Every finding on record at New London Specialty Care

Based on observation, clinical record review, facility policy review, provider and staff interview the facility failed to use a gait belt during a transfer for 2 of 2 (Resident #6 and Resident #5) residents at risk for a fall, with Resident #6 experiencing a fall which resulted in a fracture and the need for a surgical repair. The facility reported a census of 43 residents.Findings include:1. Review of Resident #6's the Minimum Data Set (MDS) assessment tool dated 1/30/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The diagnoses list included acute and chronic respiratory failure with hypoxemia (low oxygen level in the blood), diabetes, congestive heart failure and morbid obesity. The MDS assessed Resident #6 required substantial/maximal staff assistance for transfers to and from bed or chair, and repositioning in bed. The MDS identified the resident utilized a walker, wheelchair and supplemental oxygen. Review of Resident #6's Care Plan revealed the following problems:a. I am at risk for falls initiated 1/26/2026. Interventions included:1. Encourage me to use my call light for assistance, initiated 1/26/2026.2. Encourage me to wear proper footwear, initiated 1/26/2026.3. I need a safe environment without clutter, initiated 1/26/2026.4. Implement two-person assist until therapy can evaluate resident after fall, initiated 3/19/2026.5. Move oxygen concentrator closer to the restroom prior to ambulating me to bathroom, initiated 3/26/2026.6. Provide me with long O2 (oxygen) tubing in order to ambulate to the bathroom safely, initiated 3/26/2026.7. PT/OT evaluation and treat as ordered, initiated 1/26/2026.b. Activities of Daily Living (ADL's) problem initiated 1/26/2026. Interventions included, in part: 1. Ambulation/Mobility - I am an assist of 2 for transfers using four wheeled walker (FWW) and gait belt, initiated 1/26/2026, revised 3/19/2026.Review of the electronic health record (EHR) revealed the following Progress Note entered on 3/26/26 at 3:45 AM: CNA called this nurse to resident's room. Upon entering this nurse found resident lying on her left side in the doorway of her bathroom. 4WW was in the bathroom in front of resident. Resident states she lost her balance. CNA staff states resident was turning to sit on the toilet and her oxygen (O2) tubing snagged due to being too short. CNA staff turned and attempted to pull O2 tubing closer and resident fell backwards onto the floor. Resident states she hit her head and her left elbow. Rates left elbow pain 10/10 and is unable to move left arm without pain. Resident is alert and oriented. Resident moves all other extremities with no pain. Vital signs BP 180/88, HR 89, RR 20, Temp 97.3, 02 94% on 2L via nasal cannula. Provider notified and ordered the resident's transfer to the hospital Emergency Room.Review of the facility self-reported incident submitted 3/26/2026 revealed, in part: Incident Summary: Resident fall with fracture.Corrective Action Description: admitted to higher level of care.Left humerus fracture. I turned to sit on the toilet and lost my balance and fell backward. I hit my head and elbow on the floor. Document review: BIMS 15, Admit 2/13/26. After 3/19/26 resident [name redacted, Resident #6] was to be assisted by 2 staff until she could be evaluated by therapy.Resident discharged from facility on 3/26/26. Did not return. [name redacted, Resident #6] was skilled and receiving PT (physical therapy) and ST (speech therapy). Therapy did not change her assistance level. Through the investigation, we determined that [name redacted, CNA (Certified Nursing Assistant)] was not using a gait belt for transfer.Review of a [hospital name redacted] Discharge summary dated [DATE] revealed, in part: Diagnoses: Fracture of distal end of left humerus.Summary of Events Leading to Admission.Patient is a [AGE] year-old female who presented to the emergency department after a mechanical fall.Per patient she was being assisted at her nursing facility to go to the bathroom when her oxygen tubing became tangled on her feet. Per resident she tried to help staff untangle herself when she lost her balance fell mainly on her left side. Per resident she mainly stroke her left elbow and her head.CT (computed tomography - type of x-ray, often called a CAT scan) of left upper arm with results of highly comminuted and displaced fracture (a bone break where bone shatters into three or more pieces, fragments separate and move out of their normal alignment) of distal humerus, bones osteopenia (low bone density), no joint dislocation, extensive tissue swelling. Orthopedic surgeon consulted who recommended surgical intervention. Patient has agreed to undergoing surgery.Staff interviews revealed:a. 6/11/26 at 7:15 a.m. Staff I, CNA stated the resident's oxygen reached the bathroom without a problem, the resident was a mechanical lift transfer at times, staff were supposed to check the communication book when they get to work for any changes, and can also check the Kardex (a quick summary of resident needs in the electronic clinical record) for the resident's care requirements. b. 6/15/26 at 2:30 p.m. Staff E, CNA stated Resident #6 was a 1 person assist for transfer the last time she had worked with her prior to 3/26/26. Staff E stated when she got to work for the night shift that started at 10 p.m. on 3/25/26 she did not review the communication book and her gait belt was in her car and she didn't think to get it out of her car that night. Staff E stated she transferred Resident #6 by herself that night, without a gait belt. She explained Resident #6's oxygen tubing got caught on furniture and when she pulled on the tubing to free it Resident #6 fell. c. 6/11/26 at 8:58 a.m. Staff G, interim Director of Nursing (DON) stated the resident's transfer method changed to 2 staff assist with gait belt and walker on 3/19/26, the change was recorded in their communication book that all staff were required to read and sign. Staff G stated Staff E had not signed the communication book when she worked on 3/26/26. Staff G stated the aides were expected to have and use their gait belts, and to follow resident care plans.d. 6/15/26 at 1:15 p.m. the Administrator stated Staff E, CNA was terminated because she failed to follow the facility's policy for resident transfers and use of the gait belt. 2. Review of Resident #5's MDS assessment dated [DATE] revealed a BIMS score of 13 out of 15 indicating intact cognition. The diagnoses list included vascular dementia, peripheral vascular disease (poor circulation), diabetes and weakness. The MDS indicated the resident independently used a walker and required substantial staff assistance to reposition in bed, transfer to and from bed and chair, and from chair to chair. Review of Resident #5's Care Plan dated 8/28/24, revealed a Focus area to address Activities of Daily Living (ADL's). Interventions included, in part: Transfer - Resident is assisted of 1 for all transfers in room with CGA for safety with FWW. Offer to ambulate Resident to lunch daily with assist of 1, gait belt, Front Wheeled Walker, and CGA with wheelchair following. Ambulate resident as far as she can tolerate to the lunch room. I may refuse, initiated 11/09/2025.During an observation on 6/11/26 from 6:53 a.m. to 7:04 a.m., while Resident #5 in her bed, Staff O, CNA provided morning care and prepared to transfer the resident out of bed. After assisting the resident to get dressed and apply a prosthetic on her left lower leg, Staff O assisted Resident #5 to sit on the side of the bed with the wheelchair positioned next to the bed. Staff O stated the resident transferred with 1:1 and a stand pivot. Without a gait belt, Staff O assisted Resident #5 to stand while supporting the resident from under the residents arms. The resident grabbed the armrests of her wheelchair and held them as she turned. Staff O directed the resident to turn to her left, take a few steps to turn and then sit in the wheelchair. Resident #5 transferred to the wheelchair without incident. After the transfer Staff O asked if she used a gait belt for the transfer, and she stated no, and added she used gait belts that were in residents' rooms and she did not know if there was a gait belt in Resident #5's room.During an interview on 6/11/26 at 8:52 a.m., Staff G, interim Director of Nursing (DON) and Staff A, RN and MDS nurse asked about Resident #5's transfer observed at 6:52 a.m., stated Staff O, CNA should have used a gait belt as directed. Review of the facility policy titled Safe Lifting and Movement of Residents revised July 2017, revealed a Policy Statement which declared: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. The Policy Interpretation and Implementation section directed, in part:2. Manual lifting of residents shall be eliminated when feasible.3. Nursing staff, in conjunction with rehabilitation staff, shall assess individual residents needs for transfer assistance eon a ongoing basis, Staff will document resident transferring and lifting needs in the care plan.4. Staff responsible for direct resident care will be trained int eh use of manual (fait/transfer belts, lateral boards) and mechanical lifting devices.7. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques.

Based on clinical record review, facility policy review and staff interview the facility failed to notify the primary care provider of a fall in a timely manner for 1 of 3 (Resident #7) reviewed for change in condition. The facility reported a census of 43 residents.Findings include:Review of Resident #7's Minimum Data Set assessment dated [DATE] revealed a diagnoses list which included dementia, diabetes with neuropathy, and acute osteomyelitis (bone infection) of left ankle. The Brief Interview for Mental Status score of 9 out of 15 indicated a moderate cognitive impairment. Review of the [name of hospital redacted] Progress Notes dated 3/9/26 revealed, in part: Assessment and Plan: #s/p (status post) fall, #nondisplaced (stable) fracture of left superior pubis ramus (upper front bone of pelvis). Patient fell from wheelchair. ED physician spoke to orthopedics, recommended conservative management, weightbearing as tolerated and outpatient follow-up.Review of Resident #7's Care Plan dated 11/17/25, revealed a Problem area to address I am at risk for falls.The facility's Falls-Clinical Protocol policy, dated as revised March, 2018 directed, in part:a. The staff will evaluate and document falls that occur while the individual is in the facility.b. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved.Review of a Nurses Note in the electronic health record (EHR) dated 3/7/26 at 11:10 p.m. revealed: Late Entry: Upon arriving to the facility nurse noticed res yelling out in pain while sitting in recliner in the common area. The current nurse [name redacted] report to the writing nurse on the resident at 22:30 (10:30 p.m.). [name redacted] reported the res had a fall at 2000 (8:00 p.m.), she had notified family, PCP (primary care provider), and facility manager. There was a skin tear on R (right) forearm that [name redacted] had cleaned, placed steri strips and island dressing. After telling PCP res was in extreme pain and could not move right leg he reordered to send res out. The writing nurse had called for transfer via ambulance and called [name of hospital redacted] ER (emergency room) to give report on resident. Later in the shift writing nurse called to receive report on res and was reported by [name redacted, RN (Registered Nurse)] he had a fracture and was waiting for therapy evaluation to have him admitted . Review of the EHR view Progress Note for Nurses dated 3/7/26 at 11:10 p.m., revealed a Created Date of 3/13/26 11:27 p.m., by Staff J, Licensed Practical Nurse (LPN).Review of an Incident, Accident, Unusual Occurrence Note in the EHR dated 3/8/26 at 8:51 p.m., revealed: Late Entry: Summary: Resident observed on floor. Resident assisted to recliner safely. Assessment done and Neuro checks initiated. VSS (vital signs stable). RN gently assessed bilateral hips and bilateral extremities for pain or discomfort. At baseline, resident had limited ROM (range of motion) and pain in RLE (right lower extremities). Resident denied any pain at this time. RN notified Provider and residents son, [name redacted]. Resident started complaining of pain in RLE and was unable to get comfortable. RN notified Provider; resident was sent out to local ED (emergency department) for further evaluation. Review of the EHR view Progress Note for the Incident, Accident, Unusual Occurrence Note dated 3/8/26 at 8:51 p.m. revealed a Created Date of 3/21/26 1:16 p.m. by Staff K, Registered Nurse (RN).During an interview on 6/10/26 at 4:53 p.m. Staff J, Licensed Practical Nurse (LPN) stated she worked the night shift 10 p.m. to 6 a.m. that started on 3/8/26. When she got to work at 10 p.m. Resident #7 was in the recliner in the common area by the TV and yelled about pain in his leg. Staff J recalled, Staff K was the nurse on duty for 2 p.m. to 10 p.m., and when he [Resident #7] yelled Staff K was taking his vital signs. Staff J stated Staff K, RN reported to her the resident fell and she [Staff K] did not realize the resident had been hurting until she started moving him. Staff J recalled Staff K stated the resident had pain with the transfer after the fall but it has subsided once she put him in the recliner. Staff J stated she thought the resident should have already been sent out for evaluation and helped Staff K with what needed to be done to get him sent out. Staff J explained for a fall the nurse on duty should document the fall, assessment and the actions taken. She added the nurse is required to assess the resident, if is an unwitnessed fall start a neurological assessment with post fall vital signs, notify the provider even if there is no injury identified at the time. During an interview on 6/12/26 at 4:27 p.m. Staff K, RN stated she'd worked at the facility since November, 2025, and had been a nurse for 10 years. Staff K stated she worked the evening of that Resident #7 fall. Staff K stated when she saw the resident he just laid there on the floor. She added she thought he was on his right side. Staff K recalled the resident did not have pain, other than his left leg and that was not new. She added he could move everything. Staff K stated two staff members got under his arms, they had a gait belt around his waist, and she was behind him and helped the 2 staff to stand him up. Staff K stated Resident #7 was able to bear weight on both legs and did not have any symptoms of pain. She stated they then pivoted him to the chair and he sat there for an hour and seemed fine. Staff K recalled the resident started to have pain and became louder about an hour later. She stated she could not remember what time he fell, but thought it was between 7:30 and 8 p.m. Staff K stated she initially messaged the facility's Nurse Practitioner (NP) and said he was uncomfortable after the fall, the NP said to monitor until morning. Staff K stated she called the NP again after the night shift nurse arrived and the NP thought the resident needed to be seen so they sent him to the hospital. Staff K recalled she completed every 15-minute checks of vital signs (VS) and neuro checks and there were no changes. She explained she did not call the family or the manager on call because she wasn't aware she was supposed to. Staff K stated she thought she started to write a note about the fall, but couldn't remember and stated she should have documented his fall and her assessments on the day it occurred.During a call on 6/15/26 at 11:52 a.m., the facility's contracted provider network answering service stated there was no documentation of a call by the facility about Resident #7's fall on 3/8/26. During an interview on 6/15/26 at 4:23 p.m. the facility's NP stated the only call or message he received about Resident #7's fall on 3/8/26 came in at 10:28 p.m. on 3/8/26, and he directed the staff to send him out due to his pain and probable injuries, he had no notice or knowledge of the fall prior to that call.During an interview on 6/15/26 at 1:21 p.m. Staff N, RN, former DON (from mid-December, 2025 until the end of March, 2026) stated staff never called her about the resident's fall on 3/8/26, she found out the next morning when she came in to work. Staff N stated Staff K, RN was a seasoned nurse and she knew she was supposed to call the provider any time there was a fall, with or without injuries, and to also call the manager on call and the family. Staff K should have also documented about his fall that night before she left work, it was not acceptable to chart about that 2 weeks later.During an interview on 6/11/26 at 8:58 a.m. Staff G, RN, interim DON stated if a resident fell the nurse was required to assess the resident, provide care required, notify the provider even if no injury, the manager on call and the family of the fall, and document all of the information in the resident's record on the day of the fall. In an email exchange on 6/16/26 with the facility Administrator, the Administrator communicated the facility had no other documentation that the provider was notified of Resident #7's fall on 3/8/26.

Based on observation, clinical record review, facility policy review, and staff and resident interviews, the facility failed to prevent a resident-to-resident incident (Resident #1 and Resident #2) which resulted in Resident #1 throwing a pack of disposable wipes at Resident #2 causing two days of discomfort. The facility reported a census of 43 residents.Findings include:Review of a facility's self-reported incident submitted 6/3/26 described a resident [Resident #1] threw a package of wet wipes in roommate's [Resident #2] direction, contact made, no injuries observed and the residents were separated.1. Review of Resident #1 Minimum Data Set (MDS) assessment dated [DATE] revealed diagnosis of cerebrovascular accident (a stroke) with hemiplegia (paralysis on 1 side of the body) and depression. The Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicated a moderate cognitive impairment. The MDS indicated Resident #1 dependent on staff for all activities of daily living (ADL's) with exception of eating and oral hygiene.During an interview on 6/10/26 at 10:36 a.m., when asked about an incident with a previous roommate [Resident #2], Resident #1 stated the roommate was singing and he did not like that so he threw wipes at him. When asked if he had said anything to him before that or if he had asked him to stop singing the resident said no. 2. Review of Resident #2's MDS assessment dated [DATE] revealed Resident #2 diagnoses of diabetes, legal blindness, mood disorder, and post-traumatic stress disorder (PTSD). The BIMS score of 15 out of 15 indicated intact cognition. The assessment revealed the resident required limited staff supervision or touch assistance for ambulation due to severely impaired vision. Review of an Incident, Accident, Unusual Occurrence note in the electronic health record (EHR) dated 6/3/26 at 6:58 p.m. revealed: Resident was lying in bed and his roommate threw a package of wipes at him striking his chest. Resident is upset and angry at the situation. Resident states he doesn't know why the roommate did it.Review of a Nursing Note entered in the EHR on 6/3/26 at 7:01 p.m. revealed Head to toe completed following incident of resident's roommate throwing a package of wipes at him. No injuries noted upon assessment.During an interview 6/10/26 at 9:50 a.m., Resident #2 he was singing when his roommate [Resident #1] threw something at him that hit him in the middle of his chest, his chest hurt for 2 days. Resident #2 stated he was caught off-guard because his roommate had not said anything to him and he couldn't see that he'd thrown anything at him due to his blindness. Review of Resident #2's June 2026 Medication Administration Record and Treatment Administration Record (MAR/TAR) revealed on 6/3/26 a pain of 4 documented and 650 milligrams (mg) of acetaminophen (Tylenol) oral administered as ordered by the physician for pain, with relief of pain documented.During an interview on 6/10/26 at 3:03 p.m. Staff B, Certified Nursing Assistant (CNA), stated she worked on the evening of the incident between Resident's #1 and #2. There had been no indication that Resident #1 would do something like that. She answered Resident #2's call light right before supper, he was very upset, said Resident #1 had thrown a package of wet wipes at him. Later that night he said his chest hurt and that his room-mate threw the wet wipe package at him because he didn't like his singing.6/10/26 at 3:49 p.m. Staff A, Registered Nurse (RN) stated she was on duty when Resident #1 threw a package of wet wipes at Resident #2. She assessed the resident for injury and did not see any marks or bruising on the resident. Resident #2 said he had pain in his chest where he was struck by the wipes, it was mild, she medicated him with Tylenol and that was effective. She had not seen an signs of injury since the day of the incident. Review the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised 2021, directed that all residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The policy directed that residents were to be protected from abuse by facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, and/or any other individual.

Based on clinical record review, facility policy review, personnel file review and staff interviews, the facility failed to ensure that a staff who changed positions from a dietary employee to a certified nursing assistant completed orientation and demonstrated skill competencies prior to working independently with residents. The facility reported a census of 43 residents.Findings include:Review of a facility's self-reported incident submitted on 3/26/26 described a fall experienced by Resident #6 while being transferred without the use of a gait belt by one staff [Staff E, Certified Nursing Assistant (CNA)]. The fall resulted in fracture that required a surgical repair. Review of Resident #6 Care Plan dated 1/26/26 revealed a Focus areas to address:a. I am at risk for falls, with the Intervention: Implement two-person assist until therapy can evaluate resident after fall, initiated 3/19/2026.b. Activities of Daily Living (ADL's), with the Intervention: Ambulation/Mobility - I am an assist of 2 for transfers using four wheeled walker (FWW) and gait belt, initiated 1/26/2026, revised 3/19/2026.A review of Staff E, CNA's personnel file revealed:a. An initial hire date of 5/30/23 for the position of dietary employee. b. An undated Direct Care Worker inquiry form indicated Staff E certified as a Certified Nursing Assistant on 6/7/25, had an active status, without employment.c. A CNA Job Description form signed by Staff E on 6/20/25. d. No information found in file which indicated Staff E's start date as a CAN, completion of CNA orientation or verification of CNA competency. e. A Disciplinary Action form dated 4/2/26 described Staff E terminated as the result of failure to follow a resident's care plan and safe transfer procedures. This failure resulted in a resident fall with major injury.During an interview on 6/10/26 at 2:26 p.m. Staff F, Business Office Manager and Human Resources Director, stated she could not say when Staff E changed positions from dietary to that of a CNA. Staff F stated after the change, Staff E had still worked in the kitchen when needed. Staff F stated she does not have documentation of a CNA Skills Check List or competency assessments for Staff E as a CNA.During an interview on 6/11/26 at 8:58 a.m., Staff G, interim Director of Nursing (DON) stated she could not find any documentation of Staff E's training and not sure of her start date as a CNA. Staff G stated Resident #6's Care Plan was changed to a 2 staff transfer with gait belt and walker on 3/19/26. The change in the Care Plan was documented in their communication book that all staff were required to read and sign, Staff E had not signed the communication book when she worked on 3/26/26. Staff G added all staff were expected to follow the resident's Care Plan. Review of the facility policy titled Orientation revised October 2017, revealed a Policy Statement which declared: An orientation program is conducted for newly hired nurses aids. The Policy Interpretation and Implementation section directed, in part:1. All newly hired nurse aides must attend an orientation program within their first 5 days of employment.2. The orientation program includes, but is not limited to:c. An introduction to resident care procedures, which includes:A review of the facility's policies and procedures;A review of the facility's in-service training program;A review of the facility's infection control practices;Review of the facility policy titled Competency of Nursing staff revised May 2019 revealed a Policy Statement which declared:1. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State Law.2. In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will:a. Participate in a facility-specific, competency-based staff development and training program; andb. Demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care.The Policy Interpretation and Implementation section directed, in part: 2. The following factors are considered in the creation of the competency-based staff development and training program:An evaluation of the current program to ensure basic nursing competencies;Any gaps in education or training that may be contributing to poor outcomes;Specialized skills or training needed based on the resident population;A method to track, assess, plan, implement and evaluate the effectiveness of training; andA method to evaluate critical thinking skills and management of care in complex environments with multiple interruptions.

Based on observation, facility policy review resident and staff interviews, the facility failed to maintain room meal trays at a palatable and safe temperature for one of one meal service observed. The facility reported a census of 43 residents. Findings include: Review of Resident Council Meeting Questions for January 2026 revealed residents stated the food is not always up to temperature and breakfast trays are late and the hamburgers and waffles are usually lukewarm.During an interview on 2/23/26 at 1:07 PM, Resident #27 stated she ate breakfast in bed and the food was cold all the time. Resident #27 stated the facility needed food warmers. During an observation on 2/25/26 at 8:12 AM, rooms trays are delivered down A hall first. During an observation on 2/25/26 at 8:20 AM, a breakfast test tray was temped with Staff G, Activities Coordinator with the following results:French toast- 97.5 degrees FSausage - 102.6 degrees FMilk- 47.5 degrees FDuring an interview on 2/25/26 at 9:54 AM, Resident #27 asked how her breakfast was and Resident #27 stated she only took a bite of her sausage it was less than warm. Resident #27 stated she asked the facility to warm up her food 75% of the time. Resident #27 stated the food was supposed to be warm and she wouldn't eat it unless it was warm. During an interview on 2/25/26 at 1:16 PM, Staff E, Dietary Staff queried on the process with room trays and Staff E stated dietary prepared the room trays and the Certified Nurse Aides (CNAs) delivered them. Staff E stated the CNA did not always come very quickly to pick up the trays. Staff E stated on average the trays sat for 10 minutes before the CNAs delivered the trays. Staff E asked if the residents ever mentioned the food being cold and Staff E stated it had been awhile since anyone complained about it because the facility was getting them out quicker. Staff E stated the residents said the pancakes and bread were cold and breakfast was harder to keep warm. During an interview on 2/26/26 at 9:13 AM, Staff F, [NAME] asked about the room trays and Staff F stated the dietary staff get them ready for the CNAs to pass them but sometimes the trays sit for 15 minutes before the CNAs were ready to pass them. Staff F stated the delivery part was the problem because the food temperatures were good before they trays were sent out. During an interview on 2/26/26 at 9:19 AM, the Dietary Manager informed of the temperature on the breakfast room tray on 2/25/26 and the Dietary Manager stated they tried to get staff to pass the trays on time. The Dietary Manager stated she would look into finding ways to keep the food at the required temperatures. The Dietary Manager queried what the holding temperatures needed to be for the room trays and she stated the cold items should not be over 40 degrees F and the hot food items should be 135 degrees F or above. The Facility Food Preparation and Service Policy revised on April 2019 revealedFood Preparation, Cooking and Holding Time/TemperaturesThe danger zone for food temperatures is between 41 F and 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness.

Based on observation, clinical record review, facility policy review manufacturer instructions of facility equipment, and staff interviews, the facility failed to ensure 1 of 1 resident (Resident #27) transported in a wheelchair chair with feet in a safe position (Resident #27), and failed to ensure resident safety when using a mechanical sit to stand device for 1 of 1 resident (Resident #27). The facility reported a census of 43 residents. Findings include: Review of the Minimum Data Set (MDS) assessment, dated 1/22/26 revealed Resident #27 scored a 9 out of 15 on the Brief Interview for Mental Status (BIMS) exam, a moderate impairment of cognition. The list of diagnoses of non-Alzheimer's dementia, generalized muscle weakness, and unspecified lack of coordination included. The MDS indicated Resident #27 dependent for most transfers, used a manual wheelchair and dependent to wheeling 150 feet in the corridor. Review of the Care Plan revealed the following Focus areas:a. Activities of Daily Living (ADL's), dated 8/28/24 which included Interventions, in part: Transfer - I am a hoyer (a brand name for a mechanical lift) for all transfers except for toilet transfers. I am a stand eaze (also called ezstand or EZ stand a type of lift that assists the resident from a sitting to a standing position and after secured they propelled to the desired location) with assist of 2 for toileting transfers, initiated 3/5/25. b. I am risk for falls, dated 8/28/25 with an Intervention Do not leave me resident alone in the bathroom, initiated 1/2/26. c. I have impaired cognitive function/dementia or impaired thought processes related to my diagnosis of vascular dementia, revised 5/15/25 with an Intervention Provide cues, re-orient and supervise as needed, initiated on 9/10/24. Review of a document titled Unwitnessed Fall, Date 1/2/26 at 5:00 PM revealed a Nursing Description: Staff nurse heard faint yelling, CNA (Certified Nursing Assistant) went to check down the hallway to check resident rooms, CNA called for nurse. Upon entering shower room the resident was observed on the floor in a sitting position with Ezstand sling under arms, still attached to ezstand. Resident was assessed for injuries, none noted. VSS (vital signs stable). Resident was cleaned and hoyered to wheelchair. Neuro check started. PCP notified. Family notified. Education to staff done. The Notes section revealed RCA (Root Cause Analysis): left alone on EZ stand in bathroom. Intervention: do not leave alone in bathroom. On 2/25/26 at 3:31 PM, Staff A, Registered Nurse (RN) queried on the incident [1/2/26] with Resident #27 in the bathroom and Staff A stated after staff notified her of the incident, she went to the whirlpool bathroom and found the resident on the floor. Staff A described the resident had the mechanical sit to stand under him, and it was still attached to him. Staff A stated the lift should have not been attached to the resident. When asked if is standard practice to leave a resident alone with the lift attached, Staff A stated she did not think it was acceptable to leave the resident alone. Staff A explained her understanding was if the brakes were on, residents could be left alone in the whirlpool room still attached to the mechanical sit to stand.On 2/26/26 at 8:50 AM, when asked if a resident could be hooked up to the EZ stand while on the toilet, Staff B, CNA stated yes, some residents wanted to stay hooked up to the machine, but Staff B always locked the wheels and gave the resident a call light. Staff B stated staff needed to stay with Resident #27 as he may fall asleep or try to grab at the machine. Staff B stated staying with Resident #27 is not new and staff needed to always stay with him as it was not safe to leave him alone. During an interview on 2/26/26 at 11:01 AM, Staff C, CNA queried on leaving residents in the mechanical sit to stand in the bathroom and Staff C stated that was how she was trained but the lift needed to be fully down and the wheels locked. Staff C stated she would not leave Resident #27 alone because she would be afraid Resident #27 would try to get up or fall.During an interview on 2/26/26 at 11:34 AM, Staff D, CNA queried on the incident [1/2/26] with Resident #27 and Staff D stated she helped another aide get Resident #27 into the mechanical sit to stand and take him into the whirlpool room to use the bathroom. Staff D stated she asked the aide if they needed help with giving Resident #27 the call light or locking the brakes and the aide said no, so Staff D left. Staff D stated a little while later, a nurse said she heard yelling and sent the CNAs to walk up and down the halls to find it. Staff D explained she did not hear the yelling so she continued to chart. Staff D stated when she did hear the yelling, she asked another CNA if they got Resident #27 off the toilet. Staff D explained the aide said no so she went to the whirlpool room and found Resident #27 on the floor. Staff D described finding Resident #27 with his bottom on the ground, the stand not in the same place when she left the room earlier, and the residents' arms were around the sling, holding them up. Staff D explained in the past she had left Resident #27 in the whirlpool room alone with the wheels locked. Staff D stated she would then set a timer for 5 minutes to remind herself to check on him. Staff D added she did not know how long Resident #27 was in the bathroom by himself.During an observation on 2/25/26 at 12:32 PM, Staff B, CNA propelled Resident #27 in his wheelchair from the dining room towards his room. During the transport, Resident #27 feet were positioned outside of the foot pedals and slide across the dining room floor. Resident #27 informed Staff B he needed to use bathroom. Staff B turned Resident #27 around and propelled him in his wheelchair down Hallway B towards a bathroom. Resident #27 feet remained out of the foot pedals and slide across the floor. During an interview on 2/25/26 at 3:31 PM, Staff A, RN stated residents' feet should be on the wheelchair foot pedals when they are pushed. During an interview on 2/26/26 at 8:50 AM, Staff B, CNA queried on where a resident's feet needed to be when pushed in a wheelchair and Staff B stated on the foot pedals. Staff B stated some residents didn't like to put their feet on foot pedals and staff would have to remind the residents. Staff B stated Resident #27 didn't like to put his feet on the foot pedals and Staff B would have to put them on 3 or 4 times.During an interview on 2/26/26 at 12:13 PM, the Director of Nursing (DON) stated she was not working at the DON at the facility when the incident on 1/2/26 occured. The DON stated yes, residents could be left attached to the mechanical sit to stand in the bathroom with a call light and the brakes locked. The DON stated Resident #27 is directable and listens and maybe he was confused when it happened. The DON stated the CNAs know what residents they can leave alone in the bathroom. The DON asked if the mechanical sit to stand could be moved with the brakes on, and the DON stated yes, it would take some effort. The DON asked where feet should be when a resident is being pushed in the wheelchair and the DON confirmed feet should be on the foot pedals.After requested on 2/26/26, the facility stated they do not have a policy regarding the use of wheelchair foot pedals. Review of an undated facility policy titled Lifting Machine, Using a Mechanical Policy revealed a Purpose statement which declared The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. The policy did not address resident supervision needs.Review of the EZ Way Smart Stand Operator's Instructions, revised 5/9/25 instructed in part:a. Lower the patient (page 6)1. When lowering the patient onto a chair, toilet, wheelchair or bed, the caregiver should stand beside the patient.2. Press the down button on the hand control until the patient is fully lowered.b. Unhook harness (page 7)1. When the patient securely seated, lower the stand arm until there is enough slack to unhook the harness loops from the arm. Unhook the loops.2. Move the unit away from the patient.3. Unfasten the buckle that was across the patient's torso. Remove the harness from behind the patient by grasping the center harness handle.

Based on Facility Reported Incident Review, staff interview, resident interview, narcotic log review, clinical record review, and facility policy review the facility failed to ensure residents remained free from misappropriation of narcotic pain medications for six of nine residents reviewed for misappropriation (Resident #1, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9). The facility reported a census of 45 residents. Findings include: 1.Review of the Minimum Data Set (MDS) assessment for Resident #1 dated 9/11/25 revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment, the resident took opioid medication (narcotic pain medication). The Care Plan dated 6/10/25 revealed, I use opioid medications related to pain. The Intervention dated 6/10/25 revealed, Administer opioid medication as physician ordered and monitor for side effects. The Physician Order dated 7/23/25 revealed the resident prescribed Oxycodone 5mg (milligrams), a narcotic pain medication, to be administered every six hours as needed, and also had an order dated 9/9/25 for Oxycodone 5mg, a narcotic pain medication, to be administered four times a day for pain/discomfort. Review of Narcotic Logs for Resident #1 revealed on 9/1/25, Staff A removed Oxycodone 5mg from the resident's narcotic card in the following order: a. 9/1/25 at 7:10 PM: Staff A signed out 1 pill, which lowered medication count to 26. (Narcotic Log Page 26).b. 9/1/25 at 5:50 PM: Staff A signed out 1 pill, which lowered medication count to 25. This medication dose marked as wasted (destroyed). (Narcotic Log Page 47).c. 9/1/25 at 7:10 PM: (Time that been entered already on narcotic log): Staff A signed out 1 pill, which lowered medication count to 24. (Narcotic Log Page 47). Review of the Investigation Drug Diversion 9-13-25 revealed, It was found that [Staff A] adjusted narcotic starting number and duplicated the orders, and documented this practice had been done by Staff A for Resident #1. Review of the staff statement by Staff F, Licensed Practical Nurse (LPN), included as part of a Facility Reported Incident (FRI) Investigation revealed the following: While passing noon medications on 9/13/25 [Staff F] noticed that [Resident #1's] Oxycodone (narcotic pain medication) 5mg (milligram) blister pack had multiple slots taped. [Staff F] made a comment to the other nurse on staff who also thought this was odd. Upon inspecting the pill in slot 40, [Staff F] noticed that it did not match the other pills in the pack. [Staff F] looked up the pill description and concluded that it was an Amlodipine Besylate (blood pressure medication) 5mg and not an Oxycodone 5mg [Staff F] then inspected the other Blister packs in the Narcotics drawer. [Staff F] found more tape on the back of [Resident #5's] Oxycodone 5mg card, [Staff F] reported this additional finding to the DON (Director of Nursing).On 10/7/25 at 1:45 PM, Staff B, LPN queried if had any concerns with narcotics, and responded not anymore. Staff B explained she had just kept noticing there was tape on the back of some of the narcotics now and then, and was kind of starting to figure out who narrowing down to. Per Staff B, she never came across one with tape that she had to give. Staff B explained she didn't bring it up, was waiting on see what was going on, and realized when doing count was tape on the back of the card, described by Staff B to throw (her) off sometimes. When queried if reported to the DON, Staff B responded no, sometimes could pop, tape, initial, explain, and said no one ever said hey, this is what happened. Per Staff B, she felt extra tape, and didn't think anything of it. Per Staff B, seemed to have happened more often, was always finding on the same side of building, Staff B didn't know for sure, and if would have known for sure, would have brought something up. Staff B explained she did not notice if one drug or different drugs taped. When queried how long of a time frame she noticed/felt tape, Staff B responded probably a month. When queried if it ever came up in conversation with other staff, Staff B reported she and Staff F worked together one day, and Staff F said why is there so much tape? Staff B said check to make sure. Staff B reported she started to notice in August. On 10/9/25 at 1:13 PM, Staff F explained he went to give a resident [Resident #1] his noon dose of Oxycodone, and the card had tape on the back of it and pill taped back in. Staff F explained he thought it was odd, looked at the card, and a bunch of different slots had tape on them. Staff F explained looked over to the other nurse (later identified by Staff F as Staff B), what's going on with all the tape? Per Staff F, she said she didn't know. Staff F explained he inspected the pill, it wasn't Oxycodone, and was Amlodipine 5mg. When queried if it was in the bubble pack with the tape, Staff F confirmed it was. Staff F explained at that point he notified the DON (Director of Nursing). When queried if if was the first dose for Resident #1 that day, Staff F said no. Staff F explained had given AM dose that morning. When queried how that bubble (medication bubble in card) looked, Staff F explained that had been the same situation. When queried if AM dose also had tape, Staff F responded yes, at first he (Staff F) thought maybe somebody accidently popped it while popping previous one, and when he came across second dose with tape, said this is not a one off thing, and was weird. Staff F explained it was like scotch tape. When queried how the Amlodipine looked versus the Oxycodone, Staff F responded after he looked at the two different and the pill descriptor, both were the same size, both were white, and one side was identical on both of them. Staff F then explained the markings on the pills. Staff F explained Oxycodone was scored (had indented line on pill), and when looking at it noticed the score was missing, which prompted him to look more at the markings/look up online. Review of information included as part of a Facility Reported Incident (FRI) dated 9/13/25 revealed, [Name Redacted] DON was notified that there is an Oxycodone blister pack that had taped slots. The pill in the taped blister pack slot was inspected and was identified as Amlodipine Besylate 5mg. During investigation it was found that the frequency of administration of PRN (as needed) Narcotics is greater from [Staff A] (Licensed Practical Nurse, LPN) than any other nurse. Narcotics are being wasted more frequently by [Staff A] than any other nurse. [Staff A] has documented the narcotic as given in the Narcotic book but at times has not documented it in the MAR (Medication Administration Record). Discrepancy found in the Narcotic book with double documenting of narcotics when continuing the drug to a new page in Narcotic book. Employee interviews lead to determination that the medications were taped when [Staff A] was signed on the cart. Review of the Disciplinary Action Form for Staff A dated 9/16/25 revealed the employee was terminated due to the following: Suspect in drug diversion-Substantiated.2. Review of the MDS assessment dated [DATE] revealed Resident #5 scored 3 out of 15 on a BIMS exam, which indicated severely impaired cognition. Per this assessment, the resident had diagnoses of cancer, arthritis, and non-Alzheimer's dementia. Per this assessment, Resident #5 took opioid medication. Review of Resident #5's Care Plan dated 7/24/25 revealed, I have chosen to recieve hospice care with [Name Redacted] hospice. The Intervention dated 7/24/25 revealed, Coordinate with the hospice team to assure I experience as little pain as possible. Review of the Physician Order dated 7/25/25 revealed the resident could receive 1 tablet of Oxycodone 5mg by mouth twice daily as needed, and the additional order active 8/15/25 to 9/12/25 revealed, Oxycodone Hcl Oral Tablet 5mg with instructions to give 5mg by mouth three times a day for pain. Review of Resident #5's Narcotic Log (Page 49) revealed on 9/9/25 at 4:50 PM, Staff A removed one dose of the medication (lowered count to 26). Review of Resident #5's Narcotic Log (Page 62) revealed on 9/9/25 at 4:50 PM, Staff A removed one dose of the medication (lowered count to 25). Staff A removed one dose at 6:45 PM (lowered count to 24), and at 9:40 PM (lowered count to 23). On 9/9/25 Staff A removed four doses of Oxycodone 5mg, while three doses of Oxycodone 5mg were charted by Staff A on the MAR.Review of Resident #5's MAR dated September 2025 revealed between 9/1/25 and 9/13/25, Staff A documented they administered 17 of 20 doses of PRN Oxycodone.3. Review of the MDS dated [DATE] for Resident #6 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated intact cognition. Per this assessment, the resident took opioid medication. The Care Plan dated 7/8/25 revealed, I use opioid medication related to pain from pressure ulcers and hx (history) of CVA (cerebrovascular accident). The Intervention dated 7/8/25 revealed, Administer opioid medication as physician ordered and monitor for side effects. The Physician Order dated 8/18/25 revealed Oxycodone Hcl Oral Tablet 5mg with directions to give one tablet by mouth three times a day for pain. The Physician Order dated 8/20/25 revealed Oxycodone Hcl Oral Tablet 5 mg with directions to give one tablet orally every 12 hours as needed for pain May take PRN with the scheduled dose. Review of the Investigation Drug Diversion 9-13-25 provided by the facility revealed Resident #6's Oxycodone dated 9/9/25 at 3:25 PM was not documented on the resident's MAR.Review of Narcotic Log (Page 51) revealed Staff A removed a tablet of the medication on 9/9/25 at 3:25 PM, and removed another tablet of the medication on 9/9/25 at 7:20 PM. Resident #6's MAR dated 9/6/25 revealed Staff A documented she administered only the resident's scheduled HS (evening) Oxycodone 5mg dose that day, with no PRN doses given by Staff A.4. Review of the MDS dated [DATE] for Resident #7 revealed the resident scored 14 out of 15 on a BIMS exam, which indicated intact cognition. Per this assessment, the resident took opioid medication. The Care Plan dated 10/6/23 revealed, I use opioid medications related to sciatic pain. The Physician Order dated 10/5/23 for Resident #7 revealed, Hydrocodone-Acetaminophen Oral Tablet 5-325 with instructions to give one tablet by mouth every 6 hours as needed (PRN) for pain.The Investigation of Drug Diversion 9-13-25 provided by the facility reveled from 8/21/25 to 9/12/25, Resident #7 received 27 doses (Hydrocodone-Acetaminophen) by Staff A, and 9 doses from other nurses, and when interviewed resident, he stated he stated he rarely asked for pain medication.Review of Resident #7s Medication Administration Record (MAR) dated September 2025 revealed from 9/1/25 to 9/13/25, Staff A documented they administered 18 of 21 doses of PRN Hydrocodone Acetaminophen. Continued review of the resident's MAR revealed from 9/13/25 to 9/30/25, Resident #7 received one dose total of PRN Hydrocodone-Acetaminophen, administered on 9/20/25. Continued review of the resident's MAR revealed Staff A administered two doses of PRN Hydrocodone-Acetaminophen to Resident #7 on the following dates: 9/1/25, 9/2/25, 9/4/25, 9/6/25, 9/7/25, 9/9/25, 9/10/25, 9/11/25, and 9/12/25. The Focused Evaluation Note dated 9/8/25 at 12:53 AM revealed no pain or discomfort observed or reported for Resident #7 for the shift.Review of the Focused Evaluation Note dated 9/10/25 at 8:58 AM noted Resident #7 denied any pain.Review of the Narcotic Log (Page 28) for Resident #7's Hydrocodone/APAP (Acetaminophen) 5/325 mg revealed on the last line of the narcotic record, dated 9/10/25 at 8:45 PM, Staff A had removed one pill (lowered medication count to 26). Review of the Narcotic Log (Page 64) revealed for the first line on the new log, Staff A again charted the same date and time (9/10/25 at 8:45 PM), and lowered the medication count by one pill (lowered medication count to 25). Narcotic Log review revealed two pills had been removed by Staff A for one date and time. The Focused Evaluation Note dated 9/11/25 at 9:25 AM revealed Resident #7 denied any pain.The Focused Evaluation Notes dated 9/12/25 revealed the following:a.9/12/25 at 3:55 AM; Resident #7 had no complaints of pain or discomfort observed or reported for the shift. b. 9/12/25 at 8:43 AM: Resident #7 denied any pain. Review of Resident #7's Pain Interview dated 9/13/25 revealed the resident denied pain or hurting any time in the last 5 days. Review of Resident Interview responses for Resident #7 dated 9/13/25 included as part of the FRI included, in part, he following questions and answers: Do you feel your pain is controlled? Yes. Have you been receiving (asking for as needed) pain medication? No. On 10/8/25 at 1:01 PM, interview with the ADON revealed the following: The ADON explained she had worked a Thursday and stayed overnight to provide one to one (resident monitoring) prior to the incident. The night the ADON worked, the ADON did a partial narcotic audit of the book versus the MAR, and explained she did not get into the actual (narcotic) drawer. The ADON explained she had noticed for multiple residents, Staff A would waste a med with the nurse, would waste a narcotic, then an hour later would give the narcotic to multiple people.The ADON further explained Staff A would give a lot of narcotics in short sequence, and explained noticed Staff A gave a lot of narcotics to Resident #7. The ADON further explained she had known Resident #7 for many years, had cared for Resident #7 at another facility, some days he would take two or one Vicodin (Hydrocodone Acetaminophen) for the day, and Staff A was administering to the resident as soon as could have them, like three times a shift. The ADON explained she thought it was odd, and had just told Staff A that night if pulled a med and can't give, to waste it. When queried if Staff A wasted a lot, the ADON responded Staff A would waste an Oxycodone, hour later would give one, was wasting a lot, and in short order would give another. The ADON explained she thought it was weird, and the next morning (Friday), she told the Director of Nursing (DON) about Staff A wasting a lot of narcotics. The ADON further explained she didn't want to jump to that conclusion, it looked odd, something wasn't right, and the DON was going to talk to Staff A about the wasting.When queried if she asked Resident #7 about what she had seen, the ADON explained she did not, it was night time, and the resident would have been sleeping. Per the ADON, that is why took to the DON so could go from there. When queried if had asked Resident #7 about it from that time to current (up to 10/8/25), the ADON responded she had not, and the DON took over the lead. Per the ADON, she had noticed it was Oxycodone and Vicodin, and for patient on that, were maxing out. The ADON explained if twice a day and every 6 hours PRN, medication was being given twice a day and every 6 hours PRN. On 10/9/25 at 1:13 PM, Staff F queried about Resident #7's pain. Staff F explained typically the resident would say 2 or 3 at most (pain level), and when asked if the resident wanted anything, Tylenol or pain pill, resident would tell him no, 2 or 3 was pretty normal for him. On 10/9/25 at 3:50 PM, the MDS Coordinator queried if any narcotic concerns, stated no, said she took that back, and explained the following: The MDS Coordinator explained did a narcotic audit a week before incident occurred (with Amlodipine), and noticed Staff A signing out all the PRNs. The MDS Coordinator explained she mentioned it to the DON, and were watching. The MDS Coordinator further explained she didn't normally do the audits, and were helping the DON do the audits that week. Per the MDS Coordinator, PRNs were a lot more than most nurses. When queried if any specific residents stuck out to her, the MDS Coordinator mentioned Resident #7, extremely, and Resident #8. When queried why Resident #7, the MDS Coordinator explained when she worked the floor, on-call worked the floor, the resident never complained of pain for her. She thought it was very weird every time staff member worked was getting PRN narcs when never complained of pain. The MDS Coordinator explained she was the person who had done the resident pain interviews (part of Facility Reported Incident Investigation), and Resident #7 said he never had pain and did not need pain meds. When queried if she (MDS Coordinator) asked Resident #7 if [Staff A] gave him the medication, the MDS Coordinator responded no, she never said (Staff A's) name, asked the questions and moved on. The MDS Coordinator then explained it was probably about 4 days before notified about taped med that did the audit. On 10/13/25 at approximately 1:50 PM, Resident #7 was interviewed in his room. Resident #7 queried about his pain, and responded was real good. When asked to rate his pain on scale of 0 to 10, Resident #7 responded was 5 or 6 in hip area. When queried if he took anything for it, Resident #7 responded no, and denied requesting in September. When queried if he took more than one PRN dose in a day, Resident #7 responded no. When queried what made it better, Resident #7 responded laying here. 5. The MDS Assessment for Resident #8 dated 9/11/25 revealed Resident #8 scored 15 out of 15, which indicated intact cognition. The MDS revealed resident ranked pain as score of 01 when assessed on 00-10 scale (with 0 being no pain and 10 being worst pain you can imagine).The Care Plan dated 5/30/25 revealed, I have pain related to my current diagnosis. The Intervention dated 5/30/25 revealed, Anticipate my need for pain relief and respond immediately to any complaint of pain. On 10/9/25 at 3:50 PM, continued interview with the MDS Coordinator revealed the following for Resident #8: When the MDS Coordinator interviewed the resident, Resident #8 said did have pain, but she had requested her narcs to be discontinued because she did not want to take narcotics. The MDS Coordinator then said mostly all the PRNs were from Staff A for her (Resident #8) too. Review of Physician Orders for Resident #8 revealed from 7/28/25 to 9/15/25, the resident had Hydrocodone Acetaminophen 5-325 mg one time a day for pain (scheduled), and starting 6/28/25 was ordered Hydrocodone Acetaminophen 5-325, with directions to give 5mg every 6 hours as needed (PRN). Review of Resident #8's September 2025 MAR revealed Staff A administered scheduled Hydrocodone/Acetaminophen to the resident on 9/1/25, 9/2/25, 9/4/25, 9/9/25, 9/10/25, 9/11/25, and 9/12/25. Staff A administered 11 of 13 PRN doses of the PRN medication given between 9/1/25 and 9/13/25, administered on the following dates/times:a. 9/1/25 at 4:40 PMb. 9/2/25 at 5:30 PMc. 9/4/25 at 4:00 PMd. 9/6/25 at 9:00 AMe. 9/6/25 at 4:20 PMf. 9/7/25 at 8:20 AMg. 9/7/25 at 3:26 PMh. 9/9/25 at 5:16 PMi. 9/10/25 at 4:10 PMj. 9/11/25 at 4:00 PMk.9/12/25 at 3:40 PMReview of a Resident Interview form dated 9/13/25 for Resident #8 conducted as part of the FRI investigation the following: Resident #8 had not asked for pain meds because Resident #8 did not want to take narcotics, and Biofreeze (topical non-narcotic for pain) worked well. Review of Resident #8's Progress Notes revealed the following: The Skilled Evaluation Note dated 9/13/25 at 9:27 PM revealed Resident #8 refused the scheduled dose of bedtime Hydrocodone and stated she no longer wants it. Per the note, the Nurse Practitioner was faxed for order to discontinue bedtime Hydrocodone, and Resident #8 stated no longer wants.The Encounter Progress Note dated 9/15/25 at 12:00 AM stated, Last visit patient stated that she was having minimal discomfort and did not need her Norco (narcotic pain medication) much longer. She was only taking at HS (evening). Today she denies having any pain and wishes to d/c (discontinue) it. On 10/13/25 at 11:21 AM, Resident #8 interviewed in her room. When queried about her medications, Resident #8 said, just tell them don't want no narcotics. Resident #8 explained had previous bad experience with narcotics at a different nursing facility. When queried about September, Resident #8 acknowledged she had pain, explained the facility had tried to give her Oxycodone (narcotic pain medication) a few times, she had refused it, and told the doctor she didn't want narcotics. Per Resident #8, the doctor said would keep her on Dilaudid (narcotic pain medication) so she had a PRN (as needed), and Resident #8 said she didn't want it. Resident #8 said all she took was Tylenol (non narcotic medication) and Biofreeze (topical non-narcotic medication), explained she got by unless it was a really bad day, and said she would not take a narcotic ever again. When queried if she would take a narcotic on the days where Tylenol and Biofreeze were not effective, Resident #8 responded no. Resident #8 explained she thought she had Oxycodone, and Resident #8 explained was almost 100% sure she refused every time. When queried to her knowledge, if she had requested a PRN narcotic in September, Resident #8 denied, because didn't want it. Resident #8 explained Staff A had offered resident a PRN, and Resident #8 didn't want it. 6. Review of the MDS assessment for Resident #9 dated 7/10/25 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated intact cognition. Per this assessment, the resident took opioid medication. Review of Resident #9's Care Plan dated 2/3/25 revealed, I use opioid medications related to chronic pain. The Intervention dated 2/3/25 revealed, Administer opioid medication as physician ordered and monitor for side effects.The Physician Order dated 6/23/25 revealed Resident #9 was ordered Hydrocodone Acetaminophen 5-325 mg with directions to administer one tablet by mouth three times a day (scheduled). The resident was also prescribed Hydrocodone Acetaminophen 5-325 with directions to administer one tab by mouth as needed for pain, and could take two times a day as needed for breakthrough pain. Review of the Narcotic Log (Page 50) for Resident #9's Hydrocodone Acetaminophen revealed on 9/6/25, Staff A removed a dose of the resident's medication at 6:40 AM (lowered count to 57), 12:45 PM (lowered count to 56), and 2:20 PM (lowered count to 55). A dosage of the medication was removed at 5:45 PM (lowered count to 55), with no nurse signature present on the log. A different nurse removed a dosage of the medication at 7:15 PM (lowered count to 53). Five doses of the resident's medication were removed from the resident's medication supply on 9/6/25.Review of Resident #9's September 2025 MAR revealed on 9/6/25, Staff A signed out two scheduled doses of the medication, on MAR for AM and Mid, and another nurse signed out the resident's scheduled evening dose. The MAR revealed one PRN dose administered on 9/6/25, administered at 5:41 PM. The MAR revealed on 9/6/25 four doses of the medication were administered to Resident #9. The Investigation Drug Diversion 9-13-25 document revealed Staff A adjusted narcotic starting number and duplicated the orders (would remove multiple pills for the same date/time across different narcotic log pages) for Resident #9. Continued review of the Narcotic Log (Page 50) revealed on 9/11/25, Staff A removed a dose of the medication at 4:15 PM (count lowered to 31), then removed a dose of the medication at 8:15 PM (count lowered to 30), completing the last line on Narcotic Log (Page 50). Staff A began a new Narcotic Log sheet (Page 65), entered removal of a dose on 9/11/25 at 8:15 AM for the second time (as had already been documented on Page 50), and lowered the amount remaining to 29. Staff A next removed a dose at 9:40 PM (count lowered to 28). Review of the resident's September 2025 MAR revealed on 9/11/25, Staff A administered one scheduled dose of the medication at HS (evening), and two PRN doses, one at 4:15 PM and the other at 9:40 PM. Review of Resident #9's MAR dated September 2025 revealed from 9/1/25 to 9/12/25, Staff A documented they administered 16 of 17 doses of PRN Hydrocodone Acetaminophen. Staff A administered two doses of the resident's PRN medication to Resident #9 on 9/2/25, 9/7/25, 9/9/25, 9/10/25, 9/11/25, and 9/12/25. The resident's September 2025 MAR revealed the only times during the month the resident recieved two PRN doses of the medication was when Staff A worked. Resident #9 received three doses total of PRN Hydrocodone Acetaminophen between 9/13/25 and 9/30/25.On 10/9/25 at 12:13 PM, the DON explained the following: The ADON said had talked to Staff A about not taping medications, and had provided education. The DON learned of this on Friday (9/12). The ADON had done a narcotic audit, had noticed some wasting was off in the book, Staff A would waste, indicated was the wrong resident, and an hour later would give the medication. The DON explained she talked with Staff A on Friday, thought Staff A maybe needed some help, and DON asked Staff A what was wrong. The DON explained Staff A responded they got distracted and liked to help the CNAs (Certified Nursing Assistants). Per the DON, she provided education to Staff A about focus on medication pass. The DON explained on Friday night, per Staff H's statement included as part of FRI, Staff A reported she got in trouble for taping/wasting narcotics. The DON explained this information wasn't communicated to the DON until Saturday. On Saturday, Staff F called the DON because he had a taped med. Staff F looked at the pill, punched it out, it looked a lot like Oxycodone, and it was not Oxycodone. Per the DON, Staff F looked it up, and it was Amlodipine. This was for Resident #1. The DON further explained it was identified there was a problem, and the DON interviewed multiple staff who worked Friday and overnight who denied taping medications.The DON explained the ADON had previously talked to Staff A about taping medications. Per the DON, there was only one other person who had been on that cart, which was Staff A. The DON further explained Staff A was suspended related to being suspect in drug diversion, and was terminated due to results of investigation, where in house investigation was founded for drug diversion. The Facility Policy titled Investigating Incident of Theft and/or Misappropriation of Resident Property revised April 2021 revealed, Residents have the right to be free from exploitation, theft and/or misappropriation of personal property.

Based on Facility Reported Incident Investigation, staff interview, narcotic log review, clinical record review, and facility policy review, the facility failed to ensure safeguards were consistently implemented to account for all narcotic medications in the facility and timely identify suspected drug diversion, and failed to ensure completion of narcotic logs per accepted standards of practice for five of nine residents reviewed for pharmacy services (Resident #1, Resident #5, Resident #6, Resident #7, Resident #9). The facility reported a census of 45 residents. Findings include: Review of information included as part of a Facility Reported Incident (FRI) dated 9/13/25 revealed, [Name Redacted] DON (Director of Nursing) was notifed that there is an Oxycodone blister pack that had taped slots. The pill in the taped blister pack slot was inspected and was identified as Amlodipine Besylate (blood pressure medication) 5mg. [Staff A] has documented the narcotic as given in the Narcotic book but at times has not documented it in the MAR (Medication Administration Record). Discrepancy found in the Narcotic book with double documenting of narcotics when continuing the drug to a new page in Narcotic book. Employee interviews lead to determination that the medications were taped when [Staff A] was signed on the cart. Review of a Witness Statement by Staff F, Licensed Practical Nurse (LPN), included as part of the FRI Investigation revealed the following: While passing noon medications on 9/13/25 [Staff F] noticed that [Resident #1's] Oxycodone (narcotic pain medication) 5mg (milligram) blister pack had multiple slots taped. [Staff F] made a comment to the other nurse on staff who also thought this was odd. Upon inspecting the pill in slot 40, [Staff F] noticed that it did not match the other pills in the pack. [Staff F] looked up the pill description and concluded that it was an Amlodipine Besylate (blood pressure medication) 5mg and not an Oxycodone 5mg [Staff F] then inspected the other Blister packs in the Narcotics drawer. [Staff F] found more tape on the back of [Resident #5's] Oxycodone 5mg card, [Staff F] reported this additional finding to the DON. Review of a Witness Statement by Staff C, LPN dated 9/13/25 revealed when queried if noticed any taped narcotics on their cart, responded maybe only one. Review of a Witness Statement by Staff G, LPN dated 9/15/25 revealed, in part, she had noticed taped meds over the last week, and had also noticed narcs (narcotics) were being wasted more frequently by [Staff A].have noticed taped meds over the last week. I also noticed narcs were being waisted <sic> more frequently by [Staff A].Review of a Witness Statement by Staff H, Registered Nurse (RN) dated 9/13/25 revealed, in part, When [Staff H] reported to my shift [Staff H] asked [Staff A] to count. She stated she was not ready to count that she got in trouble for Tapeing <sic> and waisting <sic> narcotics. She was charting in Narc book. On 10/7/25 at 1:45 PM Staff B, LPN queried if had any concerns with narcs (narcotics), and responded not anymore. Staff B explained just kept noticing there was tape on the back of some of the narc now and then, and she was starting to notice. Per Staff A, was kind of starting to figure out who to narrow down to, and she never came across one with tape that she had to give. Staff B explained she didn't bring it up, and waited to see what was going on. Per Staff B, she realized when doing count there was tape on back on the cards, and would throw [person] off sometimes. When queried if reported to the DON, Staff B responded no. Staff B explained she had felt extra tape, and didn't think anything of it. Staff B explained it seemed to be happening more often. Staff B explained was always finding on same side. Staff B explained she narrowed down that staff member worked full time on that side, and seemed to always find on that side. Staff B further explained she didn't know for sure, and if would have known for sure, would have brought something up. On 10/8/25 at 10:08 AM, Staff C, LPN queried if any issues with narcotics, and responded did have some issues, one of the nurses actually. Staff C responded when counted one day, the ADON (Assistant Director of Nursing) mentioned to Staff C there were some taped meds, and said she was going to address it. Staff C explained it was mainly the other cart, and may have been one card on her cart that had tape on it. When queried if she (Staff C) saw tape on a card in her cart, Staff C acknowledged did, and explained she didn't remember whose it was, and thought it was a PRN (as needed) card. When queried if it was a narcotic, Staff C acknowledged it was. When queried when it might have been roughly, Staff C explained she thought probably the Monday or Tuesday before the incident. Per Staff C, the ADON wokrked the over night shift, she filled in for night shift so they counted together in the morning, and the ADON brought up noticed taped meds, and she had said she was going to address with the evening nurse. When queried if proceed with count (narcotic count) with taped one in there, Staff C said yeah thre was one, and was not sure if ADON said something so then they just saw it. When queried if she examined the card, Staff C responded could see there was a pill taped in there, Staff C didn't examine the pill, and it looked the same otherwise would have questioned if looked different. Staff C explained should not tape pills, acknowledged was not normal practice per Staff C, and if got a narc (narcotic) out and someone refused or punched a wrong narc, would find another nurse and destroy it with the other nurse. Staff C explained to destroy, would consign in the book. When queried if prior to incident had training about what to do if taped med, Staff C responded not that she was aware of. Staff C explained there had been training put out that if found a taped med, to notify the DON immediately.On 10/8/25 at 10:37 AM, Staff D, LPN queried if had ever seen narcotics taped. Per Staff D, ADON had noticed, and when ADON pointed it out, Staff D saw it. Per Staff D, the ADON was working either the shift before or after Staff D, and the ADON noticed the tape. When queried if Staff D had noticed it before that point, Staff D responded not really, no. When queried if it had ever come up in counts, Staff D responded no. When queried if she remembered what resident or what drug, Staff D responded they were not one hundred percent, and thought maybe it was Resident #6. When queried if the med with tape had been a narcotic, Staff D acknowledged had been. Per Staff D, could not tape meds, was not allowed, and was not something could do. On 10/8/25 at 1:01 PM, the ADON was queried about narcotic concerns. The ADON explained she wasn't at facility the day Staff F found something in the narcotic card, and the ADON explained she had worked a Thursday before had occurred, and had stayed over to work the night shift due to had one to one (resident requiring one to one monitoring). The ADON explained she heard through the grapevine that Staff A had taped a narcotic in a narcotic card, that she had taped it back. Per the ADON, Staff A happened to be there that night when came in, and ADON sat down and talked to Staff A and said not under any circumstances tape meds back in. Per the ADON, Staff A said ok, and asked to waste them? The ADON explained yes, if pull med and don't give, waste it.When queried about how she learned about the alleged taping, the ADON explained she thought she heard someone talking about it, like nurses, and asked them, said it was Staff A. That's when the ADON went to Staff A. The ADON explained she heard from staff that Staff A had taped something. When queried if she looked at the card, the ADON responded at that point, nothing was taped. The ADON explained she had asked the nurse that was on the cart, and the nurse on the cart told the ADON there were no meds taped. The ADON explained they did not visually look at the cards. Per the ADON, when she spoke to Staff A, Staff A admitted she was taping, and won't do anymore. When queried if Staff A provided explanation to why did that, the ADON responded no. When queried if there was written documentation (regarding tape conversation), the ADON responded no. When queried as to the resident name or drug name for alleged drug, the ADON unaware. When queried which medication cart was affected, the ADON was unsure. On 10/9/25 at 1:13 PM, Staff F explained when he went to give Resident #1's noon dose of Oxycodone, the card had tape on the back of it and a pill taped back in. Staff F explained were a bunch of different slots with tape on them. Staff F explained the resident's AM dose of the medication also had tape on it, at first Staff F thought maybe somebody accidently popped it while popping the previous one, and when came across the second dose taped, said this is not a one off thing. Per Staff F, it was weird. Staff F described the tape as like scotch tape. Staff F described bubbles on the card that were empty, something previously adminsitered, with tape still on the card. When queried if appropriate to tape cards, and if could tape cards, Staff F responded no, not supposed to was his understanding and that was the general rule. On 10/9/25 at 3:07 PM, Staff H, Registered Nurse (RN) explained the following. Staff H went in and worked the night shift, counted with Staff A, and with her count was correct. When Staff H came in, Staff A said she was working on the book (narcotic book). Staff H explained didn't know what was meant by working on the book. Per Staff H, Staff A said she (Staff A) had got in trouble for putting back in and taping up too many drugs, and had been talked to about it. During the interview on 10/9/25 at 3:07 PM, Staff H explained that was a big no no. On 10/13/25 at 9:57 AM, the DON explained she had heard about taping from the ADON. When queried if she should have been notified if staff noticed taping prior to the education or oingoing, the DON responded yes, [facility] knew didn't do that, would be concern, problem and needed education.On 10/13/25 at 12:08 PM, the Pharmacist queried if ever appropriate for tape on the back of a narcotic medication pack. The Pharmacist responded if needed to take out and put in, it wouldn't be good practice to do that, definitely for a control, and responded it was a grey area. 1.Review of Narcotic Logs for Resident #1 revealed on 9/1/25, Staff A pulled the following Oxycodone 5mg from the resident's narcotic card in the following order: Staff A removed one pill at 7:10 PM, which lowered the medication count to 26. Then, Staff A documented removed one pill at 5:50 PM, destroyed it, then removed another pill at 7:10 PM and lowered the narcotic count of medications remaining again. Two doses had been removed for the same date and time, documented on two separate lines of the Narcotic Logs. Continued review of the Narcotic Log (Page 47) revealed time documentation on the pill removed at 7:10 PM appeared to have been altered, as well as for a dose removed on 9/4/25 at 9:40 PM. The line of the log dated 9/7/25 at 10:20 AM revealed a previous time entry had been scribbed out, with a new time entry written.On 10/9/25 at 3:50 PM, the MDS Coordinator explained for narcotics she would go off the MAR (Medication Administration Record), triple check it, always also look to see when last got it, and if got PRN an hour ago don't want to turn around and give another. When given an example about non-chronological documentation of times, the MDS Coordinator responded that did not make sense, and should sign out when give it. 2. Review of the Physician Order dated 7/25/25 revealed Resident #5 could receive 1 tablet of Oxycodone 5mg by mouth twice daily as needed, and the additional order active 8/15/25 to 9/12/25 revealed, Oxycodone Hcl Oral Tablet 5mg with instructions to give 5mg by mouth three times a day for pain. Review of the Narcotic Log shown below revealed 6 pills of the medication removed for the day, although removal of five pills per day was ordered. Review of the resident's Narcotic Log Page 49 for Oxycodone 5mg revealed on 9/4/25, the resident had received doses of the medication at 7:23 AM, and at 12:22 PM by a different nurse.Continued review of Narcotic Log (Page 49) revealed Staff A removed one tablet of the medication from the resident's medication card at 2:35 PM (count lowered to 49), at 4:30 PM (count lowered to 48), at 7 PM (count lowered to 47), and at 9:30 PM (count lowered to 46). Review of the resident's MAR dated 9/2025 revealed Staff A signed out 4 doses of the PRN medication and one dose of scheduled Oxycodone, although the resident only prescribed two PRN doses daily. Staff A signed the PRN doses on the MAR at 2:33 PM, 2:35 PM, 7:00 PM, and 9:34 PM, which differed from the Narcotic Log page 49. 3. Review of the MDS dated [DATE] for Resident #6 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated intact cognition. Per this assessment, the resident took opioid medication. The Physician Order dated 8/18/25 revealed Oxycodone Hcl Oral Tablet 5mg with directions to give one tablet by mouth three times a day for pain. The Physician Order dated 8/20/25 revealed Oxycodone Hcl Oral Tablet 5 mg with directions to give one tablet orally every 12 hours as needed for pain May take PRN with the scheduled dose. Review of the Investigation Drug Diversion 9-13-25 provided by the facility revealed Resident #6's Oxycodone dated 9/9/25 at 3:25 PM was not documented on the resident's MAR.Review of Narcotic Log (Page 51) revealed Staff A removed a tablet of the medication on 9/9/25 at 3:25 PM, and removed another tablet of the medication on 9/9/25 at 7:20 PM. Resident #6's MAR dated 9/6/25 revealed Staff A documented she administered only the resident's scheduled HS (evening) Oxycodone 5mg dose that day, with no PRN doses given by Staff A.4. Review of the Narcotic Log Page 28 for Resident #7's Hydrocodone/APAP (Acetaminophen) 5/325 mg revealed on the last line of the narcotic record, dated 9/10/25 at 8:45 PM, Staff A had removed one pill, which dropped the medication count to 26 pills remaining. Review of the Narcotic Log Page 64 revealed for the first line on the new log, Staff A again charted the same date and time (9/10/25 at 8:45 PM), and dropped the medication count by one pill, which brought the amount remaining to 25 pills. The Narcotic Log Page 28 and Page 64 revealed two pills had been removed for one date and time. Continued review of Narcotic Log Page 64 revealed the following occurred on 9/11/25: Staff A signed out one dose of the medication at 2:45 PM (count lowered to 24), removed another pill at 9:00 PM (count lowered to 23), then charted removed a dose on 9/11/25 at 3:00 PM (count lowered to 22).5. Review of the MDS assessment for Resident #9 dated 7/10/25 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated intact cognition. Per this assessment, the resident took opioid medication. The Physician Order dated 6/23/25 revealed Resident #9 was ordered Hydrocodone Acetaminophen 5-325 mg with directions to administer one tablet by mouth three times a day (scheduled). The resident was also prescribed Hydrocodone Acetaminophen 5-325 with directions to administer one tab by mouth as needed for pain, and could take two times a day as needed for breakthrough pain. Review of the Narcotic Log (Page 50) for Resident #9's Hydrocodone Acetaminophen revealed on 9/6/25, Staff A removed a dose of the resident's medication at 6:40 AM (lowered count to 57), 12:45 PM (lowered count to 56), and 2:20 PM (lowered count to 55). A dosage of the medication was removed at 5:45 PM (lowered count to 55), with no nurse signature present on the log. A different nurse removed a dosage of the medication at 7:15 PM (lowered count to 53). Five doses of the resident's medication were removed from the resident's medication supply on 9/6/25.Review of Resident #9's September 2025 MAR revealed on 9/6/25, Staff A signed out two scheduled doses of the medication, on MAR for AM and Mid, and another nurse signed out the resident's scheduled evening dose. The MAR revealed one PRN dose administered on 9/6/25, administered at 5:41 PM. The MAR revealed on 9/6/25 four doses of the medication were administered to Resident #9. Review of a Policy document from the pharmacy dated 2/2023 revealed, Each schedule II medication at the facilty shall be recorded on two forms .Controlled Drug Receipt/Proof of Use/Disposition form. The total quantity received from pharmacy and all subsequent doses administered to the resident will be recorded on the Controlled Drug Receipt/Proof of Use/Disposition Form. Every time a dose is given, the Nursing Staff/CMA (Certified Medication Aide) will enter the date and time, dose given, the Nursing Staff/CMA's signature/initial, and the balance remaining in the container .Document in the eMAR (electronic medication administration record) or paper MAR (so your MAR form and Controlled Drug Receipt/Proof of Use/Disposition form show the same information).

Based on observations, interviews, and record review, the facility failed to ensure one resident (R)138) in the sample of 16, legs were elevated when seated in a wheelchair or in bed, per the physician's orders. The facility's deficient practice increased R138's risk of increased edema in his legs, skin breakdown and discomfort. Findings include: Review of R138's undated ADMISSION RECORD provided by the Director of Nursing (DON) revealed admitted [DATE] with multiple diagnoses to include cellulitis to the left lower limb, non-pressure chronic ulcer of other part of left lower leg, and acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity. Review of R138's Physician's Orders under Orders tab located on her Electronic Medical Record (EMR) revealed, .Elevate legs when sitting . dated 02/17/23. Review of R138's Treatment Administration Record (TAR) 02/23 under Orders tab located in the EMR revealed, .Elevate legs when sitting every shift -Start Date-02/17/2023 . -Hold Date from 02/19/2023 .to 02/19/2023 . with staff initials entered on day, evening, and night for 02/19/23-02/23/23, indicating the order was followed. Review of R138 's comprehensive Care Plan under Care Plan tab located on his EMR revealed, .venous wounds to right and left lower extremities. I have diagnosis of cellulitis, am obese, and limited mobility . please see TAR Date Initiated: 02/20/2023 . During an observation on 02/20/23 at 1:48 PM R138 was sitting in a wheelchair in his room. R138's legs were not elevated. During an observation on 02/20/23 at 1:52 PM R138 requested assistance to bed to have his legs elevated from the facility staff. LPN 1 stated to R138 that he needed to stay up in his wheelchair until physical therapy arrived in his room to conduct an evaluation. R138's legs were not elevated while seated in the wheelchair. During an observation on 02/23/23 at 8:40 AM, R138 was sitting on his wheelchair in the day area of the facility. R138's legs were not elevated while seated in the wheelchair. During a phone interview on 02/23/23 at 10:42 AM Physician (DR) 2 stated he ordered R 138's legs to be elevated on 02/17/23. DR 2 stated R138 was morbidity obese and did not walk around. During an observation and interview on 02/23/23 at 12:12 PM, R138 was seated in a wheelchair and his feet were on the floor, legs and feet swollen and not elevated per physician's order. Certified Nurse Aide (CNA) 6 stated at this time that R138's feet were tender; his legs were purplish/red/pink and very swollen. CNA 6 stated it was nursing assistants' responsibility to elevate resident's legs. Review of R138's Kardex, CNA 6 verified R138's Kardex did not include information regarding elevating his legs while sitting. CNA6 stated that she was unaware his legs needed to be elevated while he was sitting up. CNA 6 stated the wheelchair R138 was seated in did not have the ability to elevate his legs. CNA 6 stated that staff kept R138's legs elevated when his was in bed by elevating the lower part of his bed. During an observation on 02/23/23 at 1:43 AM, R138 was seated in his wheelchair and his legs were not elevated. During an interview on 02/23/23 at 1:47 PM, Licensed Practical Nurse (LPN) 1 stated R138 was admitted to the facility with cellulitis. LPN1 stated the nurse was responsible for ensuring R138's legs were elevated when seated in his wheelchair LPN 1 stated the order to elevate his legs was on R138's TAR. LPN 1 stated R138's wheelchair, he was using earlier that morning, did not have the capabilities to elevate his legs. LPN1 stated the facility did not have footrest for that wheelchair. LPN1 stated the staff should have assisted R138 to bed or find a stool or something to elevate his legs when he was seated in the wheelchair. During an interview on 02/23/23 at 6:41 PM, the DON stated she expected the staff to elevate R138's legs per physician's orders. The DON stated the nursing staff were to ensure the CNAs elevated R138's legs when he was seated in the wheelchair. The DON verified that the care plan indicated to see the TAR.

Based on observation, interview, record review, and policy review, the facility failed to implement weight loss interventions for one (Resident (R)4) of two residents reviewed for nutrition in a total sample of 16 residents. Findings include: Review of the facility's policy titled, Nutrition (Impaired)/Unplanned Weight Loss or Gain, revised 09/17, revealed 1. Residents/patients will maintain acceptable nutritional status unless unavoidable due to underlying medical conditions or personal preferences. 2. Interventions for weight gain, anorexia, and weight loss will take into account resident/ patient goals and wishes. 3. Causes of undesirable weight gain and loss will be identified and managed appropriately. Review of R4's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD), date of 02/08/23, and located in the MDS tab of the electronic medical record (EMR), revealed R4 was admitted on [DATE], had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R4 was cognitively intact, was independent with eating, had weight loss, and was not on a physician-prescribed weight-loss regimen. Review of R4's care plan dated 05/23/22 located in the EMR under the Care Plan tab revealed a focus area I have been provided with a diet order for regular, regular texture, thin liquid diet, a goal I will follow my diet as ordered, and interventions I have expressed that I would like to lose weight and Provide me with [NAME] [nutrition intervention protocol] as ordered. Review of R4's 01/04/23 diet order located in the EMR under the Orders tab revealed Regular/NAS [no added salt] diet, Level 7 Regular texture, Level 0 Thin consistency, B [breakfast]-fortified Hot Cereal, L [lunch]-Magic Cup [protein/calorie dense dessert], D [dinner]-Cottage Cheese. Review of R4's 02/06/23 Nutritional assessment dated [DATE] located in the EMR under the Assessment tab revealed .3. Details of weight change -20 lbs. [pounds] (12%) x 90 days, sig [significant] wt [weight] loss .Diet: reg [regular] diet, reg texture, thin liquids Supplements: none. [NAME]: B - fortified hot cereal, double protein L - magic cup D - cottage cheese Eats: <75% with 7 meal refusals during the past 2 wks [weeks]. Review of R4's weight history located in the EMR under the Vitals/Weight tab revealed a 26.2-pound (15%) weight loss in four months: On 02/16/23 at 145.2 lbs. On 02/09/23 at 146.0 lbs. On 02/02/23 at 143.5 lbs. On 01/26/23 at 144.0 lbs. On 01/16/23 at 145.0 lbs. On 01/12/23 at 147.0 lbs. On 01/05/23 at 146.5 lbs. On 12/29/22 at 156.0 lbs. On 12/22/22 at 151.0 lbs. On 12/15/22 at 157.0 lbs On 12/08/22 at 156.0 lbs On 12/01/22 at 159.0 lbs On 11/24/22 at 162.5 lbs On 11/17/22 at 157.2 lbs On 11/03/22 at 164.0 lbs On 10/27/22 at 171.0 lbs On 10/23/22 at 171.4 lbs Review of R4's percentage of amount eaten for 01/24/23 through 02/22/23, located in the EMR under the Task tab, revealed R4 consumed 71% of her meals at 50% or less, including refusals (60 of 84 meals at 0-50%). On 02/21/23 at 12:35 PM, R4's lunch tray consisted of Dorito chicken, Spanish rice, carrots, and bread. R4 was not served the gelatin per the menu or a Magic Cup per her diet order. No diet card was on the tray. R4 consumed 25% of her meal. During an interview on 02/21/23 at 12:39 PM, Licensed Practical Nurse (LPN)3, was asked if there was no diet card or ticket on the tray, how did she know what diets residents were supposed to get. She stated she referred to the Kardex (brief overview of information). On 02/22/23 at 12:40 PM, R4's lunch tray was observed on the hall cart heading to R4's room. No Magic Cup was on her tray as indicated in the diet order. On 02/22/23 at 12:43 PM, dietary staff (DS)1 was observed assembling the lunch trays on the tray line and was asked should R4 have received a Magic Cup as there wasn't one on her tray. DA1 checked the [NAME] list taped to the counter and stated she overlooked it and would get her one. On 02/22/23 at 1:05 PM, R4's lunch tray was served with chicken fried steak, mashed potatoes, corn, and bread as per the menu. R4 had consumed about 50% of her meal. No Magic Cup was noted on her tray. R4 was asked if she was aware she had lost weight and she said yes she'd been cutting back. R4 confirmed she doesn't get Magic Cups. R4 stated if it's like ice cream she would love to have a Magic Cup. On 02/22/23 at 6:00 PM, R4's dinner tray was observed served in her room. Her meal tray consisted of peaches, bread, salad, and goulash as per the menu. No Cottage Cheese was noted to be included on her tray per the diet order On 02/22/23 at 6:02 PM, CNA7 was observed passing hall trays. CNA7 was asked how she knew residents received the correct diet. CNA7 stated she knew the residents and what diets they get such as pureed, ground, or regular. CNA7 asked if R4 should have received cottage cheese and CNA7 stated she didn't know. On 02/22/23 at 6:04 PM, DS2 was asked if R4 should have received cottage cheese. DS2 stated her resident list didn't include cottage cheese but she would check. DA2 then went into the kitchen and a few minutes later DS2 came out with a dish of cottage cheese. DS2 confirmed R4 was supposed to get cottage cheese and took it down the hall to R4's room. During an interview on 02/23/23 at 8:48 AM, MDS Coordinator (MDSC) and Director of Nurse (DON) were asked about R4's weight loss of 15% since 10/22. MDSC stated she was aware of R4's weight loss and that R4 expressed to the Registered Dietitian (RD) her desire to lose weight. MDSC and DON stated the RD had interventions in place for R4. MDSC was asked what was R4's goal weight and her weight loss plan.? DON stated R4's weight loss was also due to edema in her lower legs and R4 was on Lasix (diuretic medication). MDSC was asked why it wasn't care planned for a planned weight loss and not documented about the effects the Lasix may be having on R4's weight. DON was asked if it was okay for Lasix to cause 15% of weight loss in four months. DON stated, 'No. The surveyor informed the DON that three meals were observed when R4 didn't receive her fortified items. DON was asked if R4 wanted to lose weight, why is her diet fortified. The DON stated it was for the protein. During a telephone interview on 02/23/23 at 1:36 PM, the RD was asked about R4's weight loss and she stated she was aware. RD stated R4 was on several nutrition interventions. The RD stated R4 was on the [NAME] that included additional items with her meals. R4 received cottage cheese at dinner, double protein and fortified hot cereal at breakfast and ice cream at lunch. RD stated R4 was at her goal weight now, Body Mass Index of 23.4, however, she wasn't aware R4 wanted to lose weight. RD agreed it wouldn't be appropriate for R4 to be managing her weight loss and it should be care planned.

Based on observations, interviews, record review and review of the facility's policy, the facility failed to ensure, one resident (R136) of three sampled residents for respiratory care, oxygen was administered per physician's prescribed flow rate of 2 liters per minute. The facility's deficient practice increased R136 risk of respiratory complications including elevated serum carbon dioxide. Findings include: Review of the facility's policy titled Oxygen Administration 10/10 provided by the Administrator revealed The purpose of this procedure is to provide guidelines for safe oxygen administration Adjust the oxygen delivery device so that .the proper flow of oxygen is being administered . Review of R136's undated ADMISSION RECORD provided by the Director of Nursing (DON) revealed admitted d of 02/15/23 with diagnosis chronic obstructive pulmonary disease. Review of R136's Physician's Orders under Orders tab located on her Electronic Medical Record (EMR) revealed . Oxygen continuously at 2 LPM [liters per minute] per nasal cannula . dated 2/15/23. Review of R136's Treatment Administration Record (TAR) dated 02/23 under Orders tab located in the EMR revealed . Oxygen continuously at 2 LPM per nasal cannula ., 2/15/23 with staff initials entered for AM [morning] from 02/16/23-02/21/23 MID [midday] 02/17/23-02/21/23 and HS [bedtime] from 02/15/23-02/17/23, -2/19/23-02/20/23. Review of R136's comprehensive Care Plan under Care Plan tab located on his EMR revealed .oxygen therapy related to congestive heart failure .Administer my oxygen as ordered . dated 02/16/23. During an observation on 02/20/23 at 1:25 PM, R136's oxygen was administered at a flow rate of 2.5 liters per minute. During an observation on 02/21/23 at 3:10 PM, R136's oxygen was administered at a flow rate of 3 liters per minute. During an observation on 02/22/23 at 8:27 AM, R136's oxygen was administered at a flow rate of 3 liters per minute. During an observation and interview on 02/22/23 at 9:23 AM, Licensed Practical Nurse (LPN)1 confirmed R136's oxygen was administered at a flow rate of 3 liters per minute. LPN 1 stated nursing staff were responsible for ensuring R136's oxygen was administered at the prescribed flow rate daily and documenting on his MAR. LPN 1 stated R136's oxygen flow rate was ordered for 2 liters per minute. During an interview on 02/23/23 at 1:07 PM, the Physician (DR)1 stated she expected the facility staff to follow R136's physician's orders for his flow rate of oxygen. DR1 stated the importance of his oxygen flow rate order was to ensure he did not develop carbon dioxide retention.

Based on observation, record review, interviews, and policy review, the facility failed to ensure the physician clarified orders for a resident's gallbladder tube [A thin tube is placed into the gallbladder that drains blocked and infected gallbladder fluid.], urostomy [surgical procedure that creates a stoma (artificial opening) for the urinary system.] or CPAP [continuous positive airway pressure machine used for treatment of sleep apnea] settings for one resident (R) 136) out of 16 sampled residents. The facility's deficient practice increased R136's risk of respiratory, urinary and gallbladder complications. Findings include: Review of the facility's policy titled Physician Services 02/21 provided by the Administrator revealed The medical care of each resident is supervised by a licensed physician .orders for the resident's immediate care and needs can be provided by physician .nurse practitioner (NP) .Supervising the medical care of residents includes .prescribing medications and therapy . Review of the facility's policy titled Ureterostomy Care provided by the Administrator revealed, .The purposes of this procedure are to promote cleanliness and to protect peristomal skin from irritation, breakdown and infection .Review the resident's care plan to assess for any special needs of the resident .the type of the appliance . Review of R136's undated ADMISSION RECORD provided by the Director of Nursing (DON) revealed admission on 02/15/23 with multiple diagnoses to include spina Biffa, chronic obstructive pulmonary disease, and type 2 diabetes. Review of R136's Physician's Orders dated 02/23 under Orders tab located on her Electronic Medical Record (EMR) revealed the following: a.urostomy every evening shift every 5 day(s) related to URINARY TRACT INFECTION, SITE NOT SPECIFIED SEPSIS, UNSPECIFIED ORGANISM dated 02/15/23 R136's physician order failed to identify the type of appliance, changing the pouch system, emptying the pouch or the urinary collection bag, protecting the skin around the stoma, recording the output, monitoring for complications or what to do every five days. b.Gall bladder drain every morning and at bedtime drain gallbladder drain until no drainage medical group manages dated 02/15/23 . R136's physician order failed to identify flushing the drain, recording the output, monitoring insertion site, monitoring the drain for displacement or dislodgement, monitoring for complications, and changing the dressing around the insertion site with frequency and directions. c.CPAP nightly per home settings one time a dated 02/20/23. R136's physician order failed to identify the CPAP settings. Review of R136's Treatment Administration Record (TAR) dated 02/23 under Orders tab located on his EMR revealed the following: a.urostomy every evening shift every 5 day(s) dated 02/15/23 . with staff's initials entered on 02/15/23 and 02/20/23. b.Gall bladder drain every morning and at bedtime drain gallbladder drain until no drainage Dr. Brown at [NAME] medical group manages dated 02/15/23 with staff's initials entered for 02/16/23-02/21/23 for AM [morning] and staff's initials entered for 02/15/23- 02/20/23 (excluding 02/18/23) for HS [bedtime], indicating R136's drain was emptied. c.CPAP nightly per home settings one time a day dated 02/20/23 , indicating the patient-specific settings were not included. Review of R136's comprehensive Care Plan under Care Plan tab located on his EMR revealed the following: a.urostomy for urine drainage .02/15/23 .assess .signs/symptoms that my ostomy is not functioning properly .02/15/23 observe .skin daily for irritation and redness ., indication no intervention for type of urostomy pouch appliance, changing the appliance, monitoring the stoma site, emptying the drainage, changing the drainage collection bag or monitoring the output of urine. b.surgical incision on right abdomen related to gallbladder drain. Date Initiated: 02/16/23 .Monitor for changes in my skin status that may indicate worsening of my surgical incision/wound and notify the doctor ., indicating there was no intervention for dislodgement, displacement, changing dressing around his insertion site, or emptying his drain and monitoring output of his drain. c.wear a CPAP nightly per home settings .02/20/23 ., without specific intervention for CPAP machine settings. Review of R136's Progress Notes dated 02/15/23 provided by the DON revealed .Patient has a ileal conduit, urostomy bag that is changed every 5 days as needed .Patient has a gallbladder drain since 01/12 that is drained twice a day .Patient uses .Bipap [Bilevel positive airway pressure] at night .ASSESSMENT AND PLAN .COPD .Bipap nightly .History of cholecystectomy .drain to be flushed .Urinary diversion site .urostomy bag to be changed every 5 days and as needed . electronically signed by NP on 02/20/23. During an observation on 02/20/23 at 11:38 AM with Licensed Practical Nurse (LPN) 1 of R136 sitting on wheelchair in his room. R136 stated he had a urostomy. R136's drainage tube was connected to a urinary collection bag under his wheelchair. R136 stated he had a gallbladder drain During an interview on 02/22/23 at 11:47 AM, the Nurse Practitioner (NP) stated that she and the physician wrote R136's orders for R136's care. NP verified R136's gallbladder tube orders were incomplete. NP stated flushing the drain, cleaning the port prior to flushing, changing insertion site dressing, monitoring form complications should be included on his orders. NP stated her expectation for the facility clinical staff was to call the provider for orders if the resident's gallbladder tube was dislodged or blocked. NP verified R136's CPAP orders did not include the setting and should have specific settings. NP stated the doctor and NP signed off and reviewed the resident's physician's orders monthly. NP verified R136's orders for his urostomy tube were incomplete and did not include changing the dressing at the insertion site, monitoring for complications, and emptying the drain. NP stated she was unsure why his physicians' orders were not completed. During an interview on 02/22/23 12:19 PM the DON verified R136's physician's orders were incomplete for his biliary tube and should include orders for assessing the insertion site, changing the dressing around the insertion site, and assessing and monitoring for complications of gallbladder/biliary tube including dislodgement and blockage of the tube. The DON verified R136's CPAP orders and urostomy tube orders were incomplete. During an interview on 02/23/23 at 01:07 PM, Physician (DR)1 stated she provided care for R136, however, had not seen the resident at the facility since his admission DR1 stated her NP had seen R136. DR 1 stated R136's physician's orders were incomplete for his urostomy, CPAP and his gallbladder tube. DR 1 stated R136's CPAP orders should include the specific settings for his CPAP machine and the facility staff should clarify his home settings with the office that performed his sleep study and prescribed his CPAP machine. DR1 stated R136's gallbladder drain order should include the correct type of tube he had, with an order to document the output of his drain, change his insertion site dressing and assess and monitor (displacement or dislodged tube) and his insertion site. DR1 stated R136's gallbladder tube orders should have been clarified by the facility staff. DR1 stated R136's urostomy tube were incomplete and should include monitor and assess his insertion site, and his output, change his bag instructions (including leakage from bag), care for insertion site including cleaning was incomplete. DR1 stated she assumed the staff at the facility would clarify the orders with the discharging hospital on admission to the facility.

Based on observation, interview, record review, and policy review, the facility failed to ensure the appropriate use of antibiotic therapy for one (Resident (R)24) of five residents reviewed for unnecessary medications in a total sample of 16 residents. Findings include: Review of the facility's policy titled Urinary Tract Infections/Bacteriuria, revised 09/17, revealed 1. The staff and physicians shall accurately identify UTIs [Urinary Tract Infections] and differentiate true infections from bacteriuria 3. The facility shall follow practices that are consistent with reliable evidence about bacteriuria and UTIs.Nurses should observe, document, and report signs and symptoms (for example, fever or hematuria) in detail and avoid premature diagnostic conclusions .New onset of nonspecific or general symptoms alone (change in mental status, decline in appetite, etc.) is not enough to diagnose a UTI. Urine odor, color and clarity also are not adequate to indicate bacteriuria or a UTI .8. The physician should consider stopping or reducing doses of antibiotics or switching parenteral to oral antibiotics in individuals with uncomplicated UTIs who have been afebrile and asymptomatic for at least 48 hours. Review of the facility's protocol titled McGeer Criteria: Antibiotic Prescribing for Urinary Tract infections, dated 2012, revealed Without Urinary Catheter Criteria I and 2 must be Present: l. At least one of the following: Acute dysuria or acute pain, swelling, or acute tenderness of the testes, epididymis, or prostate. Fever or leukocytosis And at least one of the following subcriteria: Acute costovertebral angle/pain/tenderness Suprapubic pain Gross hematuria New or marked increase in incontinence. New or marked increase in urgency. New or marked increase in frequency Suprapubic pain Gross hematuria New or marked increase in incontinence. New or marked increase in urgency. New or marked increase in frequency. 2. One of the following: At least 10 3 cfu [colony-forming units]/mL [milliliter] of no more than two species of microorganisms in voided urine sample At least 10 2 cfu/mL of any number of organisms in a specimen collected by in-and-out catheter. Review of R24's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD), date of 01/18/23, and located in the MDS tab of the electronic medical record (EMR), revealed R24 was admitted on [DATE], had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R24 was moderately impaired in cognition, required limited assistance for toileting, and was frequently incontinent of urine. Review of R24's care plan dated 02/17/23 located in the EMR under the Care Plan tab revealed I am on antibiotic therapy Keflex [antibiotic medication] related to UTI. Review of R24's Physician Orders dated 02/15/23 located in the Orders tab of the EMR, revealed an order for Keflex Oral Capsule 500 MG [milligram] (Cephalexin), Give 1 capsule by mouth three times a day for UTI for 7 Days AND Give 1 capsule by mouth one time only for UTI until 02/15/2023. Review of R24's Nurses Note dated 02/12/23 located in the Progress Note tab of the EMR, revealed Res [resident] urine has foul smelling odor noted. Urine is cloudy and Res is having increased incontinence, then denying staff to change brief. Physician [DR2]) messaged to make aware and request new orders. Res is afebrile. Temp [temperature] 97.8. Res denies pain or discomfort with urination. Will continue to monitor. Review of R24's Focused Evaluation Note dated 02/15/23 located in the Progress Note tab of the EMR, revealed Antibiotic Use Urinary tract infection Initial dose of ATB [antibiotic] given as ordered for UTI. Res. denies any pain or disc. [discomfort] or dysuria. Res. is incont. [incontinent] of urine and difficult to do Peri-cares at times. Much encouragement at those times and res. will be cooperative. Review of R24's communication note from the Patient portal provided by Licensed Practical Nurse (LPN)2, dated 02/14/23, revealed Fax [facsimile] sent on 2/12/2023-Resident's urine has foul smell and is cloudy. Resident denies pain/discomfort with urination. Resident having increased incontinence and refused to be toileted/changed. Resident remains afebrile. Temp 97.8. Any new orders? .DR2 2/14/2023 (17 hours ago) Medication allergies reviewed by Dr. Start keflex 500 mg tid [three times daily] x 7 days for UTI. Interview on 02/21/23 at 9:14 AM, R24 stated she wasn't in any pain or discomfort. During an interview on 02/21/23 at 2:41 PM, LPN2 was asked about R24's urinalysis results. LPN2 stated she was unable to find a urinalysis. LPN2 then checked online and found a communication note in the Patient Portal. LPN 2 confirmed there was no UA [urinary analysis] performed. During an interview on 02/22/23 at 5:21 PM, the Assistant Director of Nurses (ADON), was asked about R24's antibiotic prescribed for a UTI and that no UA was performed. ADON stated R24 had been on Bactrim [antibiotic] in 10/22 due to a UTI. So, when R24's urine had a foul smell, the doctor felt it necessary to prescribe another antibiotic. ADON was asked about antibiotics prescribed without a UA and asked about the facility's policy revealed urine color/odor/clarity didn't necessarily mean a UTI. The ADON stated R24's UTI was not counted as an infection and not added to their tracking/trending due to there being no evidence of a UTI from a UA. During an interview on 02/22/23 at 5:37 PM, the DON was asked about R24's prescribed antibiotic for a UTI without a UA or other confirmation. The DON stated R24's use of the antibiotic didn't meet the McGeer criteria for infection, however, the physician wanted R24 to be on it. The DON confirmed DR2 did not order a UA to confirm it. The DON stated they can make recommendations to the doctors but if they prescribe the antibiotic, they must follow the order. The DON agreed her staff could document their discussions with the physicians if an antibiotic was prescribed without evidence and the physician still insisted the antibiotic be ordered. During a telephone interview on 02/23/23 at 10:30 AM, DR2 was asked about what the facility staff told him about R24's UTI symptoms. DR2 stated he knew R24 had dementia and was incontinent. DR2 stated R24's symptoms did include increased incontinence and increased urinary frequency. When DR2 was asked what criteria he used in prescribing an antibiotic. He stated he couldn't use a criteria in patients with dementia and incontinent of urine. DR2 went on to say he didn't order a UA due to the urine culture would be multiflora because that's what happens when the staff use a hat to collect the urine. DR2 stated he wants to use the antibiotic stewardship program, but it didn't cover patients who were incontinent and had dementia. DR2 stated due to R24's incontinence and dementia, he made a judgement call to not ordered a UA because of the possibility of contamination due to urinary incontinence and dementia as even a clean catch would still be contaminated and it would be hard on R24 to straight catheterize her. MR2 stated R24 had a history of UTIs and incontinence. During an interview on 02/23/23 at 1:48 PM, LPN 1 was asked how they would know if R24's urine was cloudy if R24 was incontinent and wore a brief. LPN 1 stated that R24 does toilet and a sample could be collected.

Based on observation, interview, clinical record review, and facility policy review the facility failed to maintain a safe environment free from resident sexual abuse, verbal abuse, and physical abuse from residents at the facility when Resident #5 touched the breast of Resident #1 and Resident #7, made sexual comments to Resident #6, physically touched Resident #2, and Resident #5 was hit by Resident #8. Resident #1 stated the fact that Resident #5 had touched her breast made her feel like she wanted to kill him (Resident #5), and stated Resident #5 had made ongoing physical attempts to reach out and touch her breast. During a confidential interview an anonymous Resident expressed concern of having her door open with her bottom exposed at night for fear of attempted physical contact. Resident #6 expressed anger related to sexual comments that had been made, and expressed threats of violence towards Resident #5 if the resident did not shut their mouth. Resident #8 stated Resident #5 had made sexual comments to another resident. Resident #8 explained he felt like he wanted to get in a fight with Resident #5. This resulted in an Immediate Jeopardy when actual severe psychosocial harm occurred for residents who resided at the facility. The facility reported a census of 36 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment for Resident #5 dated 6/29/22 revealed the resident had been rarely to never understood. Per this assessment, Resident #5 had severely impaired cognitive skills for daily decision making. Resident #5 had verbal behavior symptoms towards others which occurred daily. The Care Plan dated 9/2/22 documented, I display socially inappropriate/disruptive behavior. I sometimes display sexually inappropriate behaviors.Interventions dated 9/2/22 included the following: a. I will be placed at a table by myself for meals. b. Activities staff to visit with me and provide diversional activities. c. Administer my behavior medications as ordered by physician. d. Encourage my family/responsible party to visit. e. Monitor and document my behavior. f. Praise me for demonstrating desired behavior. g. Remove me from public area's when behavior is disruptive and unacceptable. h. Talk with me in a calm voice when my behavior is disruptive. Interventions dated 10/27/22 included the following: a. I am receiving psych services. b. I will be having a medication review with my doctor. The Care Plan dated 9/15/22 documented, I have a behavior problem, I yell and repeat things frequently. Interventions per the Care Plan documented the following: a. Date initiated 8/16/22: Divert my attention. Remove me from situations as needed and take me to an alternate location as needed. b. Date initiated 9/8/22: I may need to be reminded to keep my hands to myself. c. Date initiated 8/16/22: Intervene as necessary to protect the rights and safety of others. Progress Notes for Resident #5 documented the following: The Orders-Administration Note dated 7/27/22 at 10:04 PM documented, Resident being sexually inappropriate. The Orders-Administration Note dated 7/30/22 at 11:44 PM documented, Resident was being sexually inappropriate today. The Orders-Administration Note dated 8/2/22 at 10:06 PM documented, Sexually inappropriate behaviors. The Orders-Administration Note dated 8/4/22 at 10:07 PM documented, Resident continues to struggle with keeping his hands to himself. Grabbing at both staff and other residents. The Orders-Administration Note dated 8/8/2022 at 11:17 PM documented, Resident continues to be difficult to keep from touching others. The Care Plan Conference Summary dated 8/9/22 at 3:30 PM documented, reviewed care plan for nursing, dietary, social work and activities. Resident's son was notified that resident has been having inappropriate behaviors. Resident's son stated that he would approve a psych consult and to keep him updated. The Einteract Summary dated 8/10/22 at 12:52 PM documented, in part, physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Send to ED for psych/behavioral evaluation .C. New Intervention Orders: a.Other b. redirection. Review of the SNF/NF (Skilled Nursing Facility/Nursing Facility) to Hospital Transfer Form dated 8/10/22 documented the risk alert for other had been selected, with intrusive and sexual behaviors documented. The behavioral issues and interventions section documented, intrusive behaviors. Resident is grabbing staff inappropriately. Resident is trying to grab other female residents and enter female residents rooms. Resident is making inappropriate sexual behaviors toward staff and other residents. The Mental Status Evaluation documented the following symptoms or signs: sexual outbursts and inappropriate grabbing. The Behavioral Evaluation section documented the following symptoms or signs: sexual outbursts, grabbing staff and attempting to grab other residents inappropriately. Trying to enter female residents rooms. Review of Hospital Paperwork for Resident #5, admission and discharge date [DATE], documented, History of Present Illness: Patient is an [age redacted]-year-old man who presents from nursing facility with concern for agitation. Apparently he has recently been sexually inappropriate at his nursing facility, today he cornered another resident and was screaming at her. These behaviors were abnormal for him. Patient denies any wrongdoing. He does not seem to recall yelling at anyone or doing anything wrong. The Nurses Note dated 8/10/22 at 5:37 PM documented, Received call from hospital regarding resident status, resident was being released d/t (due to) not meeting criteria for Geri Psych. Nurse suggested facility seek outpatient psychiatric treatment. The Orders-Administration Noted dated 8/10/2022 at 10:45 PM documented, in part, Resident was sent for psych eval d/t (due to) constant inappropriate behavior. Review of Discharge Instructions dated 8/10/22 documented the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The SS: Social Services Behavior History Evaluation-V3 dated 8/16/22 documented the following question (Q) and answer (A): Q: 1. Making noises, grinding teeth, moaning, crying, strange noises, screaming and/or disruptive sounds? A: a. Yes Q: 1b. If yes, is there a known trigger for this behavior? A: when he is around other people Q: Effective Intervention? A: we try to ask him to be nice and respect others Q: 13. Sexual acting out; explicit talk; physical sexual advances? A: b. no The Incident,Accident,Unusual Occurrence Note dated 9/2/2022 at 11:00 AM documented, This nurse walked up the hallway. This nurse noticed this resident sitting next to resident [Resident #7] in lobby. Resident [Resident #7] stated that this resident grabbed her right breast and tried to rub her leg. Resident #5 immediately removed from Resident #7. Administrator and Director of Nursing notified of incident. The Nurses Note dated 9/2/22 at 1:27 PM documented, POA (Power of Attorney) notified for resident to be sent to a behavioral health unit. Review of Inpatient Discharge Instructions dated 9/2/22 documented the following reason for visit: Inappropriate sexual behavior current nursing home towards another resident. Review of the SS Social Services Behavior History Evaluation-V3 assessment dated [DATE] documented the following question (Q) and answer (A): Q: 13. Sexual acting out; explicit talk; physical sexual advances? A: a.Yes. The assessment also documented Resident #5 had displayed sexual acting out behavior. Known triggers for the behavior documented, not sure. The response to the question of effective intervention documented, staff askes <sic> him to stop and talks to him about his behavior. The Progress Note by a Nurse Practitioner of the facility, date of service 9/21/22, documented the resident had been seen for follow-up hospital. History of Present (HPI) related to this visit documented, in part, Patient went to ER (emergency room ) for psych evaluation after inappropriate behaviors. Patient reported he believes he got back a week ago. No other content of the note referenced Resident #5's behaviors. The Med Management Note dated 9/29/22 documented a chief complaint of inappropriate behaviors and agitation. The HPI section documented, in part, 9/29/22 Resident #5 is a male with history of inappropriate behaviors, seen today for initial interview per facility request for medication management. Staff report Resident #5 has always made some inappropriate comments and redirected easily. Recently Resident #5 grabbed a female residents breast and put his hand down the back of her shirt and a complaint was filed with the state. Resident #5 was sent to a BHU and returned on [MEDICATION(S)] (antidepressant) 10 mg (milligram) daily. Staff report he returned in better mood and did well for about a week, and now he is back to same behaviors. Resident #5 does yell out and cause disruption in the dining room and gets into arguments with other male residents. Resident #5 does ask the female staff to go to bed with him. The Review of Systems section documented the following per the Psychiatric section: staff report inappropriate sexual comments and behaviors; irritable mood and gets into arguments with other male residents with yelling. The Med Management Note dated 10/13/22 for Resident #5 documented, in part, the following: HPI Resident #5 male with history of inappropriate sexual comments and behaviors, along with getting into arguments with other male residents. The Psychiatric History section documented, in part, Recent admission to BHU for sexually inappropriate behavior towards staff and other female residents. The Review of Systems section documented the following per the Psychiatric section: staff report inappropriate sexual comments and behaviors; irritable mood and gets into arguments with other male residents with yelling. The SPN-Focused Evaluation Note dated 10/26/22 at 11:08 AM documented, No injuries noted to Left arm from being punched in the left arm by another resident. Doctor notified On 10/27/22 at 1:15 PM, Staff A, Certified Nursing Assistant (CNA), had been queried about Resident #5's behaviors. Staff A explained Resident #5 tried to grab her by the gait belt, and would smack butt with a fly swatter. Staff A explained a lot of other women staff and residents had a problem with Resident #5 grabbing, touching, and saying things. Staff A identified a resident who did not like seeing the behavior, as well as a resident who had been bothered by Resident #5's behavior. Staff A explained Resident #5 would call people honey, and asked residents and staff to pull his [NAME] out. Staff A explained this occurred always, and she had witnessed this. When queried what she would do if the resident had sexual behaviors towards residents, Staff A responded she tried to shut down the situation, and would take the resident back to their room. Per Staff A, the resident wheeled around and rolled up on others. On 10/27/22 at 1:25 PM, when queried about Resident #5's behaviors, Staff B, CNA, explained they had seen where the resident would holler a lot and had been grabby towards females in the building. Staff B explained the resident liked to grab for peoples behinds and would grab for their belly. Staff B later clarified the behaviors had been towards staff. Staff B explained the other day Resident #5 and another male had gotten into an argument. Staff B also explained Resident #5 liked to go into other people's rooms, and explained a female resident had not been happy when Resident #5 had gone into her room. When specifically queried more about this, Staff B explained they only had known what the female resident had told her. When queried about Resident #5's behaviors towards residents, Staff B explained not as she had seen. When queried about Resident #5 having said anything to female residents, Staff B explained sometimes Resident #5 would say he wanted to go into the bathroom with them, and Staff B tried to avoid that. When queried what Staff B would do in this situation, Staff B explained she would normally just say we are not doing that and direct the resident back to his room. When queried if Resident #5 would be receptive, Staff B explained the resident did listen every now and then, and would sometimes be frustrated. On 10/27/22 at 2:19 PM, when queried about Resident #5's behaviors, Staff C, Licensed Practical Nurse (LPN) explained the resident did a lot of repeating very loud and could be disruptive. Staff C explained other residents would egg Resident #5 on as well. Per Staff C, Resident #5 did say inappropriate things sexually to staff and occasionally to the female residents, which had been why the resident sat by themself at the table. Staff C explained she had heard Resident #5 say to other female residents something like, gonna put my [NAME] in it. Staff C explained usually [NAME] was involved, and Resident #5 said they were going to put it somewhere to residents and staff. Per Staff C, she would explain it was not appropriate and to not talk like that. Staff C explained Resident #5 would usually quit. When queried if Resident #5 had touched any residents, Staff C explained Resident #5 would get real close to them, and other residents would egg him on. Per Staff C if redirection didn't stop the behavior she would remove Resident #5 from the situation. Staff C explained usually Resident #5 settled down, and she had not had to remove him. Staff C acknowledged Resident #5 did know better, part of it was his dementia, and the resident knew better. Staff C explained a female resident one time had hollered at her (Staff C) to please get Resident #5 away from her. Staff C acknowledged Resident #5 could move himself in his wheelchair, and would roll up next to other residents until he received redirection. On 10/31/22 at 3:33 PM, Staff G, Registered Nurse (RN) had been queried about Resident #5's behaviors. Staff G explained she had never seen Resident #5 do anything physically. Staff G explained Resident #5 talked constantly and said all kinds of stuff. Per Staff G, Resident #5 had asked staff to lay down with him and give him a kiss, and got kind of inappropriate. Per Resident #5, there had been a couple women that Resident #5 had always wanted to talk to. Staff G explained Resident #5 liked to talk to Resident #12. Per Staff G, Resident #2 had told her Resident #5 had been making her uncomfortable. Staff G explained if memory served right there had been an accusation of Resident #5 touching someone's knee or something on the porch. Staff G questioned if she had been thinking about the right time. When queried whose knee Resident #5 had touched, Staff G responded with Resident #2. When queried about the note she had input about Resident #5 grabbing at residents and staff, Staff G responded one of the CNAs had said the resident had grabbed her arm and pulled in bed. Per Staff G, Resident #5 made inappropriate remarks typically to staff. Staff G further explained Resident #5 had been sent out to geri psych, and had been sent back. Per Staff G, she had not seen Resident #5 touch Resident #2, Resident #2 had told Staff G, and Staff G had heard Resident #2 yell at Resident #5. Staff G explained Resident #5 had been on the porch, and Resident #2 had been on their way out of the porch. When queried who she had told, Staff G responded she had told whoever she had been working with that day. Staff G explained she could not remember if she had told the Director of Nursing (DON), or the other nurse. Staff G explained she had been at the facility one of the times Resident #5 had gone out. Staff G explained the resident had come back after supper. Per Staff G, she explained she seemed to remember Resident #5 saying he got in trouble again but was back. When queried if she would chart if she had told The DON or the Administrator, Staff G explained she should have charted in a note if they had been told. When it had been shared that Staff G had put in the note about Resident #5 having been sent out from the facility in August, Staff G explained she thought it would have been her to do the notification as she had put in the note. On 11/1/22 at 11:31 AM, Staff H, CNA explained she had worked at the facility for a few weeks, and acknowledged she had worked with Resident #5 before. When queried about the resident's behaviors, Staff H explained the resident had been sexual towards her, and she had seen him try to do things to other people and would tell him to quit. Staff H explained the resident had said some things to residents and staff. When queried as to what Resident #5 had said to residents, Staff H explained the resident made indecent proposals and said things. Staff H explained the resident liked to talk about his genitals in the middle of lunch and would say stuff. When queried if this had been when other residents had been around, Staff H responded it had been. When queried about touching, Staff H responded she had not seen Resident #5 try to touch residents, and the resident had tried touching staff. When queried as to why Resident #5 had been eating at a table by themself, Staff H explained she was not sure. Per Staff H, they had started putting a male resident next to him, but the resident had to be moved to another table for other reasons. When queried how other residents reacted, Staff H explained that a lot of them antagonized it so Resident #5 would keep going and thought it was funny. When queried how the resident would be antagonized, Staff H responded they would usually yell at Resident #5 to go back to his room, which got Resident #5 going more. Staff H further explained it would spiral, but it did not usually take long to get both parties to stop. Staff H explained someone would tell both of them to stop saying things and to leave each other alone. On 11/1/22 at 1:23 PM, Staff K, the facility's previous Activities Director, explained the following about Resident #5 's behaviors: Per Staff K Resident #5 was just loud, and she had never seen Resident #5 touch a resident or be inappropriate with a resident. Staff K explained the resident's previous occupation and explained the resident was used to joking. Staff K further explained with anything Resident #5 said to you, you could tell him (Resident #5) don't say that and Resident #5 was apologetic. Staff K explained she felt like the other residents were mean to Resident #5, and being kind to others had been brought up in resident council. Staff K explained with Resident #5 it was like a stream of consciousness ran out of his mouth. On 11/2/22 at 8:18 AM, when queried about Resident #5's behaviors, Staff L, Licensed Practical Nurse (LPN), explained Resident #5 was very sexually oriented. Per Staff L, Resident #5 often invited people to be his honey and the resident said that he needed someone to sleep with and to lay down. Per Staff L, this behavior had been mostly towards staff. When queried about behaviors towards residents, Staff L explained they would sometimes catch the resident at night trying to knock on females doors. Staff L explained they would tell Resident #5 he could not do that because they were sleeping. Staff L confirmed the resident used a wheelchair, and explained the resident did not sleep at night, would sleep during the day, and would be up all night. Per continued interview with Staff L on 11/2/22 at approximately 8:20 AM, Staff L stated, Resident #5 used to be boyfriend and girlfriend with Resident #12. When asked about when the residents had been boyfriend and girlfriend, Staff L explained it had been before the first time Resident #12 had left the facility for inappropriate behavior. Staff L explained Resident #5 and Resident #12 used to sit and eat dinner together, and Resident #12 used to let Resident #5 in her room, but Staff L did not see what had gone on. Staff L explained that sometimes at 2:00 AM Resident #5 and Resident #12 would sit and talk together in the dining room, as both residents did not sleep well. When asked if she had been aware of any concerns or complaints which involved Resident #5, Staff L acknowledged this had occurred with Resident #2. Per Staff L, Resident #2 had told Staff L stop him from coming this way, and per Staff L Resident #2 had said didn't you hear he touched me inappropriately? Per Staff L, this occurred in the middle of August or so. When queried as to why the resident ate at a table by himself, Staff L explained this was about the resident's loud booming voice. 2. The MDS for Resident #2 dated 10/19/22 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated intact cognition. 3. The MDS assessment for Resident #7 dated 8/30/22 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated the resident had been cognitively intact. The Progress Note dated 9/2/22 present in Resident #7's clinical record documented, Resident stated that resident Resident #5 grabbed her right breast. Resident also stated that resident Resident #5 tried to rub her leg. Resident Resident #5 immediately removed away from resident. No injuries noted. Administrator and Director of Nursing notified of incident. Mother was called and notified of incident. Education given to staff regarding resident Resident #5. On 11/1/22 at 1:59 PM, Resident #7 had been observed in their room in bed. When asked how other residents treated her, Resident #7 responded good. Resident #7 denied concerns, then explained the guy touched me, and explained it had been taken care of. Resident #7 then identified the guy as Resident #5. Per Resident #7, it had happened about a month ago. When queried where she had been touched, Resident #7 responded the thigh, crotch, and breast. When queried how it had made her feel, Resident #7 responded, creepy. When queried about safety, Resident #7 explained she was safe here at the facility now because he's gone. Resident #7 explained the situation had occurred in the lobby, and other residents had been around. Per Resident #7, she had notified staff and the Director of Nursing (DON). On 11/1/22 at 2:03 PM, Staff I, Licensed Practical Nurse (LPN) explained the following: Staff I had walked by Resident #7, and Resident #7 told Staff I that Resident #5 had grabbed her right breast and thigh. Per Staff I, she had made sure the resident were separated out in the common area. Staff I acknowledged she had not seen the interaction, and Resident #7 had voiced it. Staff I explained she had told the DON, and had communicated to staff they needed to keep watch on Resident #5. Staff I explained it had been reported, and residents were immediately separated. 4.The Quarterly MDS assessment for Resident #1 dated 7/13/22 revealed the resident scored 10 out of 15 on a BIMS exam, which indicated moderately impaired cognition. The MDS assessment for Resident #1 dated 10/5/22 revealed the resident scored 6 out of 15 on a BIMS exam, which indicated severely impaired cognition. On 10/27/22 at 10:28 AM, an interview had been conducted with Resident #1. Resident #1 identified Resident #5 by first name, and explained the first time Resident #5 had met Resident #1, Resident #5 had grabbed her boob. Per Resident #1, this had occurred in the dining room when they had just started to eat supper. Per Resident #1, Resident #5 had been grabbed and ran off. Resident #1 explained the resident had also hit on her twenty-three year old granddaughter, and Resident #1 had threatened to throat punch Resident #5. Resident #1 explained conversation had occurred with her family, and Resident #1 expressed he's (Resident #5) not assaulting me? When queried how the touching had made her feel, Resident #1 responded it had made her feel like she wanted to kill Resident #5. Resident #1 explained Resident #5 said things like, come here honey let's go to my room, and the resident would be brought to his table. Resident #1 explained a couple times the resident had tried to reach out for her breast, and had not made physical contact as she would not let Resident #5 close enough. When queried about feeling safe at the facility, Resident #1 responded, in part, she was safe to stay at the facility as long as Resident #5 left her alone. When queried about who had been present when she had been touched, Resident #1 responded just the nurses. When queried as to how often Resident #5 tried to touch her, Resident #1 responded every chance that Resident #5 got close. Resident #1 explained they did not need to have someone try to hit on them at their current stage in their life. 5.On 10/25/22 during a confidential interview, an anonymous resident explained there had been a man, identified by the resident as Resident #5, who would come knock on their door in the middle of the night. Per the anonymous resident, the response had been Resident #5 had dementia. The anonymous resident explained everyone knew about it. On 10/27/22 at approximately 8:15 AM, the anonymous resident expressed concern with having her door open at night with her rear end exposed, in regard to potential physical contact occurring. Resident explained they would pepperspray them. 6. The Minimum Data Set (MDS) assessment for Resident #12 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident had intact cognition. Resident #12 had been previously identified during an interview with Staff L as Resident #5's girlfriend. 7. The MDS assessment dated [DATE] revealed Resident #6 scored 15 out of 15 on a BIMS exam, which indicated intact cognition. During an interview on 10/27/22 at 4:55 PM, Resident #6 explained they would punch Resident #5 if the resident did not shut his mouth. Per Resident #6, Resident #5 had been vulgar, and said things to people that should not be said. Resident #6 explained others live here (at the facility) too. When queried about the type of things that had been said, Resident #6 explained Resident #5 had said things such as, hey baby to residents and staff. Resident #6 explained Resident #5 was mouthy, threatened to punch him (Resident #6) out, and that it happened all the time. Resident #6 explained he felt/responded to bring it on. Resident #6 further explained he did not like the way Resident #5 talked to women and guys. Resident #6 explained one day Resident #5 had gone to a female, had said weird things, and went to her table. Per Resident #6, something had been said like come to my bedroom, and he (Resident #6) had not liked that. Resident #6 further explained Resident #5 had asked him how he (Resident #6) held his penis with one hand. Resident #6 explained this had made him angry. Per Resident #6, others were tired of Resident #5 too, and explained it would come to a head pretty soon. Resident #6 explained Resident #5 did not want to shut their [expletive] mouth. Resident #6 had been queried what they did in this situation, explained they would remove themselves from the situation. When queried if staff spoke with Resident #6 about the situation, Resident #6 responded that staff did not care. 8. The MDS assessment for Resident #8 dated 10/5/22 revealed Resident #8 scored 3 out of 15 on a BIMS assessment, which indicated severe cognitive impairment. Per this assessment, Resident #8 had no physical or verbal behavioral symptoms towards others, or other behavioral symptoms not directed towards others. On 10/31/22 at 1:17 PM, Resident #8 had been queried how other residents at the facility treated him, and responded good. When queried about problems, concerns, or statements which made him feel uncomfortable, Resident #8 mentioned Resident #5's name. Resident #8 explained it was not towards him but to other residents. Per Resident #8, Resident #5 would say to the female residents, Hey why don't you go to my room and take off your clothes and stuff like that. When queried about which specific ladies had been told, Resident #8 responded he thought a resident who no longer resided at the facility. When queried how it had made him feel, Resident #8 responded like he wanted to get in a fight with Resident #5, but he had not done so. When queried if there had been a specific resident that Resident #5 had made the comment to, Resident #8 explained he thought a resident who he named, and further explained the resident no longer resided at the facility. Resident #8 had been queried if there had been a situation where any of the following had occurred between Resident #5 and Resident #8: touched, kicked, hit, or punched. Resident #8 responded I hit him (Resident #5) in the arm once. When queried what had brought the situation to that point, Resident #8 explained Resident #5 had said something. When queried about the timeframe the incident had occurred, Resident #8 explained fairly recently. On 11/7/22 at 3:59 PM, the DON explained Resident #5 had been sent out in August to geriaric behavioral health. Per the DON, information had been reported to the previous Administrator and the DON had said the resident needed to be sent out for an evaluation, and had been sent out. Per the DON, the previous Administrator had come to her office and had told her there was a problem with Resident #5. Per the DON, all she could remember was the previous Administrator told her there was a problem with a complaint that the resident had been inappropriate. When queried who the complaint had come from and what had been going on, the DON reported what she knew had been what the previous Administrator told her. The DON reported the previous Administrator communicated that Resident #2 said Resident #5 had cornered her, and had tried to run his finger down her back. Per the DON, when it was asked nobody had seen it happen. The DON explained the resident was loud and verbal, and she thought maybe the resident needed to go to the emergency room and get evaluated for geriatric behavioral health. Per the DON, as far as residents, that had been the only incident told to her. The DON further explained that the situation between Resident #2 and Resident #5 in August had been the only incident she had known of that a resident had complained or she knew Resident #2 touched a resident. Per the DON, she didn't see that, and staff said they didn't see it either, but the resident had said it happened. When queried about the situation with Resident #7, the DON explained that is the one she reported. The DON explained she had not seen it happen, and the Administrator had done all the reporting. On 11/7/22 at 4:05 PM, the DON had been queried if staff had reported behaviors to her about Resident #5 and other residents. The DON explained the resident was loud, repeated himself, and was persistent. When queried if staff had reported the resident asking people to pull his genitals out, the DON explained she had never heard that. When queried if the statement the resident wanted to go to the bathroom with other residents had come up, the DON acknowledged this had not been told to her. When queried about Resident #5 knocking on doors at nighttime, the DON explained for the most part the resident slept all night and she had not heard that the resident had been knocking on people's doors at night. The DON acknowledged Resident #5's behaviors towards residents needed to be reported, if it was actively happening redirection was needed and staff would stay with the resident, it would be reported, then investigated. On 11/8/22 at 12:32 PM, the Administrator explained the only time she had seen Resident #5 touch another resident had been when he had reached out and touched Resident #2's shoulder and said hello. Per the Administrator, otherwise she had not seen Resident #5 wheel his chair up to other people. The facility Administrator acknowledged if staff had charted or seen behaviors, they should have told the Charge Nurse or supervisor what they had seen. The Administrator acknowledged she had not been informed of Resident #5 knocking on doors at night, or certain statements made by [TRUNCATED]

Based on observation, clinical record review, staff interview, and facility policy review the facility failed to provide sufficient staff with skill sets to address a cognitively impaired male resident's (Resident #5's) behaviors towards other residents at the facility, which negatively impacted other residents within the environment (Resident #1, #2, #5, #6, #7, #8). Resident #5 had been involved in a physical altercation and displayed sexual behaviors towards others. Other residents who resided at the facility had voiced aggressive acts they would take towards Resident #5 in response to the resident's behaviors. This resulted in an Immediate Jeopardy when actual psychosocial harm occurred for residents who resided at the facility. The facility reported a census of 36 residents. Findings Include: 1. The Quarterly Minimum Data Set (MDS) Assessment for Resident #5 dated 6/29/22 revealed the resident rarely to never understood. Per this assessment, Resident #5 had severely impaired cognitive skills for daily decision making and had verbal behavior symptoms towards others which occurred daily. The Care Plan dated 9/2/22 documented, I display socially inappropriate/disruptive behavior. I sometimes display sexually inappropriate behaviors. Interventions on the Care Plan dated 9/2/22 included the following: a. 9/2/22 I will be placed at a table by myself for meals. b. Activities staff to visit with me and provide diversional activities. c. Administer my behavior medications as ordered by physician. d. Encourage my family/responsible party to visit. e. Monitor and document my behavior. f. Praise me for demonstrating desired behavior. g. Remove me from public areas when behavior is disruptive and unacceptable. h. Talk with me in a calm voice when my behavior is disruptive. Interventions on the Care Plan dated 10/27/22 included the following: a. I am receiving psych services. b. I will be having a medication review with my doctor. The Care Plan dated 9/15/22 documented, I have a behavior problem, I yell and repeat things frequently. Interventions per the Care Plan documented the following: a. Date initiated 8/16/22: Divert my attention. Remove me from situations as needed and take me to an alternate location as needed. b. Date initiated 9/8/22: I may need to be reminded to keep my hands to myself. c. Date initiated 8/16/22: Intervene as necessary to protect the rights and safety of others. Progress Notes for Resident #5 documented the following: a. The Orders-Administration Note dated 7/27/22 at 10:04 PM documented, Resident being sexually inappropriate. b. The Orders-Administration Note dated 7/30/22 at 11:44 PM documented, Resident was being sexually inappropriate today. c. The Orders-Administration Note dated 8/2/22 at 10:06 PM documented, sexually inappropriate behaviors. d. The Orders-Administration Note dated 8/4/22 at 10:07 PM documented, Resident continues to struggle with keeping his hands to himself. Grabbing at both staff and other residents. e. The Orders-Administration Note dated 8/8/2022 at 11:17 PM documented, Resident continues to be difficult to keep from touching others. The Care Plan Conference Summary dated 8/9/22 at 3:30 PM documented, reviewed Care Plan for Nursing, Dietary, Social Work and Activities. Resident's son was notified the resident has been having inappropriate behaviors. Resident's son states that he would approve a psych consult and to keep him updated. The Einteract Summary dated 8/10/22 at 12:52 PM documented, in part, documented by Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Send to ED for psych/behavioral evaluation. B. New Intervention Orders: a. Other. b. Redirection. Review of the Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form dated 8/10/22 documented the risk alert for other had been selected, with intrusive and sexual behaviors documented. The behavioral issues and interventions section documented, intrusive behaviors. Resident is grabbing staff inappropriately. Resident is trying to grab other female residents and enter female residents' rooms. Resident is making inappropriate sexual behaviors toward staff and other residents. The Mental Status Evaluation documented the following symptoms or signs: sexual outbursts and inappropriate grabbing. The Behavioral Evaluation section documented the following symptoms or signs: sexual outbursts, grabbing staff and attempting to grab other residents inappropriately. Trying to enter female residents' rooms. Review of Hospital Paperwork for Resident #5, admission and discharge date [DATE], documented, History of Present Illness: Patient is an [age redacted]-year-old man who presents from a Nursing Facility with concern for agitation. Apparently he has recently been sexually inappropriate at his nursing facility, today he cornered another resident and was screaming at her. These behaviors were abnormal for him. Patient denies any wrongdoing. He does not seem to recall yelling at anyone or doing anything wrong. The Nurses Note dated 8/10/22 at 5:37 PM documented, Received call from [Hospital Name] regarding resident status, Resident is being released due to (d/t) not meeting criteria for Geri Psych. Nurse suggested facility seek Outpatient Psychiatric Treatment. The Orders-Administration Noted dated 8/10/2022 at 10:45 PM documented, in part, Resident was sent to [name redacted] for psych evaluation d/t constant inappropriate behavior. Review of Discharge Instructions dated 8/10/22, documented the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Social Services Behavior History Evaluation-V 3 dated 8/16/22 documented the following question (Q) and answer (A): Q: 1. Making noises, grinding teeth, moaning, crying, strange noises, screaming and/or disruptive sounds? A: a. Yes Q: 1 b. If yes, is there a known trigger for this behavior? A: When he is around other people. Q: Effective Intervention? A: We try to ask him to be nice and respect others. Q: 13. Sexual acting out; explicit talk; physical sexual advances? A: b. No The Incident/Accident/Unusual Occurrence Note dated 9/2/2022 at 11:00 AM documented, this nurse walked up the hallway. This nurse noticed the resident sitting next to Resident #7 in lobby. Resident #7 states that this resident grabbed her right breast and tried to rub her leg. This resident immediately removed from resident [number redacted]. Administrator and Director of Nursing notified of incident. The Nurses Note dated 9/2/22 at 1:27 PM documented, the Resident #5's Power of Attorney (POA) notified for resident to be sent to [Facility Name in City Name Redacted]. Review of Inpatient Discharge Instructions dated 9/2/22 documented the following reason for visit: Inappropriate sexual behavior current nursing home towards another resident. Review of the Social Services Behavior History Evaluation-V 3 assessment dated [DATE] documented the following question (Q) and answer (A): Q: 13. Sexual acting out; explicit talk; physical sexual advances? A: a. Yes. The assessment also documented Resident #5 had displayed sexual acting out behavior. Known triggers for the behavior documented, not sure. The response to the question of effective intervention documented, staff asks him to stop and talks to him about his behavior. The Progress Note by a Nurse Practitioner of the facility, date of service 9/21/22, documented the resident had been seen for follow-up hospital. History of Present Illness (HPI) related to this visit documented, in part, Patient went to emergency room (ER) for a psych evaluation after inappropriate behaviors. Patient reports he believes he got back a week ago. No other content of the note referenced Resident #5's behaviors. The Medication Management Note dated 9/29/22, documented a chief complaint of inappropriate behaviors and agitation. The HPI section documented, in part, 9/29/22 - Resident #5 is a [age redacted] year old (y/o) male with history of inappropriate behaviors, seen today for initial interview per facility request for medication management. Staff report Resident #5 has always made some inappropriate comments and redirected easily. Recently Resident #5 grabbed a female resident's breast and put his hand down the back of her shirt and a complaint was filed with the state. Resident #5 was sent to a Behavioral Health Unit (BHU) and returned on [MEDICATION(S)] (antidepressant) 10 milligrams (mg) daily. Staff report he returned in a better mood and did well for about a week, and now he is back to same behaviors. Resident #5 does yell out and cause disruption in the dining room and gets into arguments with other male residents. Resident #5 does ask the female staff to go to bed with him. The Review of Systems section documented the following per the Psychiatric section: staff report inappropriate sexual comments and behaviors; irritable mood and gets into arguments with other male residents with yelling. The Medication Management Note dated 10/13/22 for Resident #5 documented, in part, the following: HPI - Resident #5 is a [age redacted] y/o male with history of inappropriate sexual comments and behaviors, along with getting into arguments with other male residents. The Psychiatric History section documented, in part, recent admission to BHU for sexually inappropriate behavior towards staff and other female residents. The Review of Systems section documented the following per the Psychiatric section: staff report inappropriate sexual comments and behaviors; irritable mood and gets into arguments with other male residents with yelling. The SPN-Focused Evaluation Note dated 10/26/22 at 11:08 AM documented, No injuries notes to Left arm from being punched in the left arm by another resident. Dr. [Name Redacted] notified. On 10/27/22 at 1:15 PM, Staff A, Certified Nursing Assistant (CNA), had been queried about Resident #5's behaviors. Staff A explained Resident #5 tried to grab her by the gait belt, and would smack her butt with a fly swatter. Staff A explained a lot of other women staff and residents had a problem with Resident #5 grabbing, touching, and saying things. Staff A identified a resident who did not like seeing the behavior, as well as a resident who had been bothered by Resident #5's behavior. Staff A explained Resident #5 would call people honey, and asked residents and staff to pull his [NAME] out. Staff A explained this occurred always, and she had witnessed this. When queried what she would do if the resident had sexual behaviors towards residents, Staff A responded she tried to shut down the situation, and would take the resident back to their room. Per Staff A, the resident wheeled around in a wheelchair and rolled up on others. On 10/27/22 at 1:25 PM, when queried about Resident #5's behaviors, Staff B, CNA, explained they had seen where the resident would holler a lot and had been grabby towards females in the building. Staff B explained the resident liked to grab for peoples behinds and would grab for their belly. Staff B later clarified the behaviors had been towards staff. Staff B explained the other day Resident #5 and another male had gotten into an argument. Staff B also explained Resident #5 liked to go into other people's rooms, and explained a female resident had not been happy when Resident #5 had gone into her room. When specifically queried more about this, Staff B explained they only had known what the female resident had told her. When queried about Resident #5's behaviors towards residents, Staff B explained none as she had seen. When queried about Resident #5 having said anything to female residents, Staff B explained sometimes Resident #5 would say he wanted to go into the bathroom with them, and Staff B tried to avoid that. When queried what Staff B would do in this situation, Staff B explained she would normally just say to Resident #5 we are not doing that and direct the resident back to his room. When queried if Resident #5 would be receptive, Staff B explained the resident did listen every now and then, and would sometimes be frustrated. On 10/27/22 at 2:19 PM, when queried about Resident #5's behaviors, Staff C, Licensed Practical Nurse (LPN) explained the resident did a lot of repeating very loud and could be disruptive. Staff C explained other residents would egg Resident #5 on as well. Per Staff C, Resident #5 did say inappropriate things sexually to staff and occasionally to the female residents, which had been why the resident sat by themselves at the table. Staff C explained she had heard Resident #5 say to other female residents something like, gonna put my [NAME] in it. Staff C explained usually [NAME] was involved, and Resident #5 said they were going to put it somewhere to residents and staff. Per Staff C, she would explain it was not appropriate and to not talk like that. Staff C explained Resident #5 would usually quit. When queried if Resident #5 had touched any residents, Staff explained Resident #5 would get real close to them, and other residents would egg him on. Per Staff C if redirection didn't stop the behavior she would remove Resident #5 from the situation. Staff C explained usually Resident #5 settled down, and she had not had to remove him. Staff C acknowledged Resident #5 did know better, part of it was his dementia, and the resident knew better. Staff C explained a female resident one time had hollered at her (Staff C) to please get Resident #5 away from her. Staff C acknowledged Resident #5 could move himself in his wheelchair, and would roll up next to other residents until he received redirection. On 10/27/22 at 3:02 PM, information which included any hospital records for any inpatient behavioral health stays in 2022 for Resident #5 had been requested. On 10/27/22 at 3:34 PM, the Director of Nursing (DON) explained they would need to get the Power of Attorney (POA) to sign to release the resident's psychiatric records. On 10/31/22 at 3:33 PM, Staff G, Registered Nurse (RN) had been queried about Resident #5's behaviors. Staff G explained she had never seen Resident #5 do anything physically. Staff G explained Resident #5 talked constantly and said all kinds of stuff. Per Staff G, Resident #5 had asked staff to lay down with him and give him a kiss, and got kind of inappropriate. Per Resident #5, there had been a couple women that Resident #5 had always wanted to talk to. Staff G explained Resident #5 liked to talk to Resident #12. Per Staff G, Resident #2 had told her Resident #5 had been making her uncomfortable. Staff G explained if memory served right there had been an accusation of Resident #5 touching someone's knee or something on the porch. Staff G questioned if she had been thinking about the right time. When queried whose knee Resident #5 had touched, Staff G responded with Resident #2. When queried about the note she had input about Resident #5 grabbing at residents and staff, Staff G responded one of the CNAs had said the resident had grabbed her arm and pulled in bed. Per Staff G, Resident #5 made inappropriate remarks typically to staff. Staff G further explained Resident #5 had been sent out to Geri Psych, and had been sent back. Per Staff G, she had not seen Resident #5 touch Resident #2, Resident #2 had told Staff G, and Staff G had heard Resident #2 yell at Resident #5. Staff G explained Resident #5 had been on the porch, and Resident #2 had been on their way out of the porch. When queried who she had told, Staff G responded she had told whoever she had been working with that day. Staff G explained she could not remember if she had told the Director of Nursing (DON), or the other nurse. Staff G explained she had been at the facility one of the times Resident #5 had gone out. Staff G explained the resident had come back after supper. Per Staff G, she explained she seemed to remember Resident #5 saying he got in trouble again but was back. When queried if she would chart if she had told The DON or the Administrator, Staff G explained she should have charted in a note if they had been told. When it had been shared that Staff G had put in the note about Resident #5 having been sent out from the facility in August, Staff G explained she thought it would have been her to do the notification as she had put in the note. On 11/1/22 at 11:31 AM, Staff H, CNA explained she had worked at the facility for a few weeks, and acknowledged she had worked with Resident #5 before. When queried about the resident's behaviors, Staff H explained the resident had been sexual towards her, and she had seen him try to do things to other people and would tell him to quit. Staff H explained the resident had said some things to residents and staff. When queried as to what Resident #5 had said to residents, Staff H explained the resident made indecent proposals and said things. Staff H explained the resident liked to talk about his genitals in the middle of lunch and would say stuff. When queried if this had been when other residents had been around, Staff H responded it had been. When queried about touching, Staff H responded she had not seen Resident #5 try to touch residents, and the resident had tried touching staff. When queried as to why Resident #5 had been eating at a table by themselves, Staff H explained she was not sure. Per Staff H, they had started putting a male resident next to him, but the resident had to be moved to another table for other reasons. When queried how other residents reacted, Staff H explained that a lot of them antagonized it so Resident #5 would keep going and thought it was funny. When queried how the resident would be antagonized, Staff H responded they would usually yell at Resident #5 to go back to his room, which got Resident #5 going more. Staff H further explained it would spiral, but it did not usually take long to get both parties to stop. Staff H explained someone would tell both of them to stop saying things and to leave each other alone. On 11/1/22 at 12:42 PM, Staff J, previous Social Services staff, had been interviewed about Resident #5. Staff J explained he knew he had had a couple talks with Resident #5 related to the resident at the dining room table voicing different things. Per Staff J, he had had to stop arguments quite a few times between Resident #5 and Resident #6. Staff J explained that recently he had heard staff said the resident had made inappropriate comments. Staff J explained the resident rambled sometimes and let things slip. Staff J explained that he had heard staff say someone (later identified as Resident #2) had complained about Resident #5 and comments towards her. When queried about Resident #5 physically touching other residents, Staff J explained that he had not heard/talked to Resident #5 about that. Staff J explained he had heard in stand up in the past few weeks that Resident #5 had walked by Resident #2 and had touched her elbow. When queried about Geri Psych and hospitalization , Staff J explained the resident had gone to the emergency room (ER) for being aggressive, and Resident #5 had been arguing with Resident #6 quite a bit. Staff J explained the old Administrator had put Resident #5 at a table by himself to decrease tension between Resident #5 and Resident #6. When queried about the situation between Resident #5 and Resident #7, Staff J explained that he knew it had been discussed at stand up, and further explained he had not been at the facility when the resident had been sent out. When asked about a plan to address Resident #5's behaviors, Staff J responded the resident had been watched closer in the dining hall, a one to one (monitoring) had not been done, and the resident would be corrected in the dining hall related to being loud. When queried if Social Services would address Resident #5 grabbing at residents, Staff J responded if it had not already been address then Social Work would address. When queried how it would be known if addressed, Staff J explained if it had been discussed in stand up then they would know it had been addressed. When queried about concerns with Resident #6 and Resident #5, Staff J explained Resident #5 would say he had to eat, and where is the food. Resident #6 would respond back and forth, and Resident #6 would be frustrated to hear the same things over and over again. When queried as to follow up if a resident had been sent to the hospital with behaviors, Staff J responded he would not see it at a sit down evaluation, and he had never written anything down. When queried if there had been behavior monitoring for Resident #5, Staff J responded not that he had known of. On 11/1/22 at 1:23 PM, Staff K, the facility's previous Activities Director, explained the following about Resident #5's behaviors: Per Staff K, Resident #5 was just loud, and she had never seen Resident #5 touch a resident or be inappropriate with a resident. Staff K explained the resident's previous occupation and explained the resident was used to joking. Staff K further explained with anything Resident #5 said to you, you could tell him don't say that and Resident #5 was apologetic. Staff K explained she felt like the other residents were mean to Resident #5, and being kind to others had been brought up in resident council. Staff K explained with Resident #5 it was like a stream of consciousness ran out of his mouth. On 11/2/22 at 8:18 AM, when queried about Resident #5's behaviors, Staff L, Licensed Practical Nurse (LPN), explained Resident #5 was very sexually oriented. Per Staff L, Resident #5 often invited people to be his honey and the resident said that he needed someone to sleep with and to lay down. Per Staff L, this behavior had been mostly towards staff. When queried about behaviors towards residents, Staff L explained they would sometimes catch the resident at night trying to knock on females doors. Staff L explained they would tell Resident #5 he could not do that because they were sleeping. Staff L confirmed the resident used a wheelchair, and explained the resident did not sleep at night, would sleep during the day, and would be up all night. Per continued interview with Staff L on 11/2/22 at approximately 8:20 AM, Staff L, Resident #5 used to be boyfriend and girlfriend with Resident #12. When asked about when the residents had been boyfriend and girlfriend, Staff L explained it had been before the first time Resident #12 had left the facility for inappropriate behavior. Staff L explained Resident #5 and Resident #12 used to sit and eat dinner together, and Resident #12 used to let Resident #5 in her room, but Staff L did not see what had gone on. Staff L explained that sometimes at 2:00 AM Resident #5 and Resident #12 would sit and talk together in the dining room, as both residents did not sleep well. When asked if she had been aware of any concerns or complaints which involved Resident #5, Staff L acknowledged this had occurred with Resident #2. Per Staff L, Resident #2 had told Staff L stop him from coming this way, and per Staff L Resident #2 had said didn't you hear he touched me inappropriately? Per Staff L, this occurred in the middle of August or so. When queried as to why the resident ate at a table by himself, Staff L explained this was about the resident's loud booming voice. 2. The MDS for Resident #2 dated 10/19/22 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated intact cognition. 3. On 10/27/22 at 3:42 PM, the Administrator explained there were five residents at the facility who were not kind to Resident #5. Per the Administrator, when Resident #1 had been taken back to their room and Resident #5 had been in their doorway, Resident #1 would call Resident #5 a nasty name. Per the Administrator, Resident #2 would do the same. The Administrator explained Resident #1 and Resident #2 would say they had rights, and per the Administrator Resident #5 had rights too to not hear that. When queried if this conflict/concern had been going on since the Administrator had started in their position in August, the Administrator explained if it had occurred at that time she had not noticed then. The Administrator further explained that in the last month or so she had started to notice things that were not nice to him (Resident #5). The Administrator explained an example when Resident #5 had been talking to themselves, and Resident #9 had said, tell that guy to shut up. The Administrator explained there had been a movie on, and per the Administrator the television program could still be heard. The Administrator acknowledged the situation had been getting bad. Per the Administrator, Resident #5 had been sent to psych, had come back better for a week or so, and now had been talking more. On 10/27/22 at approximately 5:18 PM, the following observation occurred in the dining room. Resident #5 had been present in their wheelchair a table by themselves in the dining room. Staff had not been present with Resident #5. At the table next to Resident #5, Resident #1 and Resident #6 had been present. Resident #6 had been in closest proximity to Resident #5. Observation revealed Resident #5 spoke loudly, and said things including, but not limited to, the following: ham and eggs, bacon and toast, get something to eat honey I'm hungry, and Honey come here. Resident #6 replied, Leave her alone. Resident #5 stated, Come on and warm me up honey put some covers on. Resident #6 responded, Shut-up for a while. Observation revealed Resident #6 in his wheelchair facing Resident #5. Resident #6 hit his fist on his leg repeatedly. Resident #1 had been heard to participate in the running conversation. Resident #5 spoke loudly about bacon and eggs, and said keep quiet honey, keep quiet. Resident #6 responded, you gonna make me? On 10/27/22 at 5:22 PM, a staff member brought Resident #5 a paper activity. Resident #5 stated, Honey come here, you gonna be my bunny honey? Resident #5 and Resident #6 made statements back and forth, and Resident #1 had been heard to participate in the conversation as well. Staff helped Resident #5 apply his jacket, and at approximately 5:27 PM staff put a chair by Resident #5 and sat down. 4. The MDS Assessment for Resident #8 dated 10/5/22 revealed Resident #8 scored 3 out of 15 on a BIMS Assessment, which indicated severe cognitive impairment. Per this Assessment, Resident #8 had no physical or verbal behavioral symptoms towards others, or other behavioral symptoms not directed towards others. On 10/27/22 at approximately 3:40 PM, the facility's Administrator had been queried who had been involved in the resident to resident incident between Resident #5 and other resident documented on 10/26/22. The Administrator identified the other resident as Resident #8. Per the Administrator, Resident #5 had not been talking at the time. Resident #8 had been escorted in their wheelchair back to the room. Resident #8 had been passing Resident #5, and Resident #8 had hit Resident #5 in the arm. When queried if there had been an interaction occurring between them at the time, the DON explained there had not been an interaction. On 10/31/22 at 1:17 PM, Resident #8 had been queried how other residents at the facility treated him, and responded good. When queried about problems, concerns, or statements which made him feel uncomfortable, Resident #8 mentioned Resident #5's name. Resident #8 explained it was not towards him but to other residents. Per Resident #8, Resident #5 would say to the female residents, hey why don't you go to my room and take off your clothes and stuff like that. When queried about which specific ladies had been told, Resident #8 responded he thought a resident who no longer resided at the facility. When queried how it had made him feel, Resident #8 responded like he wanted to get in a fight with Resident #5, but he had not done so. When queried if there had been a specific resident that Resident #5 had made the comment to, Resident #8 explained he thought a resident who he named, and further explained the resident no longer resided at the facility. Resident #8 had been queried if there had been a situation where any of the following had occurred between Resident #5 and Resident #8: touched, kicked, hit, or punched. Resident #8 responded I hit him (Resident #5) in the arm once. When queried what had brought the situation to that point, Resident #8 explained Resident #5 had said something. When queried about the timeframe the incident had occurred, Resident #8 explained fairly recently. Resident #8 also explained he would be at his table where he ate, and Resident #5 would come up in their wheelchair beside Resident #5 and would get in his space. Per Resident #8, Resident #5 would start mumbling and said hey, did we ever go to the fish fry at the city next to us? Resident #8 responded he would say no, he didn't want to go to it, and would say why don't you go back to your table? Resident 8 explained Resident #5 would go back if Resident #8 said it sternly enough. 5. The MDS Assessment for Resident #7 dated 8/30/22 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated the resident had been cognitively intact. The Progress Note dated 9/2/22 present in Resident #7's clinical record documented, Resident states that Resident #5 grabbed her right breast. Resident also states that Resident #5 tried to rub her leg. Resident #5 immediately removed away from resident. No injuries noted. Administrator and Director of Nursing notified of incident. Mother, [Name Redacted], called and notified of incident. Education given to staff regarding Resident #5. On 11/1/22 at 1:59 PM, Resident #7 had been observed in their room in bed. When asked how other residents treated her, Resident #7 responded good. Resident #7 denied concerns, then explained the guy touched me, and explained it had been taken care of. Resident #7 then identified the guy as Resident #5. Per Resident #7, it had happened about a month ago. When queried where she had been touched, Resident #7 responded the thigh, crotch, and breast. When queried how it had made her feel, Resident #7 responded, creepy. When queried about safety, Resident #7 explained she was safe here (at the facility) now because he's gone. Resident #7 explained the situation had occurred in the lobby, and other residents had been around. Per Resident #7, she had notified staff and the Director of Nursing (DON). On 11/1/22 at 2:03 PM, Staff I, Licensed Practical Nurse (LPN) explained the following: Staff I had walked by Resident #8 and Resident #8 told Staff I that Resident #5 had grabbed her right breast and thigh. Per Staff I, she had made sure the resident were separated out in the common area. Staff I acknowledged she had not seen the interaction, and Resident #7 had voiced it. Staff I explained she had told the DON, and had communicated to staff they needed to keep watch on Resident #5. Staff I explained it had been reported, and residents were immediately separated. 6. The Quarterly Minimum Data Set (MDS) Assessment for Resident #1 dated 7/13/22 revealed the resident scored 10 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. The Minimum Data Set (MDS) Assessment for Resident #1 dated 10/5/22 revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. On 10/27/22 at 10:28 AM, an interview had been conducted with Resident #1. Resident #1 identified Resident #5 by first name, and explained the first time Resident #5 had met Resident #1, Resident #5 had grabbed her boob. Per Resident #1, this had occurred in the dining room when they had just started to eat supper. Per Resident #1, Resident #5 had been grabbed and ran off. Resident #1 explained the resident had also hit on her twenty-three year old granddaughter, and Resident #1 had threatened to throat punch Resident #5. Reside [TRUNCATED]

Based on interview, clinical record review, the facility failed to report all allegations of abuse. A resident sexual abused another resident who resided at the facility when Resident #5 touched the breast of Resident #1 and Resident #7. Resident #5 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed other instances of allegations of abuse, and staff interview revealed an alleged incident involving Resident #2 and Resident #5 that did not get reported. This resulted in an Immediate Jeopardy to residents who currently resided at the facility. Facility reported a census of 36 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment for Resident #5 dated 6/29/22 revealed the resident had been rarely to never understood. Per this assessment, Resident #5 had severely impaired cognitive skills for daily decision making. Per the assessment, Resident #5 had verbal behavior symptoms towards others which occurred daily. The Care Plan dated 9/2/22 documented, I display socially inappropriate/disruptive behavior. I sometimes display sexually inappropriate behaviors. Interventions dated 9/2/22 included the following: a. I will be placed at a table by myself for meals. b. Activities staff to visit with me and provide diversional activities. c. Administer my behavior medications as ordered by physician. d. Encourage my family/responsible party to visit. e. Monitor and document my behavior. f. Praise me for demonstrating desired behavior. g. Remove me from public area's when behavior is disruptive and unacceptable. h. Talk with me in a calm voice when my behavior is disruptive. Interventions dated 10/27/22 included the following: a. I am receiving psych services. b. I will be having a medication review with my doctor. The Care Plan dated 9/15/22 documented, I have a behavior problem, I yell and repeat things frequently. Interventions per the Care Plan documented the following: a. Date initiated 8/16/22: Divert my attention. Remove me from situations as needed and take me to an alternate location as needed. b. Date initiated 9/8/22: I may need to be reminded to keep my hands to myself. c. Date initiated 8/16/22: Intervene as necessary to protect the rights and safety of others. Progress Notes for Resident #5 documented the following: The Orders-Administration Note dated 7/27/22 at 10:04 PM documented, Resident being sexually inappropriate. The Orders-Administration Note dated 7/30/22 at 11:44 PM documented, Resident was being sexually inappropriate today. The Orders-Administration Note dated 8/2/22 at 10:06 PM documented, Sexually inappropriate behaviors. The Orders-Administration Note dated 8/4/22 at 10:07 PM documented, Resident continues to struggle with keeping his hands to himself. Grabbing at both staff and other residents. The Orders-Administration Note dated 8/8/2022 at 11:17 PM documented, Resident continues to be difficult to keep from touching others. The Care Plan Conference Summary dated 8/9/22 at 3:30 PM documented, reviewed care plan for nursing, dietary, social work and activities. Resident's son was notified that resident has been having inappropriate behaviors. Resident's son stated that he would approve a psych consult and to keep him updated. The Einteract Summary dated 8/10/22 at 12:52PM documented, in part, physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Send to ED for psych/behavioral evaluation .C. New Intervention Orders: a.Other b. redirection. Review of the SNF/NF (Skilled Nursing Facility/Nursing Facility) to Hospital Transfer Form dated 8/10/22 documented the risk alert for other had been selected, with intrusive and sexual behaviors documented. The behavioral issues and interventions section documented, intrusive behaviors. Resident is grabbing staff inappropriately. Resident is trying to grab other female residents and enter female residents rooms. Resident is making inappropriate sexual behaviors toward staff and other residents. The Mental Status Evaluation documented the following symptoms or signs: sexual outbursts and inappropriate grabbing. The Behavioral Evaluation section documented the following symptoms or signs: sexual outbursts, grabbing staff and attempting to grab other residents inappropriately. Trying to enter female residents rooms. Review of Hospital Paperwork for Resident #5, admission and discharge date [DATE], documented, History of Present Illness: Patient is a man who presents from nursing facility with concern for agitation. Apparently he has recently been sexually inappropriate at his nursing facility, today he cornered another resident and was screaming at her. These behaviors were abnormal for him. Patient denies any wrongdoing. He does not seem to recall yelling at anyone or doing anything wrong. The Nurses Note dated 8/10/22 at 5:37 PM documented, Received call from hospital regarding resident status, Resident is being released d/t (due to) not meeting criteria for Geri Psych. Nurse suggested facility seek outpatient psychiatric treatment. The Orders-Administration Noted dated 8/10/2022 at 10:45 PM documented, in part, Resident was sent to hospital for psych eval d/t (due to) constant inappropriate behavior. Review of Discharge Instructions dated 8/10/22 documented the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The SS: Social Services Behavior History Evaluation-V3 dated 8/16/22 documented the following question (Q) and answer (A): Q: 1. Making noises, grinding teeth, moaning, crying, strange noises, screaming and/or disruptive sounds? A: a. Yes Q: 1b. If yes, is there a known trigger for this behavior? A: when he is around other people Q: Effective Intervention? A: we try to ask him to be nice and respect others Q: 13. Sexual acting out; explicit talk; physical sexual advances? A: b. no The Incident,Accident,Unusual Occurrence Note dated 9/2/2022 at 11:00 AM documented, This nurse walked up the hallway. This is nurse noticed this resident sitting next to resident Resident #7 in lobby. Resident #7 stated that this resident grabbed her right breast and tried to rub her leg. This resident immediately removed from Resident #7. Administrator and Director of Nursing notified of incident. The Nurses Note dated 9/2/22 at 1:27 PM documented, POA (Power of Attorney) notified for resident to be sent to behavioal health unit. Review of Inpatient Discharge Instructions dated 9/2/22 documented the following reason for visit: Inappropriate sexual behavior current nursing home towards another resident. Review of the SS Social Services Behavior History Evaluation-V3 assessment dated [DATE] documented the following question (Q) and answer (A): Q: 13. Sexual acting out; explicit talk; physical sexual advances? A: a.Yes. The assessment also documented Resident #5 had displayed sexual acting out behavior. Known triggers for the behavior documented, not sure. The response to the question of effective intervention documented, staff askes him to stop and talks to him about his behavior. The Progress Note by a Nurse Practitioner of the facility, date of service 9/21/22, documented the resident had been seen for follow-up hospital. History of Present (HPI) related to this visit documented, in part, Patient went to ER (emergency room ) for psych evaluation after inappropriate behaviors. Patient reports he believes he got back a week ago. No other content of the note referenced Resident #5's behaviors. The Med Management Note dated 9/29/22 documented a chief complaint of inappropriate behaviors and agitation. The HPI section documented, in part, 9/29/22 Resident #5 is a male with history of inappropriate behaviors, seen today for initial interview per facility request for medication management. Staff report Resident #5 has always made some inappropriate comments and redirected easily. Recently Resident #5 grabbed a female residents breast and put his hand down the back of her shirt and a complaint was filed with the state. Resident #5 was sent to a BHU and returned on [MEDICATION(S)] (antidepressant) 10 mg (milligram) daily. Staff report he returned in better mood and did well for about a week, and now he is back to same behaviors. Resident #5 does yell out and cause disruption in the dining room and gets into arguments with other male residents. Resident #5 does ask the female staff to go to bed with him. The Review of Systems section documented the following per the Psychiatric section: staff report inappropriate sexual comments and behaviors; irritable mood and gets into arguments with other male residents with yelling. The Med Management Note dated 10/13/22 for Resident #5 documented, in part, the following: HPI Resident #5 is a male with history of inappropriate sexual comments and behaviors, along with getting into arguments with other male residents. The Psychiatric History section documented, in part, Recent admission to BHU for sexually inappropriate behavior towards staff and other female residents. The Review of Systems section documented the following per the Psychiatric section: staff report inappropriate sexual comments and behaviors; irritable mood and gets into arguments with other male residents with yelling. The SPN-Focused Evaluation Note dated 10/26/22 at 11:08 AM documented, No injuries noted to Left arm from being punched in the left arm by another resident. Doctor notified. On 10/27/22 at 1:15 PM, Staff A, Certified Nursing Assistant (CNA), had been queried about Resident #5's behaviors. Staff A explained Resident #5 tried to grab her by the gait belt, and would smack butt with a fly swatter. Staff A explained a lot of other women staff and residents had a problem with Resident #5 grabbing, touching, and saying things. Staff A identified a resident who did not like seeing the behavior, as well as a resident who had been bothered by Resident #5's behavior. Staff A explained Resident #5 would call people honey, and asked residents and staff to pull his [NAME] out. Staff A explained this occurred always, and she had witnessed this. When queried what she would do if the resident had sexual behaviors towards residents, Staff A responded she tried to shut down the situation, and would take the resident back to their room. Per Staff A, the resident wheeled around and rolled up on others. On 10/27/22 at 1:25 PM, when queried about Resident #5's behaviors, Staff B, CNA, explained they had seen where the resident would holler a lot and had been grabby towards females in the building. Staff B explained the resident liked to grab for peoples behinds and would grab for their belly. Staff B later clarified the behaviors had been towards staff. Staff B explained the other day Resident #5 and another male had gotten into an argument. Staff B also explained Resident #5 liked to go into other people's rooms, and explained a female resident had not been happy when Resident #5 had gone into her room. When specifically queried more about this, Staff B explained they only had known what the female resident had told her. When queried about Resident #5's behaviors towards residents, Staff B explained not as she had seen. When queried about Resident #5 having said anything to female residents, Staff B explained sometimes Resident #5 would say he wanted to go into the bathroom with them, and Staff B tried to avoid that. When queried what Staff B would do in this situation, Staff B explained she would normally just say we are not doing that and direct the resident back to his room. When queried if Resident #5 would be receptive, Staff B explained the resident did listen every now and then, and would sometimes be frustrated. On 10/27/22 at 2:19 PM, when queried about Resident #5's behaviors, Staff C, Licensed Practical Nurse (LPN) explained the resident did a lot of repeating very loud and could be disruptive. Staff C explained other residents would egg Resident #5 on as well. Per Staff C, Resident #5 did say inappropriate things sexually to staff and occasionally to the female residents, which had been why the resident sat by themself at the table. Staff C explained she had heard Resident #5 say to other female residents something like, gonna put my [NAME] in it. Staff C explained usually [NAME] was involved, and Resident #5 said they were going to put it somewhere to residents and staff. Per Staff C, she would explain it was not appropriate and to not talk like that. Staff C explained Resident #5 would usually quit. When queried if Resident #5 had touched any residents, Staff explained Resident #5 would get real close to them, and other residents would egg him on. Per Staff C if redirection didn't stop the behavior she would remove Resident #5 from the situation. Staff C explained usually Resident #5 settled down, and she had not had to remove him. Staff C acknowledged Resident #5 did know better, part of it was his dementia, and the resident knew better. Staff C explained a female resident one time had hollered at her (Staff C) to please get Resident #5 away from her. Staff C acknowledged Resident #5 could move himself in his wheelchair, and would roll up next to other residents until he received redirection. On 10/31/22 at 3:33 PM, Staff G, Registered Nurse (RN) had been queried about Resident #5's behaviors. Staff G explained she had never seen Resident #5 do anything physically. Staff G explained Resident #5 talked constantly and said all kinds of stuff. Per Staff G, Resident #5 had asked staff to lay down with him and give him a kiss, and got kind of inappropriate. Per Resident #5, there had been a couple women that Resident #5 had always wanted to talk to. Staff G explained Resident #5 liked to talk to Resident #12. Per Staff G, Resident #2 had told her Resident #5 had been making her uncomfortable. Staff G explained if memory served right there had been an accusation of Resident #5 touching someones knee or something on the porch. Staff G questioned if she had been thinking about the right time. When queried whose knee Resident #5 had touched, Staff G responded with Resident #2. When queried about the note she had input about Resident #5 grabbing at residents and staff, Staff G responded one of the CNAs had said the resident had grabbed her arm and pulled in bed. Per Staff G, Resident #5 made inappropriate remarks typically to staff. Staff G further explained Resident #5 had been sent out to geri psych, and had been sent back. Per Staff G, she had not seen Resident #5 touch Resident #2, Resident #2 had told Staff G, and Staff G had heard Resident #2 yell at Resident #5. Staff G explained Resident #5 had been on the porch, and Resident #2 had been on their way out of the porch. When queried who she had told, Staff G responded she had told whoever she had been working with that day. Staff G explained she could not remember if she had told the Director of Nursing (DON), or the other nurse. Staff G explained she had been at the facility one of the times Resident #5 had gone out. Staff G explained the resident had come back after supper. Per Staff G, she explained she seemed to remember Resident #5 saying he got in trouble again but was back. When queried if she would chart if she had told The DON or the Administrator, Staff G explained she should have charted in a note if they had been told. When it had been shared that Staff G had put in the note about Resident #5 having been sent out from the facility in August, Staff G explained she thought it would have been her to do the notification as she had put in the note. On 11/1/22 at 11:31 AM, Staff H, CNA explained she had worked at the facility for a few weeks, and acknowledged she had worked with Resident #5 before. When queried about the resident's behaviors, Staff H explained the resident had been sexual towards her, and she had seen him try to do things to other people and would tell him to quit. Staff H explained the resident had said some things to residents and staff. When queried as to what Resident #5 had said to residents, Staff H explained the resident made indecent proposals and said things. Staff H explained the resident liked to talk about his genitals in the middle of lunch and would say stuff. When queried if this had been when other residents had been around, Staff H responded it had been. When queried about touching, Staff H responded she had not seen Resident #5 try to touch residents, and the resident had tried touching staff. When queried as to why Resident #5 had been eating at a table by themself, Staff H explained she was not sure. Per Staff H, they had started putting a male resident next to him, but the resident had to be moved to another table for other reasons. When queried how other residents reacted, Staff H explained that a lot of them antagonized it so Resident #5 would keep going and thought it was funny. When queried how the resident would be antagonized, Staff H responded they would usually yell at Resident #5 to go back to his room, which got Resident #5 going more. Staff H further explained it would spiral, but it did not usually take long to get both parties to stop. Staff H explained someone would tell both of them to stop saying things and to leave each other alone. On 11/1/22 at 1:23 PM, Staff K, the facility's previous Activities Director, explained the following about Resident #5 's behaviors: Per Staff K Resident #5 was just loud, and she had never seen Resident #5 touch a resident or be inappropriate with a resident. Staff K explained the resident's previous occupation and explained the resident was used to joking. Staff K further explained with anything Resident #5 said to you, you could tell him don't say that and Resident #5 was apologetic. Staff K explained she felt like the other residents were mean to Resident #5, and being kind to others had been brought up in resident council. Staff K explained with Resident #5 it was like a stream of consciousness ran out of his mouth. On 11/2/22 at 8:18 AM, when queried about Resident #5's behaviors, Staff L, Licensed Practical Nurse (LPN), explained Resident #5 was very sexually oriented. Per Staff L, Resident #5 often invited people to be his honey and the resident said that he needed someone to sleep with and to lay down. Per Staff L, this behavior had been mostly towards staff. When queried about behaviors towards residents, Staff L explained they would sometimes catch the resident at night trying to knock on females doors. Staff L explained they would tell Resident #5 he could not do that because they were sleeping. Staff L confirmed the resident used a wheelchair, and explained the resident did not sleep at night, would sleep during the day, and would be up all night. Per continued interview with Staff L on 11/2/22 at approximately 8:20 AM, Staff L, Resident #5 used to be boyfriend and girlfriend with Resident #12. When asked about when the residents had been boyfriend and girlfriend, Staff L explained it had been before the first time Resident #12 had left the facility for inappropriate behavior. Staff L explained Resident #5 and Resident #12 used to sit and eat dinner together, and Resident #12 used to let Resident #5 in her room, but Staff L did not see what had gone on. Staff L explained that sometimes at 2:00 AM Resident #5 and Resident #12 would sit and talk together in the dining room, as both residents did not sleep well. When asked if she had been aware of any concerns or complaints which involved Resident #5, Staff L acknowledged this had occurred with Resident #2. Per Staff L, Resident #2 had told Staff L stop him from coming this way, and per Staff L Resident #2 had said didn't you hear he touched me inappropriately? Per Staff L, this occurred in the middle of August or so. When queried as to why the resident ate at a table by himself, Staff L explained this was about the resident's loud booming voice. 2. The MDS for Resident #2 dated 10/19/22 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated intact cognition. 3. The MDS assessment for Resident #7 dated 8/30/22 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated the resident had been cognitively intact. The Progress Note dated 9/2/22 present in Resident #7's clinical record documented, Resident stated that resident Resident #5 grabbed her right breast. Resident also stated that Resident #5 tried to rub her leg. Resident #5 immediately removed away from resident. No injuries noted. Administrator and Director of Nursing notified of incident. Mother was called and notified of incident. Education given to staff regarding Resident #5. On 11/1/22 at 1:59 PM, Resident #7 had been observed in their room in bed. When asked how other residents treated her, Resident #7 responded good. Resident #7 denied concerns, then explained the guy touched me, and explained it had been taken care of. Resident #7 then identified the guy as Resident #5. Per Resident #7, it had happened about a month ago. When queried where she had been touched, Resident #7 responded the thigh, crotch, and breast. When queried how it had made her feel, Resident #7 responded, creepy. When queried about safety, Resident #7 explained she was safe here (at the facility) now because he's gone. Resident #7 explained the situation had occurred in the lobby, and other residents had been around. Per Resident #7, she had notified staff and the Director of Nursing (DON). On 11/1/22 at 2:03 PM, Staff I, Licensed Practical Nurse (LPN) explained the following: Staff I had walked by Resident #7, and Resident #7 told Staff I that Resident #5 had grabbed her right breast and thigh. Per Staff I, she had made sure the resident were separated out in the common area. Staff I acknowledged she had not seen the interaction, and Resident #7 had voiced it. Staff I explained she had told the DON, and had communicated to staff they needed to keep watch on Resident #5. Staff I explained it had been reported, and residents were immediately separated. 4. The Quarterly Minimum Data Set (MDS) assessment for Resident #1 dated 7/13/22 revealed the resident scored 10 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. The Minimum Data Set (MDS) assessment for Resident #1 dated 10/5/22 revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. On 10/27/22 at 10:28 AM, an interview had been conducted with Resident #1. Resident #1 identified Resident #5 by first name, and explained the first time Resident #5 had met Resident #1, Resident #5 had grabbed her boob. Per Resident #1, this had occurred in the dining room when they had just started to eat supper. Per Resident #1, Resident #5 had grabbed and ran off. Resident #1 explained the resident had also hit on her twenty-three year old granddaughter, and Resident #1 had threatened to throat punch Resident #5. Resident #1 explained conversation had occurred with her family, and Resident #1 expressed he's (Resident #5) not assaulting me? When queried how the touching had made her feel, Resident #1 responded it had made her feel like she wanted to kill Resident #5. Resident #1 explained Resident #5 said things like, come here honey let's go to my room, and the resident would be brought to his table. Resident #1 explained a couple times the resident had tried to reach out for her breast, and had not made physical contact as she would not let Resident #5 close enough. When queried about feeling safe at the facility, Resident #1 responded, in part, she was safe to stay [at the facility] as long as Resident #5 left her alone. When queried about who had been present when she had been touched, Resident #1 responded just the nurses. When queried as to how often Resident #5 tried to touch Resident #1, Resident #1 responded every chance that Resident #5 got close. Resident #1 explained they did not need to have someone try to hit on them at their current stage in their life. 5.On 10/25/22 during a confidential interview, an anonymous resident explained there had been a man, identified by the resident as Resident #5, who would come knock on their door in the middle of the night. Per the anonymous resident, the response had been the resident (male) had dementia. The anonymous resident explained everyone knew about it. On 10/27/22 at approximately 8:15 AM, the anonymous resident expressed concern with having her door open at night with her rear end exposed, in regard to potential physical contact occurring. Resident #5 explained they would pepperspray them. 6. The Minimum Data Set (MDS) assessment for Resident #12 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident had intact cognition. Resident #12 had been previously identified during an interview with Staff L as Resident #5's girlfriend. 7. The MDS assessment dated [DATE] revealed Resident #6 scored 15 out of 15 on a BIMS exam, which indicated intact cognition. During an interview on 10/27/22 at 4:55 PM, Resident #6 explained they would punch Resident #5 if the resident did not shut his mouth. Per Resident #6, Resident #5 had been vulgar, and said things to people that should not be said. Resident #6 explained others live here (at the facility) too. When queried about the type of things that had been said, Resident #6 explained Resident #5 had said things such as, hey baby to residents and staff. Resident #6 explained Resident #5 was mouthy, threatened to punch him (Resident #6) out, and that it happened all the time. Resident #6 explained he felt/responded to bring it on. Resident #6 further explained he did not like the way Resident #5 talked to women and guys. Resident #6 explained one day Resident #5 had gone to [a female], had said weird things, and went to her table. Per Resident #6, something had been said like come to my bedroom, and he (Resident #6) had not liked that. Resident #6 further explained Resident #5 had asked him how he held his penis with one hand. Resident #6 explained this had made him angry. Per Resident #6, others were tired of Resident #5 too, and explained it would come to a head pretty soon. Resident #6 explained Resident #5 did not want to shut their [expletive] mouth. Resident #6 had been queried what they did in this situation, explained they would remove themselves from the situation. When queried if staff spoke with Resident #6 about the situation, Resident #6 responded that staff did not care. 8. The MDS assessment for Resident #8 dated 10/5/22 revealed Resident #8 scored 3 out of 15 on a BIMS assessment, which indicated severe cognitive impairment. Per this assessment, Resident #8 had no physical or verbal behavioral symptoms towards others, or other behavioral symptoms not directed towards others. On 10/31/22 at 1:17 PM, Resident #8 had been queried how other residents at the facility treated him, and responded good. When queried about problems, concerns, or statements which made him feel uncomfortable, Resident #8 mentioned Resident #5's name. Resident #8 explained it was not towards him but to other residents. Per Resident #8, Resident #5 would say to the female residents, Hey why don't you go to my room and take off your clothes and stuff like that. When queried about which specific ladies had been told, Resident #8 responded he thought a resident who no longer resided at the facility. When queried how it had made him feel, Resident #8 responded like he wanted to get in a fight with Resident #5, but he had not done so. When queried if there had been a specific resident that Resident #5 had made the comment to, Resident #8 explained he thought a resident who he named, and further explained the resident no longer resided at the facility. Resident #8 had been queried if there had been a situation where any of the following had occurred between Resident #5 and Resident #8: touched, kicked, hit, or punched. Resident #8 responded I hit him (Resident #5) in the arm once. When queried what had brought the situation to that point, Resident #8 explained Resident #5 had said something. When queried about the timeframe the incident had occurred, Resident #8 explained fairly recently. On 11/1/22 at 8:53 AM, the Administrator explained Resident #5 did not have any other facility reported incidents or incident reports other than 9/2/22 and 10/26/22. On 11/7/22 at 3:50 PM, the Director of Nursing (DON) had been queried about staff reporting. When queried about staff education on reporting, the DON explained that staff did online training, and the information would be reviewed when staff did their onboarding. The DON also explained staff had six months to complete Dependent Adult Abuse training. When queried about what should be reported, the DON explained any incidents which is considered abuse should be reported. The DON explained the current process was to report to the Charge Nurse, DON, and to the Administrator. Per the DON, they always let staff report to the Charge Nurse anything they saw concerning happening, any aggression, or any abuse of any sort. The DON explained the previous way it had been done was staff would go to the Charge Nurse, who would report to the DON or to the Administrator. When queried about the time frame for reporting, the DON explained staff needed to report right away. On 11/7/22 at 3:54 PM, the Director of Nursing (DON) had been queried as to the process that should happen if a staff member charted inappropriate behavior, or grabbing at other residents. The DON responded staff needed to let them know if this had been happening, and if charting it it needed to be reported because that behavior was inappropriate or abuse. Per the DON, the physician would be notified. On 11/8/22 at 4:05 PM, the DON had been queried if staff had reported behaviors to her about Resident #5 and other residents. The DON explained the resident was loud, repeated himself, and was persistent. When queried if staff had reported the resident asking people to pull his genitals out, the DON explained she had never heard that. When queried if the statement the resident wanted to go to the bathroom with other residents had come up, the DON acknowledged this had not been told to her. When queried about Resident #5 knocking on doors at nighttime, the DON explained for the most part the resident slept all night and she had not heard that the resident had been knocking on people's doors at night. The DON acknowledged Resident #5's behaviors towards residents needed to be reported, if it was actively happening redirection was needed and staff would stay with the resident, it would be reported, then investigated. On 11/8/22 at 12:32 PM, the facility's Administrator had been queried about reporting, and explained any complaints of abuse or anything they may see should be reported to the immediate supervisor, and that immediate supervisor would comes to the Administrator and the Director of Nursing. The Administrator further explained if the person that saw it felt they did not get the right response they could go to management immediately as well. The facility Administrator acknowledged if staff had charted or seen behaviors, they should have told the Charge Nurse or supervisor what they had seen. The Administrator acknowledged she had not been informed of Resident #5 knocking on doors at night, or certain statements made by the resident. The Facility Policy titled, Timely Abuse Reporting dated 11/19 documented, All allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the Charge Nurse. The Charge Nurse is responsible for immediately reporting allegations of abuse to the Administrator, or designated representative. All allegations of resident abuse shall be reported to the Iowa Department of Inspections and Appeals no later than two (2) hours a[TRUNCATED]

Based on observation, clinical record review, staff and resident interviews and Policy review, the facility failed to take measures to fully investigate allegations of abuse and failed to prevent and protect residents from further potential abuse during the investigation. A resident sexually abused another resident who resided at the facility when Resident #5 touched the breast of Resident #1 and Resident #7. Resident #1 stated the fact that Resident #5 touched her breast made her feel like she wanted to kill him. Resident#1 stated Resident #5 has made ongoing physical attempts to reach out and touch her breast. Record review revealed a history of inappropriate behaviors and a lack of protective measures taken or investigations completed. Staff interview revealed an alleged incident involving Resident #2 and Resident #5 that did not get reported to the State Agency, and staff were unable to recall some specific details about the alleged event. This resulted in an Immediate Jeopardy to residents who currently resided at the facility. The facility reported a census of 36 residents. Findings Include: 1. The Quarterly Minimum Data Set (MDS) Assessment for Resident #5 dated 6/29/22 revealed the resident rarely to never understood. Per this assessment, Resident #5 had severely impaired cognitive skills for daily decision making and had verbal behavior symptoms towards others which occurred daily. The Care Plan dated 9/2/22 documented, I display socially inappropriate/disruptive behavior. I sometimes display sexually inappropriate behaviors. Interventions on the Care Plan dated 9/2/22 included the following: a. 9/2/22 I will be placed at a table by myself for meals. b. Activities staff to visit with me and provide diversional activities. c. Administer my behavior medications as ordered by physician. d. Encourage my family/responsible party to visit. e. Monitor and document my behavior. f. Praise me for demonstrating desired behavior. g. Remove me from public areas when behavior is disruptive and unacceptable. h. Talk with me in a calm voice when my behavior is disruptive. Interventions on the Care Plan dated 10/27/22 included the following: a. I am receiving psych services. b. I will be having a medication review with my doctor. The Care Plan dated 9/15/22 documented, I have a behavior problem, I yell and repeat things frequently. Interventions per the Care Plan documented the following: a. Date initiated 8/16/22: Divert my attention. Remove me from situations as needed and take me to an alternate location as needed. b. Date initiated 9/8/22: I may need to be reminded to keep my hands to myself. c. Date initiated 8/16/22: Intervene as necessary to protect the rights and safety of others. Progress Notes for Resident #5 documented the following: a. The Orders-Administration Note dated 7/27/22 at 10:04 PM documented, Resident being sexually inappropriate. b. The Orders-Administration Note dated 7/30/22 at 11:44 PM documented, Resident was being sexually inappropriate today. c. The Orders-Administration Note dated 8/2/22 at 10:06 PM documented, sexually inappropriate behaviors. d. The Orders-Administration Note dated 8/4/22 at 10:07 PM documented, Resident continues to struggle with keeping his hands to himself. Grabbing at both staff and other residents. e. The Orders-Administration Note dated 8/8/2022 at 11:17 PM documented, Resident continues to be difficult to keep from touching others. The Care Plan Conference Summary dated 8/9/22 at 3:30 PM documented, reviewed Care Plan for Nursing, Dietary, Social Work and Activities. Resident's son was notified the resident has been having inappropriate behaviors. Resident's son states that he would approve a psych consult and to keep him updated. The Einteract Summary dated 8/10/22 at 12:52 PM documented, in part, documented by Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Send to ED for psych/behavioral evaluation. B. New Intervention Orders: a. Other. b. Redirection. Review of the Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form dated 8/10/22 documented the risk alert for other had been selected, with intrusive and sexual behaviors documented. The behavioral issues and interventions section documented, intrusive behaviors. Resident is grabbing staff inappropriately. Resident is trying to grab other female residents and enter female residents' rooms. Resident is making inappropriate sexual behaviors toward staff and other residents. The Mental Status Evaluation documented the following symptoms or signs: sexual outbursts and inappropriate grabbing. The Behavioral Evaluation section documented the following symptoms or signs: sexual outbursts, grabbing staff and attempting to grab other residents inappropriately. Trying to enter female residents' rooms. Review of Hospital Paperwork for Resident #5, admission and discharge date [DATE], documented, History of Present Illness: Patient is an [age redacted]-year-old man who presents from a Nursing Facility with concern for agitation. Apparently he has recently been sexually inappropriate at his nursing facility, today he cornered another resident and was screaming at her. These behaviors were abnormal for him. Patient denies any wrongdoing. He does not seem to recall yelling at anyone or doing anything wrong. The Nurses Note dated 8/10/22 at 5:37 PM documented, Received call from [Hospital Name] regarding resident status, Resident is being released due to (d/t) not meeting criteria for Geri Psych. Nurse suggested facility seek Outpatient Psychiatric Treatment. The Orders-Administration Noted dated 8/10/2022 at 10:45 PM documented, in part, Resident was sent to [name redacted] for psych evaluation d/t constant inappropriate behavior. Review of Discharge Instructions dated 8/10/22, documented the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Social Services Behavior History Evaluation-V 3 dated 8/16/22 documented the following question (Q) and answer (A): Q: 1. Making noises, grinding teeth, moaning, crying, strange noises, screaming and/or disruptive sounds? A: a. Yes Q: 1 b. If yes, is there a known trigger for this behavior? A: When he is around other people. Q: Effective Intervention? A: We try to ask him to be nice and respect others. Q: 13. Sexual acting out; explicit talk; physical sexual advances? A: b. No The Incident/Accident/Unusual Occurrence Note dated 9/2/2022 at 11:00 AM documented, this nurse walked up the hallway. This nurse noticed the resident sitting next to Resident #7 in lobby. Resident #7 states that this resident grabbed her right breast and tried to rub her leg. This resident immediately removed from resident [number redacted]. Administrator and Director of Nursing notified of incident. The Nurses Note dated 9/2/22 at 1:27 PM documented, the Resident #5's Power of Attorney (POA) notified for resident to be sent to [Facility Name in City Name Redacted]. Review of Inpatient Discharge Instructions dated 9/2/22 documented the following reason for visit: Inappropriate sexual behavior current nursing home towards another resident. Review of the Social Services Behavior History Evaluation-V 3 assessment dated [DATE] documented the following question (Q) and answer (A): Q: 13. Sexual acting out; explicit talk; physical sexual advances? A: a. Yes. The assessment also documented Resident #5 had displayed sexual acting out behavior. Known triggers for the behavior documented, not sure. The response to the question of effective intervention documented, staff asks him to stop and talks to him about his behavior. The Progress Note by a Nurse Practitioner of the facility, date of service 9/21/22, documented the resident had been seen for follow-up hospital. History of Present Illness (HPI) related to this visit documented, in part, Patient went to emergency room (ER) for a psych evaluation after inappropriate behaviors. Patient reports he believes he got back a week ago. No other content of the note referenced Resident #5's behaviors. The Medication Management Note dated 9/29/22, documented a chief complaint of inappropriate behaviors and agitation. The HPI section documented, in part, 9/29/22 - Resident #5 is a [age redacted] year old (y/o) male with history of inappropriate behaviors, seen today for initial interview per facility request for medication management. Staff report Resident #5 has always made some inappropriate comments and redirected easily. Recently Resident #5 grabbed a female resident's breast and put his hand down the back of her shirt and a complaint was filed with the state. Resident #5 was sent to a Behavioral Health Unit (BHU) and returned on [MEDICATION(S)] (antidepressant) 10 milligrams (mg) daily. Staff report he returned in a better mood and did well for about a week, and now he is back to same behaviors. Resident #5 does yell out and cause disruption in the dining room and gets into arguments with other male residents. Resident #5 does ask the female staff to go to bed with him. The Review of Systems section documented the following per the Psychiatric section: staff report inappropriate sexual comments and behaviors; irritable mood and gets into arguments with other male residents with yelling. The Medication Management Note dated 10/13/22 for Resident #5 documented, in part, the following: HPI - Resident #5 is a [age redacted] y/o male with history of inappropriate sexual comments and behaviors, along with getting into arguments with other male residents. The Psychiatric History section documented, in part, recent admission to BHU for sexually inappropriate behavior towards staff and other female residents. The Review of Systems section documented the following per the Psychiatric section: staff report inappropriate sexual comments and behaviors; irritable mood and gets into arguments with other male residents with yelling. The SPN-Focused Evaluation Note dated 10/26/22 at 11:08 AM documented, No injuries notes to Left arm from being punched in the left arm by another resident. Dr. [Name Redacted] notified. On 10/27/22 at 1:15 PM, Staff A, Certified Nursing Assistant (CNA), had been queried about Resident #5's behaviors. Staff A explained Resident #5 tried to grab her by the gait belt, and would smack her butt with a fly swatter. Staff A explained a lot of other women staff and residents had a problem with Resident #5 grabbing, touching, and saying things. Staff A identified a resident who did not like seeing the behavior, as well as a resident who had been bothered by Resident #5's behavior. Staff A explained Resident #5 would call people honey, and asked residents and staff to pull his [NAME] out. Staff A explained this occurred always, and she had witnessed this. When queried what she would do if the resident had sexual behaviors towards residents, Staff A responded she tried to shut down the situation, and would take the resident back to their room. Per Staff A, the resident wheeled around in a wheelchair and rolled up on others. On 10/27/22 at 1:25 PM, when queried about Resident #5's behaviors, Staff B, CNA, explained they had seen where the resident would holler a lot and had been grabby towards females in the building. Staff B explained the resident liked to grab for peoples behinds and would grab for their belly. Staff B later clarified the behaviors had been towards staff. Staff B explained the other day Resident #5 and another male had gotten into an argument. Staff B also explained Resident #5 liked to go into other people's rooms, and explained a female resident had not been happy when Resident #5 had gone into her room. When specifically queried more about this, Staff B explained they only had known what the female resident had told her. When queried about Resident #5's behaviors towards residents, Staff B explained none as she had seen. When queried about Resident #5 having said anything to female residents, Staff B explained sometimes Resident #5 would say he wanted to go into the bathroom with them, and Staff B tried to avoid that. When queried what Staff B would do in this situation, Staff B explained she would normally just say to Resident #5 we are not doing that and direct the resident back to his room. When queried if Resident #5 would be receptive, Staff B explained the resident did listen every now and then, and would sometimes be frustrated. On 10/27/22 at 2:19 PM, when queried about Resident #5's behaviors, Staff C, Licensed Practical Nurse (LPN) explained the resident did a lot of repeating very loud and could be disruptive. Staff C explained other residents would egg Resident #5 on as well. Per Staff C, Resident #5 did say inappropriate things sexually to staff and occasionally to the female residents, which had been why the resident sat by themselves at the table. Staff C explained she had heard Resident #5 say to other female residents something like, gonna put my [NAME] in it. Staff C explained usually [NAME] was involved, and Resident #5 said they were going to put it somewhere to residents and staff. Per Staff C, she would explain it was not appropriate and to not talk like that. Staff C explained Resident #5 would usually quit. When queried if Resident #5 had touched any residents, Staff explained Resident #5 would get real close to them, and other residents would egg him on. Per Staff C if redirection didn't stop the behavior she would remove Resident #5 from the situation. Staff C explained usually Resident #5 settled down, and she had not had to remove him. Staff C acknowledged Resident #5 did know better, part of it was his dementia, and the resident knew better. Staff C explained a female resident one time had hollered at her (Staff C) to please get Resident #5 away from her. Staff C acknowledged Resident #5 could move himself in his wheelchair, and would roll up next to other residents until he received redirection. On 10/31/22 at 3:33 PM, Staff G, Registered Nurse (RN) had been queried about Resident #5's behaviors. Staff G explained she had never seen Resident #5 do anything physically. Staff G explained Resident #5 talked constantly and said all kinds of stuff. Per Staff G, Resident #5 had asked staff to lay down with him and give him a kiss, and got kind of inappropriate. Per Resident #5, there had been a couple women that Resident #5 had always wanted to talk to. Staff G explained Resident #5 liked to talk to Resident #2. Per Staff G, Resident #2 had told her Resident #5 had been making her uncomfortable. Staff G explained if memory served right there had been an accusation of Resident #5 touching someone's knee or something on the porch. Staff G questioned if she had been thinking about the right time. When queried whose knee Resident #5 had touched, Staff G responded with Resident #2. When queried about the note she inputted about Resident #5 grabbing at residents and staff, Staff G responded one of the CNAs had said the resident had grabbed her arm and pulled in bed. Per Staff G, Resident #5 made inappropriate remarks typically to staff. Staff G further explained Resident #5 had been sent out to Geri Psych, and had been sent back. Per Staff G, she had not seen Resident #5 touch Resident #2, Resident #2 had told Staff G, and Staff G had heard Resident #2 yell at Resident #5. Staff G explained Resident #5 had been on the porch, and Resident #2 had been on their way out of the porch. When queried who she had told, Staff G responded she had told whoever she had been working with that day. Staff G explained she could not remember if she had told the Director of Nursing (DON), or the other nurse. Staff G explained she had been at the facility one of the times Resident #5 had gone out. Staff G explained the resident had come back after supper. Per Staff G, she explained she seemed to remember Resident #5 saying he got in trouble again but was back. When queried if she would chart if she had told the DON or the Administrator, Staff G explained she should have charted in a note if they had been told. When it had been shared that Staff G had put in the note about Resident #5 having been sent out from the facility in August, Staff G explained she thought it would have been her to do the notification as she had put in the note. On 11/1/22 at 11:31 AM, Staff H, CNA explained she had worked at the facility for a few weeks, and acknowledged she had worked with Resident #5 before. When queried about the resident's behaviors, Staff H explained the resident had been sexual towards her, and she had seen him try to do things to other people and would tell him to quit. Staff H explained the resident had said some things to residents and staff. When queried as to what Resident #5 had said to residents, Staff H explained the resident made indecent proposals and said things. Staff H explained the resident liked to talk about his genitals in the middle of lunch and would say stuff. When queried if this had been when other residents had been around, Staff H responded it had been. When queried about touching, Staff H responded she had not seen Resident #5 try to touch residents, and the resident had tried touching staff. When queried as to why Resident #5 had been eating at a table by themselves, Staff H explained she was not sure. Per Staff H, they had started putting a male resident next to him, but the resident had to be moved to another table for other reasons. When queried how other residents reacted, Staff H explained that a lot of them antagonized it so Resident #5 would keep going and thought it was funny. When queried how the resident would be antagonized, Staff H responded they would usually yell at Resident #5 to go back to his room, which got Resident #5 going more. Staff H further explained it would spiral, but it did not usually take long to get both parties to stop. Staff H explained someone would tell both of them to stop saying things and to leave each other alone. On 11/1/22 at 1:23 PM, Staff K, the facility's previous Activities Director, explained the following about Resident #5's behaviors: Per Staff K Resident #5 was just loud, and she had never seen Resident #5 touch a resident or be inappropriate with a resident. Staff K explained the resident's previous occupation and explained the resident was used to joking. Staff K further explained with anything Resident #5 said to you, you could tell him (Resident #5) don't say that and Resident #5 was apologetic. Staff K explained she felt like the other residents were mean to Resident #5, and being kind to others had been brought up in resident council. Staff K explained with Resident #5 it was like a stream of consciousness ran out of his mouth. On 11/2/22 at 8:18 AM, when queried about Resident #5's behaviors, Staff L, Licensed Practical Nurse (LPN), explained Resident #5 was very sexually oriented. Per Staff L, Resident #5 often invited people to be his honey and the resident said that he needed someone to sleep with and to lay down. Per Staff L, this behavior had been mostly towards staff. When queried about behaviors towards residents, Staff L explained they would sometimes catch the resident at night trying to knock on females doors. Staff L explained they would tell Resident #5 he could not do that because they were sleeping. Staff L confirmed the resident used a wheelchair, and explained the resident did not sleep at night, would sleep during the day, and would be up all night. Per continued interview with Staff L on 11/2/22 at approximately 8:20 AM, Staff L, explained Resident #5 used to be boyfriend and girlfriend with Resident #12. When asked about when the residents had been boyfriend and girlfriend, Staff L explained it had been before the first time Resident #12 had left the facility for inappropriate behavior. Staff L explained Resident #5 and Resident #12 used to sit and eat dinner together, and Resident #12 used to let Resident #5 in her room, but Staff L did not see what had gone on. Staff L explained that sometimes at 2:00 AM Resident #5 and Resident #12 would sit and talk together in the dining room, as both residents did not sleep well. When asked if she had been aware of any concerns or complaints which involved Resident #5, Staff L acknowledged this had occurred with Resident #2. Per Staff L, Resident #2 had told Staff L stop him from coming this way, and per Staff L Resident #2 had said didn't you hear he touched me inappropriately? Per Staff L, this occurred in the middle of August or so. When queried as to why the resident ate at a table by himself, Staff L explained this was about the resident's loud booming voice. 2. The MDS for Resident #2 dated 10/19/22 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated intact cognition. 3. The MDS Assessment for Resident #7 dated 8/30/22 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated the resident had been cognitively intact. The Progress Note dated 9/2/22 present in Resident #7's clinical record documented, Resident states that Resident #5 grabbed her right breast. Resident also stated that Resident #5 tried to rub her leg. Resident #5] immediately removed away from resident. No injuries noted. Administrator and Director of Nursing notified of incident. Mother, [Name Redacted], called and notified of incident. Education given to staff regarding Resident #5. On 11/1/22 at 1:59 PM, Resident #7 observed in their room in bed. When asked how other residents treated her, Resident #7 responded good. Resident #7 denied concerns, then explained the guy touched me, and explained it had been taken care of. Resident #7 then identified the guy as Resident #5. Per Resident #7, it had happened about a month ago. When queried where she had been touched, Resident #7 responded the thigh, crotch, and breast. When queried how it had made her feel, Resident #7 responded, creepy. When queried about safety, Resident #7 explained she was safe here (at the facility) now because he's gone. Resident #7 explained the situation had occurred in the lobby, and other residents had been around. Per Resident #7, she had notified staff and the Director of Nursing (DON). On 11/1/22 at 2:03 PM, Staff I, Licensed Practical Nurse (LPN) explained the following: Staff I had walked by Resident #8, and Resident #8 told Staff I that Resident #5 had grabbed her right breast and thigh. Per Staff I, she had made sure the resident were separated out in the common area. Staff I acknowledged she had not seen the interaction, and Resident #7 had voiced it. Staff I explained she had told the DON, and had communicated to staff they needed to keep watch on Resident #5. Staff I explained it had been reported, and residents were immediately separated. 4. The Quarterly Minimum Data Set (MDS) Assessment for Resident #1 dated 7/13/22 revealed the resident scored 10 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. The Minimum Data Set (MDS) Assessment for Resident #1 dated 10/5/22 revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. On 10/27/22 at 10:28 AM, an interview had been conducted with Resident #1. Resident #1 identified Resident #5 by first name, and explained the first time Resident #5 had met Resident #1, Resident #5 had grabbed her boob. Per Resident #1, this had occurred in the dining room when they had just started to eat supper. Per Resident #1, Resident #5 had been grabbed and ran off. Resident #1 explained the resident had also hit on her twenty-three year old granddaughter, and Resident #1 had threatened to throat punch Resident #5. Resident #1 explained the conversation had occurred with her family, and Resident #1 expressed he's (Resident #5) not assaulting me? When queried how the touching had made her feel, Resident #1 responded it had made her feel like she wanted to kill Resident #5. Resident #1 explained Resident #5 said things like, come here honey let's go to my room, and the resident would be brought to his table. Resident #1 explained a couple times the resident had tried to reach out for her breast, and had not made physical contact as she (Resident #1) would not let Resident #5 close enough. When queried about feeling safe at the facility, Resident #1 responded, in part, she was safe to stay at the facility as long as Resident #5 left her alone. When queried about who had been present when she had been touched, Resident #1 responded just the nurses. When queried as to how often Resident #5 tried to touch Resident #1, Resident #1 responded every chance that Resident #5 got close. Resident #1 explained they did not need to have someone try to hit on them at their current stage in their life. 5. On 10/25/22 during a confidential interview, an anonymous resident explained there had been a man, identified by the resident as Resident #5, who would come knock on their door in the middle of the night. Per the anonymous resident, the response had been the resident (male) had dementia. The anonymous resident explained everyone knew about it. On 10/27/22 at approximately 8:15 AM, the anonymous resident expressed concern with having her door open at night with her rear end exposed, in regard to potential physical contact occurring. Resident #5 explained they would pepper spray them. 6. The Minimum Data Set (MDS) assessment for Resident #12 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident had intact cognition. Resident #12 had been previously identified during an interview with Staff L as Resident #5's girlfriend. 7. The MDS assessment dated [DATE] revealed Resident #6 scored 15 out of 15 on a BIMS exam, which indicated intact cognition. During an interview on 10/27/22 at 4:55 PM, Resident #6 explained they would punch Resident #5 if the resident did not shut his mouth. Per Resident #6, Resident #5 had been vulgar, and said things to people that should not be said. Resident #6 explained others live here (at the facility) too. When queried about the type of things that had been said, Resident #6 explained Resident #5 had said things such as, hey baby to residents and staff. Resident #6 explained Resident #5 was mouthy, threatened to punch him (Resident #6) out, and that it happened all the time. Resident #6 explained he felt/responded to bring it on. Resident #6 further explained he did not like the way Resident #5 talked to women and guys. Resident #6 explained one day Resident #5 had gone to a female, had said weird things, and went to her table. Per Resident #6, something had been said like come to my bedroom, and he (Resident #6) had not liked that. Resident #6 further explained Resident #5 had asked him how he (Resident #6) held his penis with one hand. Resident #6 explained this had made him angry. Per Resident #6, others were tired of Resident #5 too, and explained it would come to a head pretty soon. Resident #6 explained Resident #5 did not want to shut their [expletive] mouth. Resident #6 had been queried what they did in this situation, explained they would remove themselves from the situation. When queried if staff spoke with Resident #6 about the situation, Resident #6 responded that staff did not care. 8. The MDS Assessment for Resident #8 dated 10/5/22 revealed Resident #8 scored 3 out of 15 on a BIMS Assessment, which indicated severe cognitive impairment. Per this assessment, Resident #8 had no physical or verbal behavioral symptoms towards others, or other behavioral symptoms not directed towards others. On 10/31/22 at 1:17 PM, Resident #8 had been queried how other residents at the facility treated him, and responded good. When queried about problems, concerns, or statements which made him feel uncomfortable, Resident #8 mentioned Resident #5's name. Resident #8 explained it was not towards him but to other residents. Per Resident #8, Resident #5 would say to the female residents, Hey, why don't you go to my room and take off your clothes and stuff like that. When queried about which specific ladies had been told, Resident #8 responded he thought a resident who no longer resided at the facility. When queried how it had made him feel, Resident #8 responded like he wanted to get in a fight with Resident #5, but he had not done so. When queried if there had been a specific resident that Resident #5 had made the comment to, Resident #8 explained he thought a resident who he named, and further explained the resident no longer resided at the facility. Resident #8 had been queried if there had been a situation where any of the following had occurred between Resident #5 and Resident #8: touched, kicked, hit, or punched. Resident #8 responded I hit him (Resident #5) in the arm once. When queried what had brought the situation to that point, Resident #8 explained Resident #5 had said something. When queried about the timeframe the incident had occurred, Resident #8 explained fairly recently On 11/1/22 at 8:53 AM, the Administrator explained Resident #5 did not have any other facility reported incidents or incident reports other than 9/2/22 and 10/26/22. On 11/7/22 at 3:54 PM, the Director of Nursing (DON) had been queried as to the process that should happen if a staff member charted inappropriate behavior, or grabbing at other residents. The DON responded staff needed to let them know if this had been happening, and if charting it, it needed to be reported because that behavior was inappropriate or abuse. Per the DON, the physician would be notified. On 11/8/22 at 4:05 PM, the DON had been queried if staff had reported behaviors to her about Resident #5 and other residents. The DON explained the resident was loud, repeated himself, and was persistent. When queried if staff had reported the resident asking people to pull his genitals out, the DON explained she had never heard that. When queried if the statement the resident wanted to go to the bathroom with other residents had come up, the DON acknowledged this had not been told to her. When queried about Resident #5 knocking on doors at nighttime, the DON explained for the most part the resident slept all night and she had not heard that the resident had been knocking on people's doors at night. The DON acknowledged Resident #5's behaviors towards residents needed to be reported, if it was actively happening redirection was needed and staff would stay with the resident, it would be reported, then investigated. On 11/8/22 at 12:32 PM, the facility's Administrator had been queried as to what would trigger an investigation, and responded any reports of abuse. The Facility Policy titled Mandatory Reporting Abuse Investigation dated 2019 documented, All Allegations of Resident abuse should be reported immediately to the charge nurse. The Charge Nurse is responsible for immediately reporting the allegations of abuse to the Director of Nursing, Administrator, or designated representative. Should an incident or suspected incident of resident abuse (as defined above) be reported or observed, the Administrator or his/her designee will designate a member of management to investigate the alleged incident. The Administrator or designee will designate a member of management to investigate the alleged incident. The Administrator or designee will complete documentation of the allegation of resident abuse and collect any supporting documents relative to the alleged incident and complete the following: a. Review documentation in resident record (including review of assessment and resident injury). b. Assess the resident for injury if the allegation involved physical or sexual abuse. c. Provide proper notifications to Primary Care Provider, responsible party, etc. d. Attempt to obtain witness statements (oral and/or written) from all known witnesses. e. If there is physical evi [TRUNCATED]

Based on clinical record review, policy review, and staff interview, the facility failed to implement an effective, comprehensive quality assurance and performance improvement (QAPI) program to correct negative outcomes after staff became aware of inappropriate sexual behavior by Resident #5 directed at other residents. The facility reported a census of 36 residents. Findings include: 1. The Orders-Administration Note dated 7/27/22 at 10:04 PM documented, Resident #5 being sexually inappropriate. The Orders-Administration Note dated 7/30/22 at 11:44 PM documented, Resident #5 was being sexually inappropriate today. The Orders-Administration Note dated 8/2/22 at 10:06 PM documented, Sexually inappropriate behaviors. The Orders-Administration Note dated 8/4/22 at 10:07 PM documented, Resident continues to struggle with keeping his hands to himself. Grabbing at both staff and other residents. The Orders-Administration Note dated 8/8/2022 at 11:17 PM documented, Resident continues to be difficult to keep from touching others. The Care Plan Conference Summary dated 8/9/22 at 3:30 PM documented, Reviewed care plan for nursing, dietary, social work and activities. Resident's son was notified that resident has been having inappropriate behaviors. Resident's son states that he would approve a psych consult and to keep him updated. The Einteract Summary dated 8/10/22 at 12:52PM documented, in part, physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Send to ED for psych/behavioral evaluation .C. New Intervention Orders: a. Other b. redirection Review of the SNF/NF (Skilled Nursing Facility/Nursing Facility) to Hospital Transfer Form dated 8/10/22 documented the risk alert for other had been selected, with intrusive and sexual behaviors documented. The behavioral issues and interventions section documented, intrusive behaviors. Resident is grabbing staff inappropriately. Resident is trying to grab other female residents and enter female residents rooms. Resident is making inappropriate sexual behaviors toward staff and other residents. The Mental Status Evaluation documented the following symptoms or signs: sexual outbursts and inappropriate grabbing. The Behavioral Evaluation section documented the following symptoms or signs: sexual outbursts, grabbing staff and attempting to grab other residents inappropriately. Trying to enter female residents rooms. The Incident,Accident,Unusual Occurrence Note dated 9/2/2022 at 11:00 AM documented, This nurse walked up the hallway. This is nurse noticed this resident sitting next to resident [Resident #7] in lobby. Resident [Resident #7] states that this resident grabbed her right breast and tried to rub her leg. This resident immediately removed from resident [number redacted].Administrator and Director of Nursing notified of incident Review of the facility QAPI program for the period of 8/1/22-11/8/22 revealed a 10/24/22 Quarterly Quality Assurance committee minute report. The report stated under the topic Resident Behavior Concerns: [Resident #5's name], increase [MEDICATION(S)](a medication used to treat seizures and [CONDITION(S)]). The minutes lacked documentation of further corrective actions or solutions with regard to Resident #5's behavior. The facility policy Quality Assurance and Performance Improvement Program, revised March 2020, stated the QAPI committee would identify and help to resolve negative outcomes and implement systems to correct potential issues in quality of care. During an interview on 11/8/22 at 9:15 a.m., the DON(Director of Nursing) stated she had not additional QAPI/QA committee documentation other than what she provided above. During an interview on 11/8/22 at 11:45 a.m., the Administrator stated she was not aware of the concerns staff related regarding Resident #5's behavior. She stated if she had been aware of the concerns, they would have discussed the situation more in QAPI meetings and would have talked about more interventions.

Based on personnel file review, policy review, and staff interview, the facility failed to implement training's for multiple training topics for 5 of 5 staff reviewed(Staff G, H, K, N, and O). The facility reported a census of 36 residents. Findings Include: 1. An untitled, undated facility staff education report listed hire dates and training completed during the period of 11/2/21-11/2/22 for Staff G Registered Nurse(RN), Staff H Certified Nursing Assistant(CNA), Staff K CNA, Staff N CNA and Staff O CNA. The report listed a hire date of 7/7/22 for Staff G, a hire date of 1/12/01 for Staff H, a hire date of 6/25/03 for Staff K, a hire date of 12/21/21 for Staff N and a hire date of 11/30/21 for Staff O. The report lacked documentation that Staff G,H,K,N, and O completed resident rights and QAPI(Quality Assurance and Performance Improvement) training, lacked documentation Staff G, H, K, and O completed communication training, lacked documentation Staff G, K, and O completed behavioral health training, lacked documentation Staff G and O completed abuse prevention training, lacked documentation Staff G and H completed infection control training, and lacked documentation Staff H and K completed compliance and ethics training. The facility policy Staff Development Program, revised May 2019, stated all personnel must participate in initial orientation and regularly scheduled in-service training. The policy listed effective communication, resident rights, abuse prevention, QAPI, dementia management, infection control, and compliance and ethics as a required training topics. During an interview on 11/2/22 at 1:25 p.m., the Nurse Consultant stated the facility had no other documentation of staff education. During an interview on 11/3/22 at 11:20 a.m., The Corporate Nurse stated staff should complete all mandatory training.

Based on staff file review, policy review, and staff interview, the facility failed to ensure 4 of 5 staff members completed effective communications training(Staff G, H, K, and O). The facility reported a census of 36 residents. Findings include: An untitled, undated facility staff education report listed hire dates and training completed during the period of 11/2/21-11/2/22 for Staff G Registered Nurse(RN), H Certified Nursing Assistant (CNA), K CNA, and O CNA. The report listed a hire date of 7/7/22 for Staff G, a hire date of 1/12/01 for Staff H, a hire date of 6/25/03 for Staff K, and a hire date of 11/30/21 for Staff O. The report lacked documentation the above staff completed communication training. The facility policy Staff Development Program, revised May 2019, stated all personnel must participate in initial orientation and regularly scheduled in-service training. The policy listed effective communication as a required training topic. During an interview on 11/2/22 at 1:25 p.m., the Nurse Consultant stated the facility had no other documentation of staff education. During an interview on 11/3/22 at 11:20 a.m., The Corporate Nurse stated staff should complete all mandatory training.

Based on staff interview, facility policy, and observation the facility failed to perform cardiopulmonary resuscitation (CPR) until emergency medical staff (EMS) arrived for a resident without heartbeat and respirations, who also lacked signs of irreversible death. The facility reported to have 12 residents with a full code status at the time of the incident. The facility reported a census of 37 residents. A determination was made that the facility's noncompliance with the requirement of participation placed residents in the facility in immediate jeopardy, beginning [DATE]. On [DATE] at 1:00 PM the facility was notified of the immediate jeopardy at F678 and given the IJ template. Findings include: The Admission Minimum Data Set (MDS) dated [DATE] documented Resident#6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident required extensive assistance of two staff members for bed mobility, dressing, and toilet use. The Care Plan with initiated date of [DATE], documented a focus area of Advanced Directives/ Code Status. The Care Plan directed staff to honor the wishes of the resident, and to see the CPR declaration page. The goal documented the advanced directives were to be followed per resident/family request. Resident #6's clinical record lacked a CPR declaration page. The Cardiopulmonary Resuscitation policy dated ,d+[DATE], documented the purpose was to prolong life when biological death is not imminent. The Cardiopulmonary Resuscitation policy directed staff as follows: 1. Upon finding, call for help. Certified personnel to attend resident, other staff to make emergency calls. 2. Observe for symptoms of cardiac arrest: loss of consciousness, absence of carotid or femoral pulses, absence of audible heart sounds, absence of breath sounds, convulsions. 3. Patient must be on hard surface (floor or board on bed). 4. Check for carotid or femoral pulses or audible heart signs. 5. If no pulse is observed, start chest compressions. 6. Check for pulse again. 7. If pulses are absent, begin CPR. 8. Notify family and physician of emergency status. 9. Document observations and care delivered. *American Heart Association recommends CPR NOT to be initiated under the following circumstances: 1. Presence of dependent lividity (or rigor mortis defined as post mortem hypostasis of the blood following death that causes a purplish re discoloration of the skin closest to the ground) 2. Rigor mortis (rigor mortis is the stiffening of muscles due to the absence of an organic compound). 3. Decapitation. 4. Visible decomposition. A Progress Note with effective date of [DATE] at 4:10 a.m. documented as follows; Resident #6 had been found unresponsive and without pulse or respirations, two person CPR was initiated. Emergency services had been notified. At 4:25 a.m. CPR had been discontinued because of no change in condition. Emergency Medical Services arrived at 4:30 a.m Family had been notified at 4:25 a.m. and message left for the doctor at 4:30 a.m On [DATE] at 9:30 a.m. the Director of Nursing gave the surveyor a list of the full code residents that had been kept at the nurses station. The list contained 11 resident names with Resident#6's name scratched out on the list. During an observation on [DATE] from 9:43 a.m. to 9:46 a.m. all the residents on the list had a green dot outside of their rooms by their nameplate and room number. During interviews on [DATE] at 7:38 p.m. and on [DATE] at 11:03 p.m. Staff A, License Practical Nurse (LPN) reported if a resident is found unresponsive look for the code status. Staff A reported that outside the door of a residents room a green dot would mean the resident is a full code. Staff A reported if you start CPR you would only stop when fire rescue, or EMS takes over. Staff A reported there is a list at the nurses station of the full code residents in a booklet. Staff A reported if you can't find a code status then you would treat the resident as a full code. Staff A reported that if the EMS response is slow while CPR is in progress, 911 should be called again. During interviews on [DATE] at 8:00 p.m. and on [DATE] at 11:12 a.m. Staff B, Registered Nurse (RN) reported a residents code status can be found in a chart at the nurses station that had a list of all the full code residents. Staff B reported that another place to look is outside the residents room, a green dot by the residents door means the resident is a full code. Staff B reported if you can't find the code status, then you treat the resident as a full code. Staff B reported that with a full code you do not stop CPR, you follow the residents wishes. Staff B reported you only stop CPR when being relieved by EMS. During an interview on [DATE] at 9:16 a.m. Staff E, CNA reported that on night shift rounds her and Staff F, CNA did not think that Resident#6 had been breathing, so she went and got Staff G, LPN. Staff E reported Staff G started compressions and she used the ambu bag (device to assist resident with breathing). Staff E reported Staff G told Staff F to call 911. Staff E reported that she had switched spots with Staff G. Staff E reported she had been instructed by Staff G to stop CPR. Staff E reported the CPR lasted at least ten minutes. Staff E reported that the resident felt warm and that the residents left ear had been turning black. During an interview on [DATE] at 7:18 a.m. Staff F, CNA reported that night shift rounds are completed at midnight, 2:00 a.m. and at 4:00 a.m. Staff F reported Resident#6 had been checked on at midnight and had been ok. Staff F reported on 2:00 a.m. rounds the resident had struggled a little with breathing, Staff G, LPN put oxygen on the resident, which seemed to help. Staff F reported at 4:00 a.m. rounds the resident had not been breathing, had no pulse and had been cold to touch. Staff F reported getting the nurse (Staff G, LPN). Staff F reported Staff G started CPR, as the resident had been a full code. Staff F reported that she went to call 911, and it took about 25 minutes for the paramedics to get to the facility. Staff F reported she had waited at the door for EMS to get to the facility. During interviews on [DATE] at 6:43 a.m. and on [DATE] at 9:01 a.m. Staff G, LPN reported she normally worked nights and had been the only nurse in the building. Staff G reported she had been working when Resident #6 passed away, and his code status had been a full code. Staff G reported on [DATE] Resident #6 had been seen at around 3:00 a.m. to 3:30 a.m. when the resident had been mouth breathing, so she put his oxygen tubing in his mouth. Staff G reported the residents midnight assessment had been good. Staff G reported that at 4:10 a.m. Staff F and Staff E found the resident and came and got her. Staff G reported she started CPR on Resident #6 even though the resident had been cold to touch. Staff G reported the residents chin had been hard to pull back for CPR. Staff G reported she had sent Staff F to call 911, while she and Staff E did CPR. Staff G reported that CPR had been stopped at 4:25 a.m., because there had been no improvement and it would have not made a difference. Staff G reported she had received education from the DON that CPR is to continued until the EMS arrives, and went over the CPR policy also. During an interview on [DATE] at 10:52 a.m. the Director of Nursing (DON) reported she had educated all the nurses on the CPR policy, and three staff had been reached by phone. The DON reported the policy had talked about a CPR declaration form at the nurses station. The DON reported that if a resident is found in need of CPR, one staff member should be sent to call 911, and the nurse will continue CPR until EMS arrives. The DON reported that 911 should be called again if time seems to have been a lot, like 10 minutes. The DON reported moving forward the facility will be doing drills weekly on various shifts for four weeks, and then quarterly. During an interview on [DATE] at 3:28 p.m. Staff C, LPN reported she had been educated on the CPR policy and that you don't stop CPR once it's started, only when EMS is there to take over. Staff C reported the Certified Nurses Aide (CNA) should call 911 again if EMS response time had been awhile. Staff C reported the resident CPR status can be found on a list at the nurses station, and a green dot by the name plate outside the residents room which means a full code. Staff C reported if code status could not be found the resident is treated as a full code. During an interview on [DATE] at 11:09 a.m. Staff D, LPN reported the Director of Nursing (DON) went over the written policy with her. Staff D reported that CPR is to be done until EMS takes over, and to call 911 again if the response is slow. During an interview on [DATE] at 10:00 a.m. the [NAME] County Medical Examiner (HCME) reported there had been no evidence that CPR had been performed on the resident. The HCME reported the resident had been small and frail, and there would have been obvious rib fractures, skin discoloration or abrasions. The facility corrected the immediate jeopardy on [DATE] as the facility provided education to all licensed staff regarding performing CPR when a person is found without vital signs and shows no signs of irreversible death. Education provided that 911 will be called, CPR will be initiated and stopped when EMS arrives and takes over the code and/or is called by a licensed physician. The facility also audited resident records for current DNR/Full Code status. At the time of exit the scope and severity was lowered to an E after verification of the facility's plan of corrrection was implemented.

Based on observation, record review, staff interviews, and facility policy, the facility failed to assess and prevent the development of a pressure ulcer for 1 of 2 residents sampled (Resident #1). The facility reported a census of 44 residents. Findings include: 1. Resident #1's Significant Change MDS (Minimum Data Set) with an assessment date of 04/07/2016, revealed both long and short term memory loss with poor decision-making and supervision required. The assistance of 2 staff was required for bed mobility, transfers, and toilet use. According to the MDS, the resident required a wheel chair and staff assist to propel around the unit. During this assessment period, Resident # 1 did sustain a fall without injury. The documentation identified an unhealed pressure ulcer (Stage unidentified) as present. The plan of care with a problem onset date of 06/17/2010 identified cognitive loss due to dementia and vision issues related to [MEDICAL CONDITION] for Resident # 1. The plan of care documented the resident as independent for transfers and ambulation and a four wheeled walker during waking hours, but in need of assistance with cares a night. Interventions for the potential for skin breakdown included weekly and as needed skin assessments, a pressure relief mattress, keeping the linens clean and dry, and a fortified diet. The most recent plan of care created after the pressure ulcer to the left heel developed on 02/23/2016, directed facility staff to provide weekly wound care and documentation for the left heel ulcer, use a heel riser while in bed, make sure shoes and stockings are not tight, a pressure relief mattress and chair cushion, provide a high protein diet. The plan identified Resident # 1 required the assistance of 2 staff for toilet use, transfers, and positioning. The Braden Scale (used to predict pressure ulcer risks) dated 01/18/2016 identified Resident # 1 as at low risk for skin issues. On 02/23/2016, the Braden Scale identified the resident at high risk for skin breakdown. A previous history of skin issues of unidentified origins demonstrated the facility's failure to assess the resident's need for additional safety prevention from staff. 07/04/2010 purple/red bruise to right lateral ankle. 08/04/2011 purple bruise on left inner ankle. 10/19/2011 dark purple raised bruises to left lower leg and ankle. 05/29/2013 6 centimeter bruise to left lower leg. 07/11/2013 6 centimeter by 5 centimeter dark purple bruise on left shin. 07/03/2015 right lower extremity red and swollen with a fluid filled blister. 08/25/2015 left lateral ankle pink/red, swollen, warm with pain. Post development of the left heel pressure ulcer found on 02/23/2016 (3.2 by 2 centimeter purple/black deep tissue injury to the left heel.) the facility instituted a heel riser while in bed and staff assisted positioning. A sheared area measuring 6.6 centimeters by 0.5 centimeters on the right buttock also identified on 02/23/2016 provided further proof of the resident's need for interventions for repositioning by staff and skin assessments by the licensed staff. A review of the medical record nursing progress notes from 07/20/2015 through 03/30/2016 documented: 10/29/2015 through 01/31/2016, Resident # 1 continued to spend the majority of time in bed. Nurses documented explaining the risks of not repositioning and not eating to this extremely hard of hearing and cognitively impaired resident without instituting any assistance for repositioning eating assistance from staff. On 01/31/2016, Resident # 1 spent the night in the hospital with a [DIAGNOSES REDACTED]. Upon return to the facility on [DATE], Resident # 1 complained of leg pain (does not specify which leg) and received Tylenol. On 03/21/2016, nursing identified a decline in the resident's condition and the need for staff assistance with transfers, toilet use, and positioning, almost a month after the identification of the left heel ulcer. During an observation on 04/05/2016 at 11:10 A.M., Staff C and Staff D (both Licensed Practical Nurses) entered Resident # 1's room, closed the door, washed their hands, donned gloves and laid out supplies on a clean barrier. Resident # 1 laid in a supine position on the bed with a heel riser under the lower extremities. Staff C removed the old dressing covering the left heel. Observations of the left heel showed an unstageable irregular shaped area of black/brown eschar (a hard brown/black scab) covering the wound which Staff C measured as 2.5 by 1.5 centimeters. After cleansing and placing a clean dressing, Staff C and Staff D washed their hands and left the room. Resident # 1 remained in bed with the heel riser under the lower extremities. During the treatment, observations of the top of the left foot showed an irregular pattern of black bruising over the arch. The chart contained no documentation of this area. An interview on 04/07/2016 at 09:50 A.M. with Staff E (Certified Nursing Assistant) and bath aide, revealed Resident # 1 received a bath on 02/19/2016. Staff E verbalized lotioning the resident's feet and finding no skin issues at that time. On 02/23/2016 during the bath, Staff E found the left heel pressure ulcer. She described it as a purple blister filled with fluid. Staff E notified the nurse on duty who sprayed the heel with the skin prep as directed by the facility wound protocol. A phone interview on 04/07/2016 at 02:34 P.M. with Resident # 1's Physician supplied the [DIAGNOSES REDACTED]. The Physician verified not having viewed the left heel ulcer, but had been notified of the area by the facility nursing staff and agreed the peripheral vascular [DIAGNOSES REDACTED]. In an interview on 04/06/2016 at 3:20 A.M., the Director of Nursing verbalized Resident # 1 could reposition self and be up and around in the wheel chair, so was not in need of positioning by staff or development of skin issues. In the wound inservice of 11/04/2016, the wound specialist told them pressure ulcers could come up in 24 hours. The DON cited this and the resident moving by her/himself as reasoning for not instituting any preventative skin interventions prior to the actual observation of the unstageable left heel ulcer. As for the skin issues Resident # 1 developed in July/August of 2015, the DON could not relate those issues to the left heel pressure ulcer. The Care Initiatives Pressure Ulcer protocols for Suspected Deep Tissue Injury describes the wound as purple or maroon intact skin or a blood filled blister with damage to the underlying soft tissue from pressure or shear. Prior to outward signs, the area is painful, warm or cool, firm or become boggy and mushy. A nursing meeting on wound care on 11/04/2015 identified preventative measures to be considered such as head to toe assessments on admission, at regular intervals, with significant changes which should cover resident risk factors, skin condition, nutrition. hydration, and moisture. Evolution to the outward signs may be rapid exposing additional layers of tissue. Pressure ulcers may appear within 24 hours or take up to 5 days to appear.