for injury. The investigation indicated Resident 1 inappropriately touched Resident 2, had increased sexual verbalization and attention with a focus on female residents which coincided with the 8/21/19 antidepressant medication changes. The investigation concluded Resident 2 due to her/his cognitive loss, did not respond to Resident 1's sexual abuse. On 10/9/19 the Comprehensive Care plan was revised and instructed staff to keep Resident 1 away from Resident 2 and to inform Resident 1 no touching in public spaces if Resident 1 attempted to touch female residents. No revision to the plan of care was noted in (MONTH) or (MONTH) 2019. On 10/23/19 at 12:11 PM Staff 5 stated she was in the dining room on 10/8/19 providing 1:1 meal assistance to another resident when she looked over and observed Resident 1 grabbing Resident 2's breast. Staff 5 stated she called out Resident 1's name and she/he removed her/his hand from the breast. Staff 5 stated she went to Resident 1, moved her/him to the other side of the dining room as she could not leave the dining room and returned to the resident she was assisting. Staff 5 stated she looked over at Resident 2 and saw Resident 1 had returned to her/him and her/his hand was again on Resident 2's breast. Staff 5 stated another staff member entered the dining room and removed Resident 1. Progress Notes from 10/9/19 through 10/16/19 revealed Resident 1 received 1:1 supervision from 5:00 PM through 9:00 PM daily and continued to follow the female residents, verbalize sexual comments and required continued education concerning no touching and appropriate behaviors. The notes further revealed Resident 1 continued to verbalize sexual comments and require redirection from 10/17/19 through 10/22/19 throughout all three shifts. A 10/22/19 FRI indicated on 10/22/19 at 4:15 PM Staff 9 (RN) entered Resident 1 and Resident 3's room and observed Resident 1 with her/his hand on Resident 3's groin area. Resident 3 appeared to be asleep in her/his chair. Staff 9 proceeded to instruct Resident 1 to stop and removed Resident 1's hand from Resident 3's groin area. 1:1 supervision from 4:30 PM through 9:30 PM was initiated. The FRI indicated Resident 3 was unaware of Resident 1's physical touch to her/his groin area. On 10/23/19 at 5:15 PM Staff 9 stated she entered Resident 1 and Resident 3's room on 10/22/19 and observed Resident 1 had her/his left hand grabbed onto and rubbing Resident 3's groin area. Resident 3's eyes were closed. Staff 9 stated she intervened and immediately notified the DNS and 1:1 supervision was reinstated. Staff 9 stated she went back to assess Resident 3 and Resident 3 had no knowledge of the incident which occurred. The Comprehensive Care Plan was revised on 10/22/19 to instruct staff to keep Resident 1 away from Resident 3 and Resident 1 was to have a 1:1 caregiver from 4:30 PM through 9:30 PM. On 10/2319 at approximately 1:15 PM Staff 4 (LPN) stated after the CNA staff reported the 10/8/19 resident to resident incident to her Resident 1 was placed on alert, the staff were instructed to keep Resident 1 away from Resident 1 and 1:1 supervision was initiated. Staff 4 stated the 1:1 supervision was stopped after a few days because Resident 1 was doing well and Staff 1 (Administrator) did not feel the 1:1 supervision was required. On 10/23/19 at 8:55 AM and 1:30 PM Staff 7 (RNCM) and Staff 8 (RNCM) acknowledged the 10/8/19 resident to resident incident when Resident 1 grabbed Resident 2's breast twice. Staff 7 stated 1:1 supervision was initiated on 10/9/19 for four hours in the evening hours but was stopped after five or six days because staff did not observe continuing sexual behaviors. Staff 7 and Staff 8 acknowledged Resident 1's verbal sexual behaviors leading up to the 10/8/19 incident and stated the increase of physical sexual behaviors coincided with the antidepressant medication changes. Staff 7 stated she knew she needed to update Resident 1's plan of care but the information to ensure the female residents were safe from Resident 1's sexual behaviors was verbally passed from shift to shift instead. Staff 7 acknowledged the comprehensive care plan was not updated in (MONTH) or (MONTH) 2019 when Resident 1's verbal and physical sexual behaviors increased. Staff 7 verified the 10/22/19 resident to resident incident occurred at 4:15 PM when Resident 1 was observed with her/his hand on Resident 3's groin area. Staff 7 acknowledged 1:1 supervision was restarted from 4:30 PM through 9:30 PM. Staff 8 acknowledged Resident 1 displayed sexual behaviors on all shifts and not exclusively during the 4:30 PM through 9:30 PM time period. Staff 7 and Staff 8 acknowledged Residents 1 and 3 continued as roommates, a medication change was in process and the facility had revision ideas for the plan of care but nothing was put into place. On 10/23/19 at 4:32 PM the facility was informed of the identified Immediate Jeopardy for the failure to identify, assess and reassess ongoing resident sexual behaviors to ensure residents were free from sexual abuse. Some situations of abuse do not result in an observable physical injury or the psychosocial effects of abuse may not be immediately apparent. Other residents may not be able to speak due to a medical condition and/or cognitive impairment, cannot recall what has occurred, or may not express outward signs of physical harm, pain, or mental anguish. The sexual abuse by Resident 1 to Resident 2 and 3, using a reasonable person concept, was reasonable to assume Resident 2 and Resident 3 would have suffered from recurrent anxiety. Additionally, facility residents remained at risk. The facility failed to provide supervision and monitoring to ensure the safety of Resident 2 and other female residents after Resident 1's 8/28/19 initial and then ongoing sexual behavior. The facility failed to assess and reassess Resident 1's behavioral status and effects of the antidepressant medication changes. The facility failed to ensure the ongoing safety of Resident 3 and all facility residents after the 10/22/19 sexual abuse incident. These failures placed all facility residents at risk for sexual abuse. An IJ Abatement Plan was requested. On 10/23/19 at 7:13 PM the IJ Abatement Plan, was received and approved. The Plan included: Immediate Action: 1) Resident 1 was moved to a private room to create separation from other residents during sleeping hours. 2) 1:1 supervision was implemented 24 hours a day. 3) In consultation with Resident 1's physician, Resident 1 was prescribed [MEDICATION NAME] (antipsychotic medication) with the goal of addressing sexual aggression and to treat a possible underlying mental health condition. The medication was ordered and would start upon arrival to the facility. 4) Resident 1's family was contacted to update on the changes in care. 5) All interventions would be reviewed each business day by Staff 1, Staff 2, Staff 7, Staff 8 and Staff 13 (Social Service Director) to determine effectiveness and make revisions as needed. 6) Resident 1 would be monitored for response to medication, including sedation. Education Content: Objective: Residents to be assessed, and care planned to ensure resident safety from sexual abuse. Education would be completed on 10/23/19 and 10/24/19 and would include: need to monitor, assess and reassess following antidepressant medication changes and related changes in behaviors with strong emphasis on sexually inappropriate behaviors. Behavior documentation. Documenting reassessments and revision of care plans for RNCMs. Licensed Nurses to inform RNCMs of indicated changes to care plan with strong emphasis on sexually inappropriate behaviors. Ensuring Interventions are appropriate and effective. Ongoing interventions included Staff 1, Staff 2, Staff 7, Staff 8 and Staff 13 would review all new incident reports and implement needed interventions each business day. On 10/23/19 at 7:30 PM observation, interview and record review verified the IJ Abatement Plan immediate actions were in place. The facility was awaiting the arrival of Resident 1's newly ordered [MEDICATION NAME] and planned to administer it upon its arrival. On 10/24/19 at 11:40 AM the IJ Abatement Plan was reviewed for implementation. Observations, record reviews and staff interviews confirmed the Plan was completed.

Based on interview and record review it was determined the facility failed to consistently ensure safety interventions were in place for 1 of 3 sampled residents (#1) who had a fall. As a result Resident 1 fell and sustained a scalp laceration. Findings include: Resident 1 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. On 11/4/17 a Fall Risk Assessment identified the resident was at high risk for falls related to a history of falls, medication use, memory issues, incontinence, gait impairment and drops in blood pressure. In (YEAR) Resident 1's care plan indicated the resident was at high risk for falls due to cognitive deficits with poor safety awareness, gait/balance problems, hallucinations and delusions, psychoactive drug use, vision/hearing problems, history of falls, incontinence, pain and occasional dizziness. The care plan interventions included to encourage the resident to wear non-skid footwear at all times, as much as she/he accepts, bed in lowest position and fall mat at bedside while unattended. On 12/4/17 a Fall incident report identified Resident 1 fell at 5:00 pm. Staff heard a crash and found Resident 1 lying on the floor with her/his head resting on the bottom bar of the room tray. The back of the resident's head was bleeding and it was cleansed and dressed to prevent further bleeding. Resident 1 was sent to the Emergency Department for stitches or staples for the laceration. The report identified Resident 1 was drowsy, had impaired memory and a gait imbalance when she/he ambulated without assistance to the bathroom and fell . The report identified the resident's fall mat was not in place at the bedside, she/he was not wearing non-skid socks, and while the bed was low, it was not in the lowest position. The facility determined the care plan was not followed as all interventions were not in place at the time of the fall. On 12/4/17 an Emergency Department procedure note indicated Resident 1 had a laceration repair on the scalp. There were no complications. In interview on 2/27/18 at 2:21 pm Staff 4 (LPN) reported Resident 1 was at high risk for falls and had frequent falls related to dementia with impulsiveness. On 12/4/17 she heard a crash and ran down the hall and into Resident 1's room and found her/him lying on the floor next to an over-bed tray table. It appeared the resident hit her/his head on the one of the table legs. There was a laceration to the back of the resident's head and she cleaned and dressed the wound, assessed the resident and sent her/him out to the hospital. The resident came back with staples but no [MEDICATION NAME] injury from the fall. Staff 4 reported she noticed at the time of the fall that the resident's fall mat was not in place but folded up and at the end of the bed. In interview on 3/2/18 at 9:21 am Staff 5 (CNA), who worked with Resident 1 on 12/4/17 during the day, stated it was a busy day with a lot of commotion between day and evening shifts. She reported that before the end of her shift she weighed the resident using a mechanical lift. Staff 5 stated she moved the fall mat out of the way so she could get the legs of the lift under the bed and increased the height of the bed to aid in lifting the resident. She stated after the resident was placed back in bed another resident needed assistance and she forgot to replace the fall mat and lower the bed all the way down prior to assisting the next resident. Staff 5 reported the resident did not have on non-skid socks because she/he wore regular sock with shoes when up. In interview on 3/2/18 at 12:18 pm Staff 6 (CNA), who was assigned to Resident 1 at the time of the fall, stated she started on the floor around 3:00 pm on 12/4/17. She reported she assisted Resident 1's roommate to the restroom and Resident 1 was still asleep. Staff 6 did not notice that Resident 1's fall mat was not in place or her/his bed was not in the lowest position when she was in the room. In interview on 3/2/18 at 1:21 pm Staff 2 (DNS) reported Resident 1 was care planned to have her/his bed in the lowest position, a fall mat next to the bed and to wear non-skid socks. She reported at the time of the fall, Resident 1's bed was not in the lowest position, the fall mat was not at the bed side and non-skid socks were not on the resident's feet. In interview on 3/2/18 at 1:47 pm Staff 3 (RNCM) reported the CNAs acknowledged the fall mat was at the bed side and the bed was not lowered all the way down. In addition the resident had regular socks on but she/he was supposed to always wear non-skid socks. She stated she removed the resident's regular socks from the room and counseled the CNAs regarding not following the care plan. Staff 3 reported Resident 1 had no significant impact from the fall.