Every finding on record at Sanders Ridge Health Campus

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure residents were free from misappropriation of property for 2 of 6 residents sampled for abuse, out of the total sample of 37, (Resident (R)33 and R67). The findings include:Review of the facility policy titled, Abuse and Neglect Procedural Guidelines, revised 06/27/2017, revealed misappropriation of property was defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Further review revealed the Executive Director was responsible for notification to Adult Protective Services (APS).Review of the facility policy titled, Guidelines for Narcotic Count, reviewed 12/17/2024, revealed the narcotic book was to contain a sheet providing space for the off going and oncoming nursing staff to record their signatures to indicate the narcotics had been reviewed. Per review, the narcotic count sheet was to indicate how many items were in the narcotic drawer and the medications counted to ensure they were all present and accounted for. Continued review revealed the narcotic count was to be updated by two nurses to validate the changes with initials and date, as items were added or removed. Policy review revealed at the time one nurse, or other staff qualified to give medications, passed on the keys to the medication (med) cart to the oncoming staff member, the narcotics were to be reconciled by comparing the medications in the cart to the count sheets. Further review revealed both staff members were to sign the narcotic count as accurately reconciled. In addition, review revealed if the available medications did not match the count sheets, the Director of Health Services (DHS) was to be notified. Review further revealed if the DHS was unable to determine the reason for the (narcotic) count discrepancy, a thorough investigation was to be conducted.1). Review of the clinical record for R33 revealed the facility re-admitted him on 01/20/2021, with diagnoses of hemiplegia and hemiparesis following cerebral infarction, unspecified abdominal pain, and dorsalgia (general back pain). Review of the physician orders revealed an order dated 04/17/2025, received for Hydrocodone four times a day, and a dose for once daily as needed (PRN) dated 04/17/2025.Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have modified independence in his decision making. Continued review revealed the facility assessed R33 to have had pain in the last five days, to receive scheduled pain medication, and as rating his pain as moderate (a five out of 10 on the pain scale). Further MDS review revealed the facility also assessed R33 as receiving an opioid medication.Review of the facility's investigation documentation, regarding missing narcotic medication for R33, dated 08/24/2025, revealed the facility noted the resident only had one dose of Hydrocodone (a narcotic medication) left and his nurse called the pharmacy to obtain a refill of the medication. Per review, the pharmacy informed the nurse it was too soon to refill the narcotic medication as the pharmacy delivered 60 tablets to the facility on [DATE] (eight days previously). Continued review revealed the facility determined 30 of R33's Hydrocodone tablets were missing, and during the facility investigation, the facility identified another resident had missing Hydrocodone tablets with 15 tablets noted as remaining. Review of the investigation documentation revealed however, the facility was unable to locate the narcotic medication for R33 or the Narcotic Drug Use Record for the missing medication. Further review revealed Licensed Practical Nurse (LPN) 5 reported to the (former) DHS she had taken the other resident's (R67's) narcotic medication, and the facility verified misappropriation of R67's property had occurred. Review revealed LPN 5 denied taking R33's Hydrocodone medication. Additional review revealed however, the facility, reasonably concluded LPN 5 had been involved in both instances of diversion as she confessed to taking R67's Hydrocodone, and related to the LPN's dishonesty throughout the facility's investigation, with her being the common tie to both instances. Review further revealed the pharmacy delivered 60 Hydrocodone tablets for R33 to the facility on [DATE]. Continued review of the facility investigation documentation dated 08/24/2025, revealed the facility interviewed LPN 5 on 08/24/2025, regarding where she placed the previous shift to shift count sheets, as those sheets were missing. Review revealed the facility also interviewed LPN 5 about whether she knew what happened to R33's Hydrocodone medication as pharmacy could not refill the medication yet. Per review, LPN 5 reported she did not know what happened to the narcotic count sheets. Review revealed on 08/25/2025, LPN 5 counted the medication cart and signed the shift to shift narcotic logs for her shifts worked on 08/18/2025, 08/21/2025, 08/23/2025, and 08/24/2025. According to the facility's investigation documentation, LPN 5 stated she left the shift to shift logs in the (narcotic) book when they were full. Review of the facility's documentation revealed LPN 5 was interviewed on 08/28/2025 (when the missing Hydrocodone was discovered missing for another resident), and she denied knowing what happened to the other resident's (R67's) missing medication. Continued review revealed the facility asked LPN 5 to take another drug test in a lab, based on the new incident of missing narcotic, and the LPN agreed to complete the drug screen by 10:00 AM on 08/29/2025. Further review revealed on 08/29/2025, LPN 5 stated she had taken the Hydrocodone from the other resident (R67) and stated she had a problem; however, she denied taking R33's Hydrocodone medication. In addition, LPN 5 reported taking Hydrocodone from a different resident about six months prior, but could not remember the date or who the resident had been. Review further revealed the facility's investigation documentation also included an interview with LPN 6 who stated she co-signed as witness for five residents with LPN 5 in the narcotic log, although she had not actually seen that the medication was empty.Review of the facility's Narcotic Count Sheet dated 08/16/2025, revealed 2 packs of Hydrocodone tablets had been delivered to the facility for R33. Review of the Controlled Drug Use Record (CDUR) revealed 60 tabs of Hydrocodone dispensed 08/16/2025, with 30 in each pack. Review of the facility's staffing schedules revealed LPN 5 worked on R33's unit on 08/18/2025, 08/21/2025, and 08/23/2025. The State Survey Agency (SSA) Surveyor requested the facility's documentation of the narcotic count log and received and removed medication log; however, the facility did not provide such documentation for the dates of 08/17/2025 through 08/21/202, for the unit R33 resided on. In addition, the facility failed to provide documentation of reporting the narcotic diversion (by LPN 5) to Adult Protective Services.Review of the Controlled Drug Use Record (CDUR) for R33 dated 08/16/2025, revealed 30 of the 60 tabs of Hydrocodone were pack one of the two packs dispensed on 08/16/2025. Continued review revealed LPN 5 signed as administering the narcotic medication on 08/21/2025, 08/22/2025, 08/23/2025, and 08/24/2025. However, the facility failed to provide documentation of the CDUR for R33 for the 08/16/2025 delivered second pack of 30 Hydrocodone tablets.Review of R33's medication administration record (MAR) for August 2025, revealed LPN 5 documented administering Hydrocodone to R33 throughout the month and through the morning of 08/24/2025.In interview with the (former) Director of Health Services (DHS) on 06/04/2026 at 4:01 PM, she stated the nurse on duty for R33 (LPN 4) notified her the morning of 08/24/2025 of R33's missing Hydrocodone and that it was too soon to refill the medication. She reported the pharmacy delivered 60 tabs of Hydrocodone to the facility on [DATE]. The former DHS stated during the facility's investigation, another resident's Hydrocodone was also unaccounted for, and LPN 5 later admitted to taking that medication.In interview with the Campus Clinical Support (CCS) person on 06/05/2025 at 10:04 AM, she stated on 08/24/2025, R33's nurse called the pharmacy to refill his Hydrocodone as the resident was out of the medication. She stated the pharmacy informed the nurse there should have been another card of the medication. The CCS person reported in the first week of the facility's investigation regarding the missing medication and audits, another resident had been identified as missing a narcotic medicine also. She said LPN 5 and LPN 6 signed that R67 had zero of the medication left; however, when she (the CCS) conducted an audit on 08/25/2025, there were 15 tabs of the medication still available.In interview with the facility's Executive Director (ED) on 06/05/2026 at 3:00 PM, he stated the CCS had been the primary investigator for R33's missing medication. He stated the facility determined R33's medication had been misappropriated, and during the investigation LPN 5 admitted to taking a different resident's (R67's) medication. The ED reported due to LPN 5's being a common tie to both instances of missing medications, and her denial of wrongdoing in multiple conversations over two days, the facility concluded LPN 5 had been involved in both instances (R33's and R67's) of missing medication.In interview with LPN 4 on 06/08/2026 at 9:36 AM, she stated she had been the nurse for R33 when she discovered he did not have any Hydrocodone left (on 08/24/2025). She said she called the pharmacy to obtain a refill of R33's Hydrocodone medication; however, was informed they just delivered 60 tabs to the facility for R33. LPN 4 reported checking the 60 tabs signed into the facility, however could not locate the rest of the tabs that had not already been administered. She further stated before R33's Hydrocodone was missing, the facility's system (of accounting for narcotic medications) had been flawed, as they had not been as diligent then as they were now.In additional interview with the CCS on 06/09/2025 at 10:25 AM, she stated when she conducted the audit of narcotic medications on 08/25/2025, she had not found any other missing medications. She said LPN 5 signed another resident as having no more narcotic medication on 08/25/2025, and LPN 6 co-signed that information. The CCS reported the facility discovered the missing narcotic medication for another resident on 08/28/2025, and when LPN 5 admitted taking that resident's medication the facility determined medication diversion occurred instead of missing medication. She further stated no one at the facility monitored the narcotic counts or the shift to shift narcotic counts were being completed prior to the incident.2). Review of the clinical record for R67 revealed the facility admitted the resident on 08/08/2025, with a diagnosis of diverticulitis of the large intestine with perforation and abscess. Review of the physician orders for R67 revealed an order for Hydrocodone dated 08/07/2025 - 08/17/2025, which was reordered on 08/17/2025 - 08/28/2025, every six hours as needed.Review of the admission MDS assessment dated [DATE], revealed the facility assessed R67 as having a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating the resident was cognitively intact. Further MDS review revealed the facility also assessed R67 to receive PRN pain medication and noted the resident rated her pain as three out of ten on the pain scale.Continued review of the facility's investigation documentation for the incident on 08/24/2025, for the affected resident (R67) revealed the facility investigated the resident's missing narcotic medication. Per review, during the investigation, the facility identified R67's missing Hydrocodone, and noted LPN 5 documented the resident as having 15 doses of the Hydrocodone left on 08/25/2025. Additional review revealed however, she documented zero as remaining on the Narcotic Count Sheet. According to review of the investigation documentation, the facility's audit revealed the medication was discovered as missing on 08/28/2025.Additional review of the facility's investigation documentation revealed the facility interviewed LPN 5 on 08/28/2025, and the LPN reported there had been zero Hydrocodone medication left for R67, but, she had not done anything with the medicine. Per review, the facility noted LPN 5 agreed to taking a drug screen in a lab by 10:00 AM on 08/29/2025, based on the new incident involving R67's missing narcotic medication. Continued review the facility's interview with LPN 5 on 08/29/2025, revealed she said she had taken R67's Hydrocodone and admitted to having a drug problem. Review of the CDUR for R67 dated 08/13/2025, revealed the pharmacy dispensed 30 of 30 tabs of the resident's Hydrocodone on 08/12/2025. Per review, on 08/25/2025, LPN 5 documented administering one tab to R67, and noted 15 tablets remaining. Review of the Narcotic Count Sheet for the time period of 08/22/2025 through 08/27/2025, revealed on 08/25/2025 LPN 5 noted one medication removed. Review of the facility's removed and added log dated 08/23/2025 through 08/27/2025, revealed LPN 5 noted one Hydrocodone pack for R67, with zero listed as the quantity. Additional review of the removed and added log for the same time period revealed LPN 6 also signed with LPN 5.In interview with the former DHS on 06/04/2026 at 4:01 PM, she stated during a facility investigation initiated 08/24/2025 for missing Hydrocodone for a resident, the facility discovered R67 had missing Hydrocodone discovered on 08/28/2025. The former DHS also stated LPN 5 later admitted to taking R67's Hydrocodone medication.In interview with the CCS person on 06/05/2025 at 10:04 AM, she stated during the facility's investigation dated 08/24/2025 regarding another resident's (R33's) missing narcotic, it was discovered R67 was also missing narcotic medication. She reported she completed an initial audit of all residents who had narcotic medication ordered on 08/25/2025, and R67 was noted as having 15 doses remaining. The CCS said during another audit conducted on 08/28/2025 (three days after the other audit), R67 was discovered to have zero tablets remaining, which was not possible. She further stated LPN 5 and LPN 6 both signed the medication count as being zero.In interview with the ED on 06/05/2026 at 3:00 PM, he stated during the facility's investigation of missing narcotic medication for another resident (R33) on 08/24/2025, which was ongoing on 08/25/2026, the facility discovered in its narcotic pain medication audits, R67 had missing narcotic medication. He said the facility had multiple conversations with LPN 5 over a two day period and LPN 5 denied any wrongdoing involving the missing narcotic medication. The ED explained the facility asked LPN 5 to take a drug screen in a lab on 08/29/2025, and she agreed to doing so. He reported however, LPN 5 did not go and take the drug screen as requested. The ED further stated LPN 5 admitted to taking R67's narcotic medication and the facility found LPN 6, who had signed with LPN 5 as R67 having no medications, had not actually witnessed the counted medications herself. In addition, the ED said R67 had none of the medication available at the time LPN 6 signed with LPN 5.In interview with LPN 4 on 06/08/2026 at 9:36 AM, she reported when trying to administer R33's Hydrocodone she noted the resident had none. She said she reported that information to the former DHS. The LPN stated she paid close attention after her discovery (of the missing narcotic medication for R33), and on 08/28/2025 she discovered R67 also was missing Hydrocodone tablets. She said she knew R67 had multiple packs of the narcotic pain medication. LPN 4 explained she was off work for two days, and upon her return, there was no way R67 had used all of the Hydrocodone tablets that were missing. She further stated the narcotic medication had been signed out at zero on one of the (narcotic) documentation records, but was noted as there being 15 available on another narcotic (accounting) document.In additional interview with the CCS on 06/09/2025 at 10:25 AM, she stated when she conducted an audit of narcotic medication on 08/25/2025, she had not found any other missing narcotic medications at that time (which would have included R67's). She said LPN 5 signed R67 as having no more narcotic medication on 08/28/2025, and LPN 6 co-signed with LPN 5 verifying the count. The CCS reported the facility discovered R67's medication missing on 08/28/2025, and when LPN 5 admitted to taking R67's medication, the facility determined medication diversion occurred instead of it being just a case of missing medications. She further stated prior to the missing narcotic medications incident, no one at the facility monitored the narcotic counts, nor the shift to shift narcotic counts being accurately completed.

Based on observation, interview, record review, and facility policy review, the facility failed to assess a resident for their ability to self-administer medication for 1 of 15 sampled residents, (Resident (R)202). The findings include: Review of the facility policy titled, Medication Administration- General Guidelines, revised 01/2018, residents were allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. Review of the Resident Face Sheet revealed the facility admitted R202 on 05/09/2025, with diagnosis of gastroesophageal reflux disease (GERD). Review of R202's Order History revealed an order dated 05/09/2025, for Tums (an over-the-counter antacid medication) 200 milligrams (mgs) every eight hours. During a concurrent observation and interview on 05/12/2025 at 9:55 AM, a medication cup was observed on R202's bedside that contained a Tums tablet inside. In interview, R202 stated staff gave him/her the Tums to take whenever he/she needed it. In interview on 05/12/2025 at 11:12 AM, Licensed Practical Nurse (LPN) 6 stated R202 was able to keep his/her medications at bedside. LPN 6 confirmed R202 had no order to self-administer his/her medication or keep the medication at bedside. In interview on 05/13/2025 at 12:36 PM, R202 stated he/she would like to be able to take his/her own medication without the nurse having to watch. R202 further stated he/she only got the Tums medication when he/she needed it, so nursing staff just left it for him/her to take. During a follow-up interview on 05/13/2025 at 12:43 PM, LPN 6 confirmed R202 had not been assessed for his/her ability to self-administer his/her own medication. In interview on 05/13/2025 at 1:33 PM, the Director of Health Services (DHS) stated her expectation for the facility's self-administration of medication assessment process was for the resident to be assessed to assess for the appropriateness of being able to do that. The DHS further stated a resident's medication was not allowed to be left at his/her bedside if the resident had not been assessed as able to self-administer his/her own medication. During an interview on 05/15/2025 at 8:43 AM, the Executive Director stated he expected medication generally not to be left at bedside unless the resident had a self-administration assessment of medication completed.

Based on interview, record review, facility document and policy review, the facility failed to timely report an allegation of physical abuse to the State Survey Agency (SSA) for 1 of 1 resident reviewed for abuse, out of the total sample of 15 (Resident (R) 152). The findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation Procedural Guidelines, revised 12/16/2024, revealed its purpose was to develop and implement processes, which strived to ensure the prevention and reporting of suspected or alleged resident abuse and neglect. Per review, the Executive Director (ED) and Director of Health Services (DHS) were responsible for the implementation and ongoing monitoring of abuse standards and procedures. Continued review revealed the facility was to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than two hours after the allegation was made. Review revealed the facility was to ensure reporting was completed no later than 24 hours if the events causing the allegation did not involve abuse and did not result in serious bodily injury, to the Administrator of the facility and to other officials (including the SSA and adult protective services [APS] where state law provided for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Review of the Resident Face Sheet for R152 revealed the facility admitted R152 on 04/01/2021, with a diagnosis of dementia. Review of the Significant Change in Status Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 06/12/2024, revealed the facility assessed R152 to have a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated the resident had severe cognitive impairment. Review of R152's Care Plan revealed the facility identified a problem statement initiated 04/22/2021, that noted the resident had a diagnosis of arthritis and was at risk for pain. Further review revealed the interventions included for staff to provide assistance with activities of daily living (ADLs) as needed. Review of the facility's Investigation Summary dated 08/16/2024, which noted Certified Resident Care Associate (CRCA) 1 had been assisting R152 to bed utilizing the stand assist to lift to transfer the resident from recliner to bed. Per review, R152 told the CRCA she was hurting him/her during the transfer, and swatted at the CRCA to stop. Continued review revealed CRCA 1 blocked R152's hand from hitting her by putting her hand on the resident's left forearm. Review revealed the CRCA removed the lift equipment, ensured R152's safety in the recliner, and left the room to inform the nurse of the resident's complaints of pain with transfer and to get additional assistance. Further review revealed when CRCA 1 left R152's room, the nurse was in another room providing care, so she proceeded to the next resident's room to provide care. Review revealed the nurse, (Registered Nurse (RN) 2), exited the room she was providing care in and heard R152 yelling for help. Further review revealed when the RN entered the room, she asked R152 what he/she]needed and the resident reported the CRCA hit his/her hand. According to the Internal Investigation Log Timeline/Chronology of Events and Communication, on 08/16/2024 at 8:20 PM, R152 informed RN 2 that CRCA 1 hit him/her on the hand. In interview on 05/14/2025 at 11:32 AM, CRCA 1 stated on the day of the incident, she went into R152's room to see if the resident wanted to go to bed and the resident said yes. CRCA 1 said that was between 8:00 PM and 9:00 PM on 08/16/2024. She reported as she pulled R152 up, the resident complained of pain, so she sat the resident back down and asked if he/she was being pulled too hard, and the resident said yes. The CRCA said R152 told her he/she felt like his/her shoulder was being ripped off. She stated she asked R152 if he/she felt comfortable with her trying to assist again and R152 said no and started complaining about his/her hand. CRCA 1, reported R152 swatted at her and she put up her hand to prevent the resident from hitting her. She said she removed the sit-to-stand lift, made sure R152 was safe, and left the resident's room so that the incident would not escalate. CRCA 1, stated as she was going to tell RN 2, a resident's call light was on, she went to answer the call light and while she provided care for that resident, the nurse informed her of the allegation made by R152. She further stated she had been asked to write a statement and leave the facility. CRCA 1 additionally stated she had not hit or abused R152 in any way. In interview on 05/14/2025 at 1:14 PM, RN 2 stated she heard R152 yelling, so she went to the resident's room. RN 2 said she entered R152's room around 8:00 PM on 08/16/2024, and asked R152 what she could do. She stated R152 told her, that girl hit me, and she made sure the resident was safe and went to find CRCA 1, who had been in another resident's room. RN 2 reported she escorted CRCA 1 to the nurses' station, so she could write a statement and then had the CRCA leave the facility. She stated she went back to check on R152 and the resident said he/she had no pain. RN 2 stated R152 told her CRCA 1 tried to get the resident up out of his/her chair and the resident swatted at the CRCA, who put her arm up to keep the resident from hitting her. She said CRCA 1 denied hitting R152 and R152 told her CRCA 1 was wonderful and very friendly. RN 2 further stated she then reported the incident to the Director of Health Services (DHS). In interview on 05/14/2025 at 2:01 PM, the DHS stated she did not remember the time she was notified of the incident involving R152, by RN 2. She said RN 2 informed her R152 stated CRCA 1 hit him/her on the hand. The DHS reported she had been informed CRCA 1 had been asked to write a statement and was removed from the facility. She stated she then notified the Executive Director (ED), who completed the mandatory reporting and investigation. The DHS explained staff had to report any allegation of abuse immediately and to the SSA within two hours. She said the two-hour reporting began when the allegation was made, and she expected any allegations of abuse to be reported within the two-hour reporting timeframe. In interview on 05/14/2025 at 2:25 PM, the ED stated he had been notified of the incident on 08/16/2024 at 9:00 PM, by the DHS. He said he reported the incident to the SSA on 08/16/2024 at 10:48 PM. The ED further stated the facility had two hours to report allegations of abuse to the SSA. He also stated he expected all allegations of abuse to be reported within the two-hour timeframe. In a follow-up interview on 05/15/2025 at 10:58 AM, the ED stated the allegation of abuse involving R152 was reported to him around 9:00 PM on 08/16/2024. He reported he assumed the incident happened shortly before that so he placed 8:50 PM, as the time the allegation occurred. The ED stated however, once the investigation was started, he realized RN 2 had been made aware of the allegation at 8:20 PM on 08/16/2024.

Based on interview, record review, and facility policy review, the facility failed to ensure medications were secured to prevent potential accidents for 1 of 1 residents reviewed for accidents, out of the total sample of 15 (Resident (R) 102). The findings include: Review of the facility policy titled, Medication Storage In The Facility, revised 11/2018, revealed, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Review of the Resident Face Sheet for R102 revealed the facility admitted the resident on 05/09/2025, with diagnoses of Alzheimer's disease and low back pain. Review of R102's Physician Order Report for the timeframe of 04/15/2025 through 05/15/2025, revealed an order dated 05/09/2025, for Biofreeze gel, to be applied to the lower back twice daily. Review of R102's Care Plan revealed the facility identified a problem statement initiated on 05/12/2025, that indicated the resident was at risk for lower back pain. Further review revealed the interventions noted staff where to administer medications as ordered. Review of R102's Observation Detail List Report completed 05/12/2025, revealed the resident had severe cognitive impairment. In a concurrent observation and interview on 05/12/2025 at 10:09 AM, the State Survey Agency (SSA) Surveyor observed a clear medication cup in R102's room with the resident's room number on the cup. In interview, Licensed Practical Nurse (LPN) 3 stated she placed the medication in the resident's room and assumed since the resident received Biofreeze for their lower back, that was what was in the cup. She reported medication was not to be left at a resident's bedside and said the unit had residents who wandered. LPN 3 further stated the cup of medication should not have been left on R102's nightstand, and she was embarrassed the medication had been left there. LPN 3 additionally stated she was unsure who left the medication on the nightstand. In interview on 05/12/2025 at 10:16 AM, Certified Resident Care Associate (CRCA) 4 stated she served R102 breakfast and had not seen the medication at the resident's bedside. The CRCA further stated if she had seen the medication at R102's bedside she would have removed the medication and taken it to the nurse. In interview on 05/14/2025 at 1:29 PM, the Director of Health Services (DHS) stated when giving residents medications she expected the nurses to follow the rights of medication administration, which included the right resident, right time, right dose, and the right medication. She reported medications were not to be left at a resident's bedside. The DHS said the danger of leaving medications at a resident's bedside in a dementia unit was a resident could get a medication not prescribed for them. She stated there were residents in the dementia unit where R102 lived that wandered, but had not recently wandered into others' rooms. The DHS further R102 might have the dexterity to apply the Biofreeze; however, did not have the mental capacity to administer the medication independently. In interview on 05/15/2025 at 8:36 AM, the Executive Director (ED) stated he did not expect medication to be left at a resident's bedside unless the resident had been assessed and deemed appropriate for self-administration and a physician's order had been obtained.

Based on observation, interview, record review, and review of the facility's abuse prevention policy, it was determined the facility failed to conduct a thorough investigation for a witnessed incident of resident-to-resident abuse for one (1) of seven (7) sampled residents, Resident #1. On 01/09/2021, Resident #2 entered Resident #1's room without staff awareness. At approximately 9:00 AM, a licensed nurse found Resident #2 with his/her pants and briefs down around his/her ankles while lying in bed with Resident #1. The nurse observed Resident #2 pulling on Resident #1's shoulder, arm, neck, and hair, while in bed with Resident #1. The facility's investigation and staff interviews revealed six (6) of the ten (10) residents on the Legacy Lane Memory Care Unit were interviewed after the incident. The licensed nurse performed a skin assessment on one (1) of the ten (10) residents living on Legacy Lane. The investigators interviewed the two (2) staff persons on duty at the time of the incident, but they did not interview additional staff who had knowledge of Residents #2's patterns of behavior. The findings include: Review of the facility's policy titled, Abuse and Neglect Procedural Guidelines, revised 08/29/2019, revealed the Executive Director (ED) and the Director of Health Services (DHS)were responsible for the implementation and ongoing monitoring of abuse standards and procedures. In addition, the policy stated the Executive Director was accountable for investigating and reporting; identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment occurred, the extent, and cause; and providing complete and thorough documentation of the investigation. Review of the facility's document Behavior and Mood Events-Trilogy-New Worsening/Behavior 11.28.16, dated 01/09/2021 at 5:56 PM, revealed Licensed Practical Nurse (LPN) #1 completed the form describing an incident that occurred on 01/09/2021 at 9:00 AM. Review of the Progress Note attached to the report revealed at approximately 8:50 AM, the nurse was briefly away from the Legacy Lane Unit to retrieve a drink for a resident. Upon returning, she heard a yell coming from a resident's room (room [ROOM NUMBER]). Upon entering the room, the nurse documented she saw Resident #2 lying in Resident #1's bed with Resident #1. The nurse's narrative revealed Resident #2 was tugging on Resident #1 causing him/her to yell out. The nurse documented she explained to Resident #2 that was not his/her bed and assisted Resident #2 out of the bed. The nurse documented she ensured both residents were safe and then reported the situation to the Assistant Director of Health Services (ADHS). Interview with LPN #1, on 01/20/2021 at 1:05 PM, revealed she briefly left the unit, just before 9:00 AM, to obtain a soft drink for another resident. LPN #1 said she was only away from the unit two (2) or three (3) minutes. She stated Temporary Nurse Aide (TNA) #1 remained on the unit and was assisting Resident #6 in room [ROOM NUMBER]. She said when she returned, she heard yelling coming from Resident #1's room and noted Resident #2 was no longer in the common living area. LPN #1 said she went to Resident #1's room and saw Residents #1 and #2 lying in Resident #1's bed. She stated both residents were facing the door, so she saw their faces. She stated Resident #1 was fully clothed in slacks, a shirt, and non-skid socks. LPN #1 stated Resident #2 was wearing a shirt, but his/her pants and briefs were down around his/her ankles with his/her genitalia exposed. She said she saw Resident #2 pulling and tugging on Resident #1's shoulder, leg, neck, and hair. LPN #1 said she told Resident #2 that was not his/her bed, and he/she would have to get up. She said Resident #2 resisted at first, but with coaxing, she was able to get Resident #2 out of the bed. She said she assisted the resident with pulling up his/her pants and briefs and assisted him/her out of Resident #1's room. LPN #1 said she started assessing Resident #1 while he/she was still lying in the bed and talked with the resident. She said she took Resident #1 to the bathroom and completed the skin assessment. She said Resident #1 was not physically injured. LPN #1 stated her supervisor, the ADHS, did not tell her to perform skin assessments on other residents after the incident. Review of a Resident Progress Note, in Resident #1's clinical record, dated 01/09/2021 at 9:30 AM, revealed LPN #1 documented she performed Resident #1's skin assessment in the bathroom, and no abnormalities were noted. Review of the Resident Face Sheet, in Resident #1's clinical record, revealed the facility admitted the resident, on 12/09/2020, to the Legacy Lane Memory Care Unit, with a primary admission [DIAGNOSES REDACTED]. Review of Resident #1's Brief Interview for Mental Status (BIMS) assessment for Cognitive Function, in the Minimum Data Set (MDS) assessment, dated 01/01/2021, revealed the resident was unable to complete the BIMS assessment. Observation of Resident #1's room (room [ROOM NUMBER]), on 01/19/2021 at 3:00 PM, revealed the resident had a semi-private room, and his/her bed was the one closest to the door. The resident was out of the facility at the time of the observation, but the resident's belongings remained in the room. Resident#1 had a roommate, Resident #5, who occupied the bed closest to the window. At the time of the observation, Resident #5 was sitting in a recliner eating candy. Resident #1's room was adjacent to the unit's common living space. The Common Area had a nurse's desk, a medication cart, a television, tables with chairs, and a sofa. Review of the Resident Face Sheet, in Resident #2's clinical record, revealed the facility admitted the resident to the Legacy Lane Memory Care Unit on 11/04/2020. The resident's [DIAGNOSES REDACTED]. Review of the Brief Interview for Mental Status (BIMS), in the Minimum Data Set (MDS) Admission Assessment, dated 11/09/2020, revealed Resident #2 was unable to complete the BIMS cognitive assessment. Review of the Midnight Census for the Legacy Lane Memory Care Unit, revealed ten (10) residents were residing on the unit on 01/09/2021. The facility had also added the BIMS cognitive score and the date of each screening to the Midnight Census Report. According to the Centers for Medicare and Medicaid (CMS), Quality Reporting Programs: Brief Interview for Mental Status (BIMS), 11/05/2020, the BIMS was a standardized assessment to determine a resident's cognitive function. A scale of zero (0) to fifteen (15) was used to assess the resident's cognitive function. Scores from zero (0) to seven (7) indicated severe cognitive impairment. Review of the Brief Interview for Mental Status (BIMS) assessment scores for the residents living on Legacy Lane, on 01/09/2021, revealed the residents' BIMS results ranged from zero (0) to six (6). Six (6) of the ten (10) residents had a score of zero (0); two (2) residents had a score of two (2), one (1) resident had a score of three (3), and one (1) resident had a score of six (6). Review of the facility's investigation, dated 01/09/2021, signed by the Executive Director, revealed four (4) documented resident interviews were completed by the ADHS, on 01/09/2021. The forms, labeled with each resident's name, also recorded the resident's BIMS score. The scores of the four (4) residents interviewed were two (2) scored zeros (0), one (1) scored a two (2), and one (1) scored a six (6). The interview form contained two (2) questions: Do you feel safe here? and Has anyone tried to hurt you? Three (3) of the residents indicated they felt safe and had not been hurt. One of the residents, (Resident #3), responded I don't know to both questions. There was no evidence in the investigation the ADHS attempted to interview Resident #5, who was Resident #1's roommate. Per interview with Temporary Nurse Aid (TNA) #1, on 01/20/2021 at 12:23 PM, Resident #5 was also in room [ROOM NUMBER] at the time of the incident. Review of a list for Resident BIMS scores, provided by the facility, dated 01/20/2021, revealed Resident #5's BIMS score was zero (0), with an assessment date of 12/28/2020. Additional review of the investigation, revealed the ADHS interviewed the two (2) staff that were on duty, on 01/09/2021, LPN #1 and TNA #1. However, the investigation did not reveal the investigator(s) interviewed any other staff who had recently worked with Resident #2 and had knowledge of his/her patterns of behavior. Interviews with staff members, including RN #1, on 01/21/2021 at 4:48 PM; TNA #1, on 01/20/2021 at 12:23 PM; and Resident Care Assistant (RCA) #2, on 01/19/2021 at 3:45 PM, all of whom had worked with Resident #2, revealed he/she would wander about the unit, including into other occupied resident rooms. Review of the Progress Notes, in Resident #2's clinical record, revealed staff documented the resident had wandered in and out of other residents' rooms and had to be redirected by staff, on 12/26/2020, 12/25/2020, 12/19/2020, and 12/10/2020. On 12/13/2020 at 10:00 PM, LPN #3 documented Resident #2 kept entering other rooms, and redirection was not effective. Interview with LPN #3, on 01/21/2021 at 9:12 AM, revealed Resident #2 wandered the unit, and on that occasion, the resident had wandered into empty rooms with beds. She said the resident could be aggressive with staff and latched on tightly to hand rails. She stated it could be difficult to get him/her to let go of the rail, and redirection could be difficult. She stated she had not seen Resident #2 demonstrate aggression toward other residents. Review of a Progress Note, dated 11/12/2020 at 5:35 AM, revealed the licensed nurse documented Resident #2 demonstrated increased wandering and entered almost every room on the unit. She also documented the resident was difficult to redirect and had shown increased aggression toward staff. Interview with RCA #3, on 01/21/2021 at 11:09 AM, revealed about a week ago, she had to redirect Resident #2 out of room [ROOM NUMBER], another resident's room. She said Resident #2 was in his/her wheelchair, self-propelling down the hallway, but stood up and wandered into room [ROOM NUMBER]. She stated when she tried to redirect the resident, he/she held onto the door. She stated the resident was somewhat resistive but eventually let go and walked to his/her own room. RCA #3 said, when she was on duty, the resident never got very far into another room. She stated room [ROOM NUMBER] was next door to Resident #2's room, room [ROOM NUMBER]. Additional review of the Resident Progress Notes, revealed Resident #2 exhibited aggressive, combative behavior toward staff, on 01/08/2021 at 9:31 AM, which included swinging at, fighting, and biting at the nurse. Review of the Progress Notes, in Resident # 2's clinical record, revealed on 01/07/2021 at 10:36 AM, the ADHS documented the resident demonstrated involuntary hand grasps and could be difficult to redirect. On 01/05/2021 at 10:40 PM, a licensed nurse documented Resident #2 had been combative, attempting to hit, pinch, and bite her and continued to try to squeeze staff hands and arms when staff directed him/her away from other resident room doorways. On 12/31/2020 at 11:49 PM, a licensed nurse documented Resident #2 was very agitated, trying to fight with her, and was kicking and trying to bite her while she assisted the resident with care in his/her room. On 11/19/2020, RCA #2 documented Resident #2 was rejecting care, hitting at the caregiver, and pulled the call light off the bathroom wall. Interview with LPN #2, on 01/21/2021 at 9:20 AM, revealed Resident #2 did exhibit combative behavior with staff, attempting to hit or bite, but she had not personally witnessed the resident exhibit aggression toward other residents. Interview with the ADHS, on 01/21/2021 at 2:30 PM, revealed prior to starting the investigation, on 01/09/2021, she contacted the DHS, who instructed her in how to conduct the investigation. She said after LPN #1 reported the incident, she went to Legacy Lane to ensure Residents #1 and #2 were safe. She stated she interviewed LPN #1 and TNA #1. She stated she did not interview other staff from previous shifts because they would not have had first-hand knowledge of the incident. The ADHS said LPN #1 completed a skin assessment on Resident #1, but the DHS did not instruct her to conduct a skin assessment on Resident #2. The ADHS said she selected and interviewed four (4) residents who were like Resident #1, meaning, of the same gender. In addition, she said the residents selected were the only ones known to be verbal, and who could possibly answer the interview questions. She said she also interviewed Residents #1 and #2, to determine if they felt safe, but she did not complete the questionnaire she used with the other four (4) residents. The ADHS said the DHS did not direct her to complete skin assessments on all residents on the unit. She stated Resident #2 had not previously shown aggressive behavior toward other residents, and she had no reason to think Resident #2 had bothered other residents. The ADHS said she had not reviewed the Progress Notes in Resident #2's record, but she was aware Resident #2 wandered on the unit and had wandered into empty rooms (those ready for resident occupancy). The ADHS said she was not sure if the facility had a policy that specifically directed staff to conduct skin assessments on residents incapable of answering interview questions. Interview with the DHS, on 01/21/2021 at 3:15 PM, revealed if a resident or staff member made an allegation of abuse, or if there had been an injury of unknown origin, the facility would have conducted skin sweeps on all residents as part of the investigation. The DHS said this was a witnessed and isolated incident; therefore, she did not think other staff interviews were necessary. She said Resident #2 was alone for only a couple of minutes in the living area, and there was no reason to think he/she had entered any other resident's rooms. She stated conducting a skin sweep on every single resident on the dementia unit could have been disruptive to their day. The DHS said, given the isolated nature of the incident, she thought the staff conducted a thorough investigation. She stated, even though TNA #1 remained on the unit watching Resident #2 just after the incident, LPN #1 should have called the ADHS on the phone to report the incident, instead of leaving the unit a second time. She stated the nurse was educated regarding that, after the incident. Interview with the Executive Director (ED), on 01/21/2021 at 3:51 PM, revealed through the initial interview process with the staff on duty and by interviewing the selected like residents, there was no reason to believe the incident affected other residents. He said Resident #2 did not have a history of violent behavior toward other residents. He said the DHS and ADHS launched the investigation as soon as LPN #1 reported the incident. He stated the resident and staff interviews documented by the ADHS provided a sufficient amount of information to determine this was an isolated occurrence and confirmed there were no other issues to investigate. The ED stated it was concerning to him Resident #1 experienced the incident, with Resident #2 grabbing him/her, but if administrative staff thought something else was going on, they would have gone further with the investigation.

Based on observation, interview, medical record review, and review of the facility's policy, it was determined the facility failed to protect one (1) of seven (7) sampled residents, Resident #1, from physical abuse. On 01/09/2021 at approximately 9:00 AM, a licensed nurse found Resident #2 lying in bed with Resident #1. Resident #2's pajama pants and briefs were down around his/her ankles. The licensed nurse on duty heard Resident #1 yelling from his/her room. When the nurse entered the room she witnessed Resident #2 pulling on Resident #1's shoulder, arm, leg, neck, and hair. The findings include: Review of the facility's policy titled, Abuse and Neglect Procedural Guidelines, revised 08/29/2019, revealed the Executive Director and Director of Health Services were responsible for the implementation and ongoing monitoring of abuse standards and procedures. According to the policy, physical abuse included but was not limited to hitting, slapping, punching, biting, and kicking and would include resident-to-resident abuse with or without cause. Review of Resident #1's medical record revealed the facility admitted Resident #1, on 12/09/2020, to the Legacy Lane Memory Care Unit, with primary admission [DIAGNOSES REDACTED]. Review of Resident #1's Brief Interview for Mental Status (BIMS) assessment for Cognitive Patterns, in the Minimum Data Set (MDS) assessment, dated 01/01/2021, revealed the resident was unable to complete the BIMS assessment. Review of Resident #1's Comprehensive Care Plan revealed the resident demonstrated cognitive impairment as related to his/her [DIAGNOSES REDACTED]. Observation of Resident #1's room (room [ROOM NUMBER]), on 01/19/2021 at 3:00 PM, revealed the resident had a semi-private room, and his/her bed was the one closest to the door. The resident was out of the facility at the time of the observation, but the resident's belongings were still in the room. Resident #1's roommate, Resident #5, occupied the bed closest to the window. Resident #1's room was adjacent to the unit's common living space. The Common Area had a nurse's desk, a medication cart, a television, tables with chairs, and a sofa. Interview with the Director of Health Services (DHS), on 01/19/2021 at 2:30 PM, revealed Resident #1 was currently in a psychiatric hospital for additional management of his/her [MEDICAL CONDITION] medications, and the facility anticipated the resident's return to Legacy Lane Unit once he/she discharged from the psychiatric facility. Review of Resident #1's Progress Notes, from 12/23/2020 to 01/10/2021, revealed Resident #1 exhibited combative behavior toward staff members and cursed at them when they tried to assist him/her. The notes revealed the resident frequently hallucinated, reportedly seeing babies and kids on the unit and fish on the floor. Prior to his/her transfer to the psychiatric hospital, staff documented the resident was also wandering into other residents' rooms, was walking into walls and pillars on the unit, and was becoming increasingly difficult to redirect. Resident #1 was transferred to an acute care hospital, on 01/10/2021 at 9:16 PM, and then to a psychiatric facility for treatment. Review of the Resident Face Sheet, in Resident #2's clinical record, revealed the facility admitted Resident #2 to the Legacy Lane Memory Care Unit on 11/04/2020. The resident's [DIAGNOSES REDACTED]. Review of the Brief Interview for Mental Status (BIMS) in the Minimum Data Set (MDS) Admission Assessment, dated 11/09/2020, revealed Resident #2 was unable to complete the BIMS cognitive assessment. Review of a component of Resident #2's CCP, with a start date of 11/09/2021, revealed Resident #2 demonstrated symptoms consistent with [MEDICAL CONDITION] including inattention, disorganized thinking, and an altered level of consciousness. The social aspects component of Resident #2's care plan included a revision, dated 11/11/2021, with interventions to address his/her behavior of wandering into other residents' rooms and occupying other residents' beds. Interview with the Social Services Director (SSD), on 01/21/2021 at 2:56 PM, revealed Resident #2's care plan was revised, on 01/11/2021, because Resident #2 had wandered into Resident #1's room, on 01/09/2021, and a licensed nurse found him/her in bed with Resident #1. She said management staff discussed the incident in the Clinical Care Meeting (CCM), on 01/11/2021, and the care plan was revised so all staff members would be aware of the behavior and redirect Resident #2 away from other residents and their rooms. Continued review of Resident #2's clinical record, revealed the resident was under the care of the psychiatric services group on contract with the facility, with documented visits by the provider, including a documented visit on 12/14/2020. Observation, of Resident #2, on 01/19/2021 at 3:05 PM, revealed the resident was lying in bed on his/her left side, with his/her eyes closed. Resident #2 had a private room (room [ROOM NUMBER]). The resident was fully dressed, and a private duty sitter was in Resident #2's room. Interview with Resident #2's sitter, on 01/21/2021 at 11:15 AM, revealed she stayed with the resident three (3) weekdays per week from 11:00 AM-3:00 PM. The sitter said she was not on duty on 01/09/2021. She said Resident #2 was mostly non-verbal. The sitter stated Resident #2 wore a brief, in case of incontinence, but he/she could urinate or have a bowel movement independently most of the time. She said the resident usually sat in a wheelchair that she pushed when she took him/her on walks around the unit. However, the sitter said she had seen the resident walk independently. Review of a document titled Behavior and Mood Events-Trilogy-New Worsening/Behavior 11.28.16, dated 01/09/2021 at 5:56 PM, revealed Licensed Practical Nurse (LPN) #1 completed the form detailing an incident that occurred on 01/09/2021 at 9:00 AM. Review of the progress note attached to this report revealed the nurse documented, at approximately 8:50 AM, she had briefly left the unit to retrieve a drink for another resident. Upon returning, she heard a yell come from a resident's room (room [ROOM NUMBER]). Upon entering the room, the nurse documented she saw Resident #2 lying in Resident #1's bed with Resident #1. The narrative indicated Resident #2 was tugging on Resident #1 causing him/her to yell out. The nurse documented she explained to Resident #2 that was not his/her bed, and assisted the resident out of the bed. The nurse documented she ensured both residents were safe and then reported the situation to the Assistant Director of Health Services (ADHS). Interview with Temporary Nursing Assistant (TNA) #1, on 12/20/2021 at 12:23 PM, revealed 01/09/2021 was the first day she had worked on the Legacy Lane Memory Care Unit, and at the time of the incident, she did not know the residents. TNA #1 said she passed breakfast trays, but she had not yet provided care for Resident #1. TNA #1 said she saw Resident #2 sitting in the common living area about 8:00 AM. She said she assisted Resident #2 with his/her breakfast tray, and the resident ate without assistance. TNA#1 said Resident #6 came to the Common Area and requested his/her breakfast, a soda with the meal, and he/she wanted to eat in his/her room (room [ROOM NUMBER]), so TNA #1 said she took Resident #6's breakfast to his/her room. She stated LPN #1 volunteered to get the soda for Resident #6. TNA#1 said this was just a few minutes before 9:00 AM. TNA #1 said she thought LPN #1 obtained the soda at the facility's main dining room. TNA #1 said after assisting Resident #6, she left the room at the same time LPN #1 returned to the unit through the double locked doors. TNA #1 said LPN #1 noticed Resident #2 was no longer in the Common Area, and handed her the soda to take to Resident #6. TNA #1 said she did not immediately hear any yelling but heard it when LPN #1 entered Resident #1's room. TNA #1 said once she delivered the soda, she returned to the Common Area and saw Resident #2 sitting on the floor outside Resident #1's room. She stated she had since learned LPN #1 had to remove Resident #2 from Resident #1's bed, and when Resident #2 became agitated, he/she would refuse to move his/her body, and Resident #2 sat down on the floor after leaving Resident #1's room. Interview, on 01/20/2021 at 1:05 PM with LPN #1, revealed Resident #2 sometimes used a wheelchair, but he/she could also walk independently. She said she did not remember the exact time she left the unit, but she said another resident requested a soft drink, so she retrieved the soda for the resident. LPN #1 said she was only away from the unit two (2) or three (3) minutes. She said when she returned, she heard yelling coming from Resident #1's room and noted Resident #2 was no longer in the living area. LPN #1 said she went to Resident #1's room and saw Residents #1 and #2 lying in Resident #1's bed. She stated both residents were facing the door, so she saw their faces. LPN #1 stated Resident #1 was fully dressed in slacks, a shirt, and non-skid socks. She said Resident #2, had on a shirt, but his/her pants and brief were down around his/her ankles with his/her genitalia exposed. She stated Resident #2 was pulling and tugging on Resident #1's shoulder, leg, neck, and hair. LPN#1 said she told Resident #2 that was not his/her bed, and that he/she would have to get up. She said, at first, Resident #2 resisted the redirection, but eventually she coaxed the resident to get up. She said she assisted Resident #2 with pulling up his/her pants and brief, and assisted him/her out of Resident #1's room. LPN #1 said she started assessing Resident #1 while he/she was still lying in the bed, talked with the resident, and then took the resident to the bathroom and completed the assessment. She stated, while in the bathroom, she conducted a full skin assessment, did not identify injuries, and documented the assessment in Resident #1's progress notes. LPN #1 said, after assessing Resident #1, she told the TNA to watch Resident #2, while she reported the incident to the Assistant Director of Health Services (ADHS). LPN #1 stated she went to the ADHS's office to report the situation. She stated the ADHS instructed her to complete an incident report and to watch both residents closely. LPN #1 said upon returning to the unit, she saw Resident #2 still sitting in the living area, and Resident #1 was lying in his/her bed. She stated Resident #2's sitter was not on duty on the day of the incident. Interview with Resident #2's family member, on 01/21/2021 at 12:23 PM, revealed someone on the administrative staff notified of her of the incident on 01/09/2021. She stated Resident #2 stayed confused and may have thought he/she was wet. She said that could have been why Resident #2's pants and brief were down around his/her ankles. She said she did not think Resident #2 intended to harm anyone. She stated staff informed her they would keep an eye on Resident #2 to prevent anything like that from happening again. Interview with Resident #1's family member, on 01/21/2021 at 4:30 PM, revealed the administrative staff notified him of the incident on 01/09/2021. He said the administrative staff told him the nurse on duty assessed Resident #1, and he/she was not injured. He said the facility reported they thought Resident #2's Dementia was getting worse, and staff would watch him/her closely to prevent this from happening again. He stated Resident #1 was currently out of the facility and in a psychiatric hospital for medication management. Review of the facility's Investigation of the Incident, dated 01/09/2021 and signed by the Executive Director (ED), revealed a time line with happenings documented from 8:30 AM to 9:20 AM, on 01/09/2021. At 9:20 AM, the ADHS interviewed Resident #1. The ADHS documented the resident said he/she remembered someone was pulling on him/her, and stated to the ADHS but you saved me. The documented interview further revealed Resident #1 did not remember that Resident #2 was unclothed while in his/her bed. Interview with the ADHS, on 01/20/2021 at 2:30 PM, revealed when LPN #1 reported the incident to her, she immediately went to the unit to gain more information about the situation. She stated she observed Resident #2 sitting in the hallway in his/her wheelchair, and Resident #1 was in his/her room with LPN #1. The ADHS said she interviewed Resident #1, and asked him/her to describe what happened. She stated at first Resident #1 said he/she did not know what had happened, but eventually, the resident said someone had bothered him/her. The ADHS said Resident #1 was unable to give a description of the person. The ADHS said Resident #1 was actually calm, as if nothing had happened. The ADHS stated she also tried to talk with Resident #2. She said Resident #2 had a flat affect, which was typical. She said she asked the resident if everything was okay or if there was anything wrong, but the resident did not answer. She said Resident #2 did not show signs of distress. The ADHS said the ED and DHS at the facility notified the family contacts for each of the residents and the Physician. Interview with the Executive Director (ED), on 01/21/2021 at 3:51 PM, revealed, based on the facility's knowledge of Resident #2 and his/her patterns of behavior, this was an isolated incident, and there was no intent on the part of Resident #2 to harm Resident #1. He said the facility did not consider this incident an act of abuse. The ED said the facility's census had been low in recent months; therefore, he thought the staff knew the residents on Legacy Lane (Memory Care Unit) very well. He said the staff received training on the care of residents with Dementia, and they would be aware if anything was out of the ordinary, in terms of a resident's behavior, and would report it to a Supervisor and the Physician, as needed. Review of the facility's Investigative Summary, submitted to the State Agency, on 01/12/2021, revealed the facility did not substantiate abuse had occurred.

Based on observation, interview, record review, and review of the facility's abuse prevention policy, it was determined the facility failed to follow its abuse prevention policy in order to determine the potential extent and cause after one (1) of seven (7) sampled residents, Resident #1, experienced resident-to-resident abuse. On 01/09/2021, Resident #2 entered Resident #1's room without staff awareness. At approximately 9:00 AM, a licensed nurse found Resident #2 with his/her pants and brief down around his/her ankles while lying in bed with Resident #1. The nurse observed Resident #2 pulling on Resident #1's shoulder, arm, neck, and hair, while in bed with Resident #1. The facility's investigation and staff interviews revealed six (6) of the ten (10) residents on the Legacy Lane Memory Care Unit were interviewed after the incident. The licensed nurse performed a skin assessment on one (1) of the ten (10) residents living on Legacy Lane. The investigators interviewed the two (2) staff persons on duty at the time of the incident, but they did not interview additional staff who had knowledge of Resident #2's patterns of behavior. The findings include: Review of the facility's policy titled, Abuse and Neglect Procedural Guidelines, revised 08/29/2019, revealed the Executive Director (ED) and the Director of Health Services (DHS)were responsible for the implementation and ongoing monitoring of abuse standards and procedures. In addition, the policy stated the Executive Director was accountable for investigating and reporting; identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment occurred, the extent, and cause; and providing complete and thorough documentation of the investigation. Review of the facility's document Behavior and Mood Events-Trilogy-New Worsening/Behavior 11.28.16, dated 01/09/2021 at 5:56 PM, revealed Licensed Practical Nurse (LPN) #1 completed the form describing an incident that occurred on 01/09/2021 at 9:00 AM. Review of the Progress Note attached to the report revealed at approximately 8:50 AM, the nurse was briefly away from the Legacy Lane Unit to retrieve a drink for a resident. Upon returning, she heard a yell coming from a resident's room (room [ROOM NUMBER]). Upon entering the room, the nurse documented she saw Resident #2 lying in Resident #1's bed with Resident #1. The nurse's narrative revealed Resident #2 was tugging on Resident #1 causing him/her to yell out. The nurse documented she explained to Resident #2 that was not his/her bed and assisted Resident #2 out of the bed. The nurse documented she ensured both residents were safe and then reported the situation to the Assistant Director of Health Services (ADHS). Interview with LPN #1, on 01/20/2021 at 1:05 PM, revealed she briefly left the Legacy Lane Unit, just before 9:00 AM, to obtain a soft drink for a resident. LPN #1 said she was only off the unit two (2) or three (3) minutes. She said when she returned she heard yelling coming from Resident #1's room and noted Resident #2 was no longer in the common living area. LPN #1 said she went to Resident #1's room and saw Residents #1 and #2 lying in Resident #1's bed. She stated both residents were facing the door, so she saw their faces. She stated Resident #1 was fully clothed in slacks, a shirt, and non-skid socks. LPN #1 stated Resident #2 was wearing a shirt, but his/her pants and brief were down around his/her ankles with his/her genitalia exposed. She said she saw Resident #2 pulling and tugging on Resident #1's shoulder, leg, neck, and hair. LPN#1 said she told Resident #2 that was not his/her bed, and t he/she would have to get up. She said Resident #2 resisted at first but with coaxing, she was able to get him/her out of the bed. She said she assisted Resident #2 with pulling up his/her pants and brief and assisted him/her out of the room. LPN #1 said she started assessing Resident #1 while he/she was still lying in the bed; she talked with the resident and then took him/her to the bathroom and completed the skin assessment. LPN#1 stated she did not identify any injuries and documented the assessment in Resident #1's clinical record. Review of the Resident Face Sheet, in Resident #1's clinical record, revealed the facility admitted the resident, on 12/09/2020, to the Legacy Lane Memory Care Unit, with a primary admission [DIAGNOSES REDACTED]. Review of Resident #1's Brief Interview for Mental Status (BIMS) assessment for Cognitive Patterns, in the Minimum Data Set (MDS) assessment, dated 01/01/2021, revealed the resident was unable to complete the BIMS assessment. Review of Resident #1's Comprehensive Care Plan revealed the resident demonstrated cognitive impairment as related to his/her [DIAGNOSES REDACTED]. Observation of Resident #1's room (room [ROOM NUMBER]), on 01/19/2021 at 3:00 PM, revealed the resident had a semi-private room, and his/her bed was the one closest to the door. Resident #1 was out of the facility at the time of the observation, but the resident's belongings were still near his/her bed. Resident#1 had a roommate, Resident #5, who occupied the bed closest to the window. Resident #1's room was adjacent to the unit's common living space. The Common Area had a nurse's desk, a medication cart, a television, tables with chairs, and a sofa. Interview with the Director of Health Services (DHS), on 01/19/2021 at 2:30 PM, revealed Resident #1 was currently in a psychiatric hospital for additional management of his/her [MEDICAL CONDITION] medications, and the facility anticipated the resident's return to Legacy Lane Unit once he/she was discharged from the psychiatric facility. Review of the Resident Face Sheet in Resident #2's clinical record revealed the facility admitted Resident #2 to the Legacy Lane Memory Care Unit on 11/04/2020. The resident's [DIAGNOSES REDACTED]. Review of the Brief Interview for Mental Status (BIMS), in the Minimum Data Set (MDS) Admission Assessment, dated 11/09/2020, revealed Resident #2 was unable to complete the BIMS cognitive assessment. Review of a component of Resident #2's Comprehensive Care Plan, with a start date of 11/09/2020, revealed Resident #2 demonstrated symptoms consistent with [MEDICAL CONDITION] including inattention, disorganized thinking, and an altered level of consciousness. The social aspects component of Resident #2's care plan included a revision, dated 11/11/2020, which included interventions to address the resident's behavior of wandering into other residents' rooms and occupying other residents' beds. Review of the Midnight Census for the Legacy Lane Memory Care Unit, revealed ten (10) residents were residing on the unit on 01/09/2021. The facility also added the BIMS cognitive score for each resident on the census and the date of each screening to the Midnight Census Report. According to the Centers for Medicare and Medicaid (CMS), Quality Reporting Programs: Brief Interview for Mental Status (BIMS), 11/05/2020, the BIMS was a standardized assessment to determine a resident's cognitive function. A scale of zero (0) to fifteen (15) was used to assess the resident's cognitive function. Scores from zero (0) to seven (7) indicated severe cognitive impairment. Review of the Brief Interview for Mental Status (BIMS) assessment scores of the residents living on Legacy Lane, on 01/09/2021, revealed the residents' BIMS scores ranged from zero (0) to six (6). Six of the ten (10) residents had a score of zero (0); two (2) residents had a score of two (2), one (1) resident had a score of three (3), and one (1) resident had a score of six (6). Review of the facility's Investigation of the Incident, dated 01/09/2021, signed by the Executive Director, revealed it included interviews of four (4) residents. The ADHS interviewed the residents, on 01/09/2021, and signed the completed forms. Of the four (4) residents interviewed, their BIMS scores were zero (0), two (2), and six (6). The residents were asked two questions: Do you feel safe here? and Has anyone tried to hurt you? Three (3) of the four (4) residents indicated they felt safe and had not been hurt. One (1) of the residents, Resident #3, responded I don't know to both questions. Interview with Temporary Nurse Aid (TNA) #1, on 01/20/2021 at 12:23 PM, revealed Resident #1's roommate, Resident #5, was in the room when the incident with Residents #1 and #2 occurred. TNA #1 said she thought Resident #5 remained asleep, and she was not sure the resident would have the ability to know or understand what may have occurred. There was no evidence in the investigation that the ADHS attempted to interview Resident #5. Review of a list for Resident BIMS scores, provided by the facility, dated 01/20/2021, revealed Resident #5's BIMS score was zero (0), with an assessment date of 12/28/2020. Additional review of the investigation, revealed the ADHS interviewed two (2) staff members during the course of the investigation, LPN #1 and TNA #1. Interview with Registered Nurse (RN) #1, on 01/21/2021 at 4:48 PM, revealed she had observed Resident #2 wandering into other residents' rooms, she thought, without any intention. She confirmed she had documented this observation in Resident #2's record, on 12/25/2020, and, on 12/26/2020. She said she thought staff could stop the resident before he/she got too far in the rooms. She said sometimes the resident would grab at the staff person's wrist when they tried to provide redirection. RN #1 stated the resident would frequently roll up and down the hallway in his/her wheelchair. Continued interview with TNA #1, on 01/20/2021 at 12:23 PM, revealed 01/09/2021 was her first day to work on the Legacy Lane Memory Care Unit. She stated she did receive report from the off-going night shift aide, and the only information the aide provided about Resident #2 was that he/she had wandering behavior and to try to keep the resident out of other residents' rooms. Interview with Resident Care Assistant (RCA) #2, on 01/19/2021 at 3:45 PM, revealed Resident #2 did exhibit wandering behavior. She stated Resident #2 self-propelled in the wheelchair, and she had seen him/her go in and out of other residents' rooms. RCA #2 said the resident would also wander into the model room that had an empty bed. She said when staff tried to redirect Resident #2, he/she would become agitated and resistive. Interview with RCA #3, on 01/21/2021 at 11:09 AM, revealed about a week ago, she had to redirect Resident #2 out of room [ROOM NUMBER], another resident's room. She said Resident #2 was in his/her wheelchair, self-propelling down the hallway, but stood up and wandered into room [ROOM NUMBER]. She stated when she tried to redirect the resident, he/she held onto the door. She stated the resident was somewhat resistive but eventually let go and walked to his/her own room. RCA #3 said when she was on duty, the resident never got very far into another room. She stated room [ROOM NUMBER] was next door to Resident #2's room, room [ROOM NUMBER]. Interview with the Social Services Director (SSD), on 01/21/2021 at 12:42 PM, revealed nurses reported that Resident #2 had the behavior of wandering into other residents' rooms. The SSD said staff attending the Daily Clinical Care Meetings discussed Resident #2's wandering behavior. She said she had observed Resident #2 wandering on the Legacy Lane Unit but many other residents also wandered on the unit. Interview with the ADHS, on 01/21/2021 at 2:30 PM, revealed prior to starting the investigation on 01/09/2021, she contacted the DHS, who instructed her in how to conduct the investigation. She said after LPN #1 reported the incident, she went to the unit to ensure Residents #1 and #2 were safe. She stated she interviewed LPN #1 and TNA #1. The ADHS said LPN #1 completed the skin assessment for Resident #1, but the DHS did not instruct her to conduct a skin assessment on Resident #2. The ADHS said she selected and interviewed four (4) residents who were like Resident #1, meaning, of the same gender. In addition, she said the four (4) residents selected were the only ones known to be verbal and could possibly answer the interview questions. She said she also interviewed Residents #1 and #2 but did not complete the form that included the questions to determine if they felt safe and if anyone had tried to hurt them. The ADHS said she interviewed LPN #1 and TNA #1 because they were on the unit when the incident occurred. The ADHS said she was not directed by the DHS or the ED to complete skin assessments on all residents on the unit. She stated she did not conduct the skin assessments because she had no reason to believe Resident #2 would have bothered other residents. She stated Resident #2 had not demonstrated that type of behavior in the past. The ADHS said she was not sure if the facility had a policy that specifically directed staff to conduct skin assessments on residents not capable of answering interview questions. Interview with the DHS, on 01/21/2021 at 3:15 PM, revealed if a resident or staff member made an allegation of abuse, or if there had been an injury of unknown origin, staff would have conducted skin sweeps on all residents as part of the investigation. She stated administration did not feel staff interviews were needed other than for those on duty during the event because it was a very isolated incident. She said Resident #2 was alone for only a couple of minutes, and there was no reason to think he/she had entered any other residents' rooms. She stated conducting a skin sweep on every single resident on the dementia unit could have been disruptive to their day. Interview with the Executive Director (ED), on 01/21/2021 at 3:51 PM, revealed through the initial interview process with the staff on duty and by interviewing the selected like residents, there was no reason to believe the incident affected other residents. He said Resident #2 did not have a history of violent behavior toward other residents. He said the DHS and ADHS launched the investigation as soon as LPN #1 reported the incident, and in doing so, he thought the staff followed the facility's abuse policy. He stated if administrative staff thought something else was going on, they would have gone further with the investigation.