Every finding on record at Sandridge Post Acute

Based on facility documentation, staff interviews and policy review, the facility failed to ensure that medications were properly stored and not left at the bedside for 1 of 1 residents sampled (Resident #160). The universe was 156. The deficient practice could result in residents and visitors having unrestricted access to medications. Findings include: Resident #160 was admitted to the facility on [DATE] with diagnosis that included metabolic encephalopathy, unspecified dementia, and other abnormalities of gait and mobility. Review of the care plan first initiated on March 18, 2026, revealed a focus for cognitive loss related to Alzheimer's disease or other dementias with interventions to explain all care before providing and to monitor for changes in cognitive status. Further review of the care plan revealed no evidence of Resident #160 being authorized or able to self-administer medications. Review of the modified admission minimum data set (MDS) dated [DATE] revealed Resident #160 had a brief interview for mental status (BIMS) score of 10, indicating the resident had moderate cognitive impairment. Further review of the MDS revealed the resident required moderate to maximum assistance with activities of daily living (ADLs). An observation was conducted on April 28, 2026 at 10:25 a.m. of Resident #160's room. An orange tube of diclofenac sodium, topical gel, 1% was observed on the resident's bedside table.There was no evidence of a medication self-administration evaluation within the electronic clinical record. There was no evidence of a physician's order for diclofenac sodium, topical gel, 1% within the electronic clinical record. An interview was conducted on April 28, 2026 at 10:25 a.m. with Resident #160. Resident #160 stated he obtained the diclofenac sodium, topical gel, 1% from his roommate who had an extra tube. Resident #160 stated he would use the cream on his knees where he experienced pain. An interview was conducted on April 28, 2026 at 10:35 a.m. with a certified nursing assistant (CNA/Staff #152). Staff #152 stated he assists residents with ADLs, changing residents, passing water and snacks, and ensuring the residents have everything they need. Staff #152 stated when he checks on his residents every two hours he would also ensure the resident does not have any dangerous or hazardous materials in their possession. Staff #152 further stated he would watch out for any medications left in the resident's room and immediately report anything dangerous to his nurse. Staff #152 stated if medications are left in a resident's room there is a potential for harm for anyone who enters that room. An observation was made on April 28, 2026 at 10:44 a.m. with a registered nurse (RN/Staff #167) of Resident #160's bedside table. Staff #167 stated diclofenac sodium, topical gel, 1% was a topical cream and usually used for arthritis. Staff #167 instructed the resident that he would have to confiscate the cream and obtain an order from the doctor to continue using the medication. An interview was conducted on April 28, 2026 at 10:44 a.m. with Staff #167. Staff #167 stated he does not have a set time when he rounds on his residents but stated he sees them enough throughout the day when passing medications. Staff #167 stated that he administers all kinds of medications which includes, topicals, over-the-counter medications, oral, intravenous, and intra-muscular and further stated all medications require a physician's order prior to administering. Staff #167 stated that if he noticed any medications at the resident bedside he would confiscate them and educate the resident on why medications cannot stay in a resident's room. Staff #167 stated the risks of unrestricted medications includes medication dosages not being properly monitored and the potential for overdose. At 10:54 a.m. staff #167 reviewed the electronic medical record for Resident #160 and stated that there were no orders for diclofenac sodium, topical gel, 1% or an order for self-administration of medications. Staff #167 further stated Resident #167 should not have had the cream and this practice does not meet the facilities expectations. An interview was conducted on May 1, 2026 at 8:39 a.m. with the Director of Nursing (DON/Staff #175). Staff #175 stated the facility needs a physician's order for all medications and treatments. Staff #175 stated her expectation for clinical staff is if any medications are discovered in the resident's possession to confiscate them and educate. Staff #175 stated facility staff are expected to not leave medications in a resident room if a resident is not in the room and they must hold onto the medications or 'waste' them. Staff #175 stated that if a resident wishes to self-administer, an evaluation must be completed as well as an order from the physician. Staff #175 further indicated that the ability to self-administer medications should be reflected in the care plan. Staff #175 reviewed the Resident's electronic medical record and confirmed there was no physician's order for diclofenac sodium, topical gel, 1%. Staff #175 stated there was no self-administration of medications evaluation and that the care plan did not include that Resident #175 was able to self-administer any medications. Staff #175 further stated the medication on the resident's bedside did not meet her expectations and stated potential drug interactions could occur if the facility is unaware of a medication being administered.Review of the Administering Medications policy last revised April 2019 revealed medications are administered in a safe and timely manner, and as prescribed.Review of the Self-Administration of Medications policy last revised February 2021 revealed that if it is deemed safe and appropriate for a resident to self-administer medications, it will be documented in the medical record and the care plan. Review of the policy revealed self-administered medications are to be stored in a secure place which is not easily accessible by other residents. Further review of the policy revealed if any medications are found at the bedside that are not authorized for self-administration are to be turned over to the nurse in charge.

Based on observations, interviews, review of clinical records, and review of facility policies and procedures, the facility failed to ensure that the medical record was complete and accurate for one resident (#10). This deficient practice could lead to inadequate investigation, monitoring, and follow up to ensure the resident's safety and well-being.Findings include: Resident #10 was admitted to the facility on [DATE], with diagnoses that included atherosclerotic heart disease of the native coronary artery without angina pectoris, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, dysphagia following cerebral infarction, dysphagia, paraplegia, essential (primary) hypertension, hyperlipidemia, a personal history of recurrent pneumonia, a history of falling, and gastrostomy status.A review of the intake and five-day report provided by the facility revealed that on December 18, 2025, at approximately 10:30 AM, the Administrator (staff #88) was made aware by Nurse Manager (Staff Member # 77) of an allegation of verbal abuse. Resident #10 alleged that a CNA (certified nursing assistant / Staff 66) told him to Shut the f**k up. The nurse manager, staff # 77, responded to the scene and ensured the resident was safe before immediately reporting the allegation to the Administrator. The Administrator responded to the resident's room immediately after receiving the allegation. This allegation was not entered into the resident's medical record nor documented in the facility's risk management system.A review of the quarterly Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition.An interview was conducted on January 8, 2025 at 10:40 AM with the Administrator (Staff #88), who stated that per facility's policy, all incidents were required to be entered into the Risk Management system (the facility's internal tool); however, no documentation was found for Resident #10. Staff #88 stated this action was not in accordance with facility policy. The Administrator (Staff # 88) acknowledged this lapse and expressed regret and disappointment regarding the failure to follow established procedures. Administrator (Staff # 88) further stated that the potential outcome of this omission was inadequate follow-up related to the resident's well-being and any incident in a resident's clinical record should have been documented in Risk Management and reflected in monitoring and follow-up, including the progress notes. An interview was conducted on January 8, 2025 at 11 AM with the Director of Nursing (DON / Staff #55). He stated, as per facility's policy, all incidents should have been documented under Risk Management, which served as the internal investigation record. For Resident #10, the DON stated that he was not present at the time of the incident. Incidents involving verbal abuse should have been documented under psychosocial notes in the progress notes. Documentation did not need to be uniform among all staff and could have been entered in different areas of the resident's medical record; however, it was required to be recorded somewhere within the resident's clinical chart. DON (Staff # 55) stated that for Resident #10, no documentation was found in the Risk Management system related to this incident and it was not appropriate for incidents to go undocumented. DON (Staff # 55) further stated that there were no observed adverse reactions or outcomes for the resident related to this incident. A policy titled, Charting and Documentation, with a revised date of July 2017, revealed that the facility should record any events, incidents or accidents involving the resident in their medical records.

Based on a review of clinical records, staff interviews, facility documentation, policies and procedures, and the State Agency (SA) database, the facility failed to implement its policy requiring a thorough investigation of abuse and neglect allegations for four residents (#29, #33, #37 and #38). This deficient practice could place residents at risk for ongoing abuse and neglect.Findings include: Regarding Resident #38 Resident #38 was admitted on [DATE], with diagnoses that included senile degeneration of the brain, hypertension, and a personal history of COVID-19. Resident #38 expired at the facility on [DATE]. Review of the SA database revealed that the facility submitted a self-report on [DATE]. The report indicated that Resident #38 experienced an unwitnessed fall in the resident's room on [DATE]. According to the report, a hematoma was noted on the resident's head during a skin assessment, and no other injuries were identified. The report further stated that the resident was unable to explain how or why the fall occurred and that Hospice and the resident's family representative were notified. Additionally, a request for a 5-day investigation report was made to the facility on [DATE], at 2:07 p.m.; however, the facility stated that the 5-day report was not available in its records. Further review of the resident's clinical record dated [DATE], at 3:30 p.m., revealed a change-of-condition note related to the fall. A physician assessment completed on the same date indicated that no neurological changes were observed following the incident. A nursing note documented that facility nursing staff notified the Hospice nurse to report the fall to the resident's wife on [DATE], at 5:47 p.m. Attempts to contact the nurses who were working at the time of the incident were unsuccessful. An interview with the resident's wife was conducted by telephone on [DATE], at 8:58 a.m. The wife stated that although she was not present at the facility at the time of the incident, the facility did not contact her on the date of the fall. She further stated that when she visited the resident on [DATE], she observed that he appeared to be in significant pain and went to the front office to voice her concerns. Regarding Resident #37 Resident #37 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, vascular dementia, seizures, major depressive disorder, mood disorder, nicotine dependence, adjustment disorder with mixed disturbance, and dependence on a wheelchair, among other conditions. The resident was discharged on February 28, 2023. Resident #37 had a care plan initiated on [DATE], which identified the need for extensive assistance with ADLs, including bed mobility, transfers, locomotion, and toileting, due to her medical conditions. The care plan also documented that the resident exhibited, or had the potential to exhibit, verbal behaviors related to cognitive loss and dementia, including verbal outbursts directed toward others, use of abusive language, a pattern of challenging or confrontational verbal behaviors, and a history of physical abusiveness toward staff. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, with reported symptoms of depression, including tiredness, trouble sleeping, feeling down, and little interest in activities for seven to eleven days. The same MDS indicated that the resident required one-person assistance with bed mobility and two-person assistance for transfers between surfaces, as well as assistance with other activities of daily living (ADLs). Review of nursing progress notes dated [DATE], revealed no documentation of a staff-to-resident altercation. Review of the SA database revealed that the facility submitted a self-report on [DATE]. The report indicated that on [DATE], Resident #37 reported to a nurse that a certified nurse aide (CNA), staff #45, was very rough during care on [DATE], resulting in a 1.5 cm bruise on the resident's left arm. The report stated that staff #45 was temporarily suspended while the investigation was conducted. It further indicated that three additional staff members and eight residents were interviewed as part of the investigation. However, the 5-day report provided by the facility was incomplete and did not include staff or resident interview accounts. A request was made on [DATE] and the facility was unable to provide documentation of any disciplinary action taken against staff #45. Attempts to contact nursing staff who worked on [DATE], were unsuccessful. An interview was conducted with staff #13, who was present at the facility at the time of the incident and is currently the Acting Director of Nursing, on [DATE], at 11:43 a.m. Staff #13 stated that she did not recall the incident involving Resident #37. She further stated that current practice is for the facility to complete internal investigations separately unless there is an injury, skin tear, or bleeding, in which case documentation is included in the nursing progress notes for clinical monitoring. An interview with CNA staff #22 was conducted on [DATE], at 9:50 a.m. Staff #22 stated that during an incident investigation, staff are required to follow facility protocol, which includes reporting the incident to management and completing questionnaires detailing staff accounts related to the incident. Staff #22 further stated that random residents are interviewed to determine whether they feel safe residing at the facility. An interview with the facility Administrator, who also serves as the Abuse Coordinator (staff #20), was conducted on [DATE], at 12:30 p.m. Staff #20 stated that the 5-day report should include resident demographic information; the date and time of the incident; a description of the incident; interviews with witnessing staff; and interviews with residents or others present at the scene. Staff #20 reiterated that random resident interviews are included in the 5-day report and stated that the facility is required to notify the resident's family representative immediately following the incident. Staff #20 also stated that former staff records should be retained at the facility for at least five years. -Regarding resident #29: The resident was admitted [DATE], and discharged [DATE], with diagnoses that include chronic obstructive pulmonary disease; schizophrenia; bipolar disorder, unspecified; anxiety disorder, unspecified; major depressive disorder, recurrent, unspecified; and personal history of transient ischemic attack, and cerebral infarction, without residual deficits. Review of the care plan initiated on [DATE] revealed a focus area for mood, resident is at risk for fluctuating mood symptoms related to sadness, depression, anxiety, fear caused by functional changes. Interventions include observe signs and symptoms for worsening sadness, depression, anxiety, fear, anger, and agitation. Review of a social service progress note dated [DATE] at 10:00AM revealed social services assisted the resident with a call to Veteran Affairs (VA) for his share of costs. It was later identified that the resident stated he wanted to close his account at the bank due to some misappropriation of funds and that the resident would need a valid identification card in order to close his account. Further review of the complaint tracking system revealed no facility reported incidents for misappropriation of funds. Review of the facility reportable event record and report with a discovery date of [DATE] at 3:00PM revealed that resident #29 reported that he was missing a wallet. The resident reported to facility staff that his wallet went missing sometime around his last hospital stay in July. The resident did not recall reporting the missing wallet to any staff member. The resident stated he did not believe his wallet was stolen, and he did not want police involvement. The resident stated that his VA card and social security card were missing. Further review of the facility reportable event record and report revealed that the facility was unable to determine what happened with resident #29's wallet. The interventions included interview of two nurses and three certified nursing assistants, and that facility social work will assist resident in recovering a new VA card and social security card. Additional review of the reportable event record and report revealed no documented interviews with staff, residents, and resident #29. On [DATE] at 2:07PM, a written request was made for the five day investigation for resident #29. The written request was returned on [DATE] at 2:20PM stating we do not have this information. An email was received [DATE] at 2:38PM from the administrator (staff #23) stating This email is confirmation that we do not have the following information that you requested: 5 day investigation for resident #29, 5 day investigation for resident #38, and Grievance log for [DATE]. An interview was conducted on [DATE] at 2:26PM with the administrator (staff #23). Staff #23 stated that he is also the abuse coordinator and that misappropriation is a reportable incident. Staff #23 stated that he coordinates investigating reported incidents, which would include interviewing the staff, social services, witness, and the alleged victim. Staff #23 stated he keeps written record of interviews, but is unsure what previous management did. Regarding Resident #33: Resident #33 was initially admitted to the facility on [DATE], with a readmission date of [DATE], and a diagnosis of dementia. Review of the Care Plan dated [DATE], with a revision on [DATE], revealed resident #33 was at a risk for falls related to cognitive loss, lack of safety awareness, and impaired mobility. Interventions included having the resident's bed in the lowest position, assistance with getting in and out of bed, reminders to use the call light when attempting to ambulate or transfer, maintaining a clutter-free environment, and placing all personal items within reach when the resident is in bed. Review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicates the resident was cognitively intact. The facility reported to the State Agency (SA) that resident #33 was walking by the nurse's station and had a witnessed fall in an incident dated [DATE]. Review of the records and documentation requests revealed that the facility did not conduct a through investigation as resident clinical records had not been updated, staff and resident interviews had not been completed, and facility policies and procedures were not followed. Review of the clinical record revealed the facility had completed a change of condition on [DATE], at 8:39 PM, documenting the resident had grimacing pain from the left hip. Review of the progress note dated [DATE], at 7:10 AM stated the resident's power of attorney (POA) wanted the resident sent to the hospital for an evaluation of the injury. A physician's general note dated [DATE], at 8:19 AM stated, resident #33 got into an altercation with a resident, and that led to a fall and a left hip fracture. Further review of the clinical record did not reveal any indication of a resident-to-resident altercation. The facility incident report addressed the resident's fall but failed to include the resident to resident altercation as probable cause for fall. An interview was conducted on [DATE], at 11:03 AM with Licensed Practical Nurse (LPN, staff #13), Unit Manager. She confirmed the clinical record did not indicate how the resident fell; however, because the general note from the physician stated the resident fell due to a resident-to-resident altercation that resulted in a hip fracture is what should be believed. Attempts were made for to conduct interviews but either no one remembered the incident, or staff were no longer employed and could not be contacted. Review of the facility policy titled Accidents and Incidents – Investigating and Reporting (revised [DATE]) indicated that an incident report must include:(1) the date and time of the incident; (2) the nature of the injury or illness; (3) the circumstances surrounding the incident; (4) the location of the incident; (5) names and accounts of witnesses; (6) the injured person's account; (7) the date and time the attending physician was notified and the physician's response; (8) the date and time the family was notified and by whom; (9) the condition of the injured person, including vital signs; (10) the disposition of the injured person; (11) corrective actions taken; (12) follow-up information; (13) other pertinent data as required; and (14) the signature and title of the person completing the report. The policy further states that the nurse supervisor, charge nurse, the department director or supervisor is responsible for completing the incident report and submitting the original to the Director of Nursing Services within 24 hours of the incident. However, according to staff #20 there was no 5-day investigation report on record for the incident involving Resident #38. Review of the facility policy titled Retention of Medical Records indicated that medical records of discharged residents are to be retained for a period of six years. Review of the policy titled Charting and Documentation (revised [DATE]) stated that all services provided to the resident, progress toward care plan goals, and any changes in the resident's medical, physical, functional, or psychosocial condition must be documented in the medical record. The policy further stated that the medical record must facilitate communication among the interdisciplinary team and include documentation of changes in condition, events, incidents, or accidents involving residents. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised [DATE], states that The resident abuse, neglect and exploitation prevention program consists of a facility -wide commitment and resource allocation to support the following objectives: . Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.Review of the facility policy titled Abuse, Negect, Exploitation or Misappropriation – Reporting and Investigating, revised [DATE], states that The individual conducting the investigation as a minimum . interviews any witnesses to the incident, . interviews the resident, . interviews staff members. This policy also states The follow up investigation report will provide as much information as possible at the time of submission.

Based on record review, staff interviews, review of facility policies and review of SA database, the facility failed to ensure a through investigation was conducted for abuse and misappropriation of property for two residents (#29 and #33). The deficient practice could result in ongoing abuse of residents.Findings include: -Regarding resident #29Resident #29 was admitted [DATE], and discharged [DATE], with diagnoses that include chronic obstructive pulmonary disease; schizophrenia; bipolar disorder, unspecified; anxiety disorder, unspecified; major depressive disorder, recurrent, unspecified; and personal history of transient ischemic attack, and cerebral infarction, without residual deficits. Review of the care plan initiated on March 2, 2022 revealed a focus area for mood, resident is at risk for fluctuating mood symptoms related to sadness, depression, anxiety, fear caused by functional changes. Interventions include observe signs and symptoms for worsening sadness, depression, anxiety, fear, anger, and agitation. Review of a social service progress note dated August 19, 2022 at 10:00AM revealed social services assisted the resident with a call to Veteran Affairs (VA) for his share of costs. It was later identified that the resident stated he wanted to close his account at the bank due to some misappropriation of funds and that the resident would need a valid identification card in order to close his account. Further review of the complaint tracking system revealed no facility reported incidents for misappropriation of funds. Review of the facility reportable event record and report with a discovery date of November 18, 2022 at 3:00PM revealed that resident #29 reported on November 17, 2022 that he was missing a wallet. The resident reported to facility staff that his wallet went missing sometime around his last hospital stay in July. The resident did not recall reporting the missing wallet to any staff member. The resident stated he did not believe his wallet was stolen, and he did not want police involvement. The resident stated that his VA card and social security card were missing. Further review of the facility reportable event record and report revealed that the facility was unable to determine what happened with resident #29's wallet. The interventions included interview of two nurses and three certified nursing assistants, and that facility social work will assist resident in recovering a new VA card and social security card. Additional review of the reportable event record and report revealed no documented interviews with staff, residents, and resident #29. On December 17, 2025 at 2:07PM, a written request was made for the five day investigation for resident #29. The written request was returned on December 17, 2025 at 2:20PM stating we do not have this information. An email was received December 17, 2025 at 2:38PM from the administrator (staff #23) stating This email is confirmation that we do not have the following information that you requested: 5 day investigation for resident #29, 5 day investigation for resident #38, and Grievance log for November 2022. An interview was conducted on December 18, 2025 at 2:26PM with the administrator (staff #23). Staff #23 stated that he is also the abuse coordinator and that misappropriation is a reportable incident. Staff #23 stated that he coordinates investigating reported incidents, which would include interviewing the staff, social services, witness, and the alleged victim. Staff #23 stated he keeps written record of interviews, but is unsure what previous management did. -Regarding Resident #33: Resident #33 was initially admitted to the facility on [DATE], with a readmission date of September 9, 2022, and a diagnosis of dementia. Review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicates the resident was cognitively intact. Review of the Care Plan dated July 4, 2019, with a revision on October 24, 2022, revealed resident #33 was at a risk for falls related to cognitive loss, lack of safety awareness, and impaired mobility. Interventions included having the resident's bed in the lowest position, assistance with getting in and out of bed, reminders to use the call light when attempting to ambulate or transfer, maintaining a clutter-free environment, and placing all personal items within reach when the resident is in bed. The facility reported to the State Agency (SA) that resident #33 was walking by the nurse's station and had a witnessed fall in an incident dated September 7, 2022. Review of the clinical record revealed the facility had completed a change of condition on September 6, 2022, at 8:39 PM, documenting the resident had grimacing pain from the left hip. Review of the progress note dated September 7, 2022, at 7:10 AM stated the resident's power of attorney (POA) wanted the resident sent to the hospital for an evaluation of the injury. A physician's general note dated September 10, 2022, at 8:19 AM stated, resident #33 got into an altercation with a resident, and that led to a fall and a left hip fracture. Further review of the clinical record did not reveal any indication of a resident-to-resident altercation. Review of the records and documentation requests revealed that the facility did not conduct a through investigation as resident clinical records had not been updated, staff and resident interviews had not been completed, and facility policies and procedures were not followed. An interview was conducted on December 17, 2025, at 11:03 AM with Licensed Practical Nurse (LPN, staff #13), Unit Manager. She confirmed the clinical record did not indicate how the resident fell; however, because the general note from the physician stated the resident fell due to a resident-to-resident altercation that resulted in a hip fracture is what should be believed. Attempts were made to conduct interviews but either no one remembered the incident, or staff were no longer employed and could not be contacted. The facility's policy on Accidents and Incidents-Investigating and Reporting, dated July 2017, states, All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. The following data, as applicable, shall be included on the Report of Incident/Accident Form; a. the date and time the accident or incident took place; b. the nature of the injury/illness (e.g., bruise, fall, nausea, etc.); c. The circumstances surrounding the accident or incident d. where the accident or incident took place; e. the names of witnesses and their accounts of the accident or incident; f. the injured person's account of the accident or incident; g. the time the injured person's attending physician was notified, as well as the time the physician responded and his or her instructions; h. the date/time the injured person's family was notified and by whom; i. the condition of the injured person, including his/her vital signs; j. the disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work, etc.); k. any corrective action taken; l. follow-up information; m. other pertinent data as necessary or required; n. the signature and title of the person completing the report. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2017, states that The resident abuse, neglect and exploitation prevention program consists of a facility -wide commitment and resource allocation to support the following objectives: . Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, revised December 2025, states that The individual conducting the investigation as a minimum . interviews any witnesses to the incident, . interviews the resident, . interviews staff members. This policy also states The follow up investigation report will provide as much information as possible at the time of submission.

Based on observations, interviews, and a review of facility policy and procedure, the facility failed to ensure that three medication carts were secured in accordance with professional standards and facility policy when left unattended. The deficient practice could result in residents, visitors, and/or staff members having unrestricted access to medications and medical supplies.Findings include:An observation conducted on December 16, 2025, at 11:13 a.m., revealed that a medication cart on the Beta 2 unit was unattended and unlocked while outside of the direct line of sight of staff. The observation was evidenced by the State Agency (SA) being able to pull open three drawers holding resident medications, over-the-counter (OTC) medications, and diabetic supplies, including lancets.An observation conducted on December 16, 2025, at 11:21 a.m., revealed that the fill-in Director of Nursing and Licensed Practical Nurse Manager (LPN Manager/Staff#13) walked by the unlocked medication cart on the Beta 2 unit and locked it as she walked by. An interview was conducted on December 16, 2025, at 11:21 a.m. with the fill-in Director of Nursing and LPN Manager, Staff#13, who stated that the medication cart did not belong to her and that she did not know the location of the nurse who was responsible for the cart. The Nurse Manager stated that the cart was unlocked, and that was why she locked the cart as she walked by. The Nurse Manager stated that it was not the expectation or process in the building to leave medication carts unattended and unlocked, and she further stated that the risk of leaving the cart unlocked was that anyone could get into the cart and access medications and diabetic supplies, including lancets. An observation conducted on December 16, 2025, at 11:27 a.m. revealed that a medication cart on the Beta 1 unit was unattended and unlocked while the nursing staff was in a resident room. An interview was conducted on December 16, 2025, at 11:28 a.m. with a Licensed Practical Nurse (LPN/Staff#202) who stated that it was not her process, or the facility's process, to leave medication carts unlocked and unattended. The LPN stated that there was an inherent risk to any medication cart being unlocked, and that the risk here was that someone could steal medications from the cart.An observation conducted on December 17, 2025, at 8:02 a.m., revealed that a medication cart on the Beta 2 unit was unattended and unlocked while outside of the direct line of sight of staff. The nurse was observed in a resident room. An interview was conducted on December 17, 2025, at 8:08 a.m. with a Licensed Practical Nurse (LPN/Staff#41) who stated that she left her medication cart unlocked, and it was not her process to leave it unlocked when she walked away from it. The LPN further stated that the risk of leaving her medication cart unlocked was that someone could get into it and take medications from the cart. The LPN also opened the drawers and stated that the cart was holding narcotic medications, diabetic supplies, lancets, medicated patches, and alcohol pads.A follow-up interview was conducted on December 18, 2025, at 8:24 a.m. with the fill-in Director of Nursing and Licensed Practical Nurse Manager (Staff #13), who stated that nursing staff would be expected to lock their medication cart when walking away from it. The LPN manager stated that the risks of leaving medication carts unlocked included the possibility that anyone could access the cart to obtain blood sugar supplies and potentially ingest medications from it. A review of a policy titled, Medication Labeling and Storage, revised in December 2025, revealed that nursing staff were responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The policy also revealed that compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals should have been locked when not in use, and trays or carts used to transport such items should not be left unattended if open or otherwise potentially available to others.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that resident-identifiable information and records were kept confidential and not visible to the public. The deficient practice could result in the violation of residents' rights to privacy.Findings include:An observation conducted on December 16, 2025, at 11:27 a.m., revealed that an unattended medication cart on the Beta 1 unit had a laptop on top of it with resident records open on the screen. The nurse was observed in a resident room.An interview was conducted on December 16, 2025, at 11:28 a.m. with a Licensed Practical Nurse (LPN/Staff#202) who stated that it was not her process, or the facility's process, to leave her laptop open with resident records visible and unattended. The LPN stated that the risk of leaving the records open on her laptop was that it was a Health Insurance Portability and Accountability Act (HIPAA) violation. An observation conducted on December 17, 2025, at 8:02 a.m., revealed that a medication cart on the Beta 2 unit was unattended and had a laptop on top of it with resident records open on the screen. The nurse was observed in a resident room. An interview was conducted on December 17, 2025, at 8:08 a.m. with a Licensed Practical Nurse (LPN/Staff#41) who stated that she left her medication cart unattended, and it was not her process to leave resident records open on her laptop when she walked away from it. The LPN further stated that the risk of leaving her laptop open and unattended was the exposure of patient information, and it was a violation of their rights. An interview was conducted on December 18, 2025, at 8:24 a.m. with the fill-in Director of Nursing and Licensed Practical Nurse Manager (LPN Manager/Staff#13), who stated that nursing staff leaving their medication cart would be expected to ensure their computer screen was not open because it would violate HIPAA. The LPN manager stated that if a nurse were to leave resident records open on the medication cart and unattended, it would violate their right to privacy because their personal information, date of birth , and medications could be visible. A Review of a policy titled, Resident Rights, revised in February 2021, revealed that the unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing the privacy of information issues. All inquiries concerning the release of resident information should be directed to the HIPAA compliance officer.

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure 1 of 3 sampled residents (Resident # 16) was free from abuse by another resident (# 22). The deficient practice could result in other residents being abused. Findings include: -Regarding Resident (# 22) Resident (# 22) was admitted to the facility on [DATE] with diagnoses of major depressive disorder, Post Traumatic Stress Disorder, bipolar disorder, and hemiplegia and hemiparesis affecting left non-dominant side. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment. It was also noted that the resident is rarely understood. A comprehensive care plan dated December 3, 2024, revealed that Resident (# 22) makes statements of auditory hallucination and delusions. Interventions include, maintaining calm with a slow, understandable approach, and staff to observe for signs and symptoms of depression and emotional distress notifying physician as needed. A comprehensive care plan dated December 4, 2024, revealed that Resident (# 22) has a behavioral problem including history of methamphetamine use with hallucinations, paranoia, and irritability. The care plan also revealed that Resident (# 22) at times would leave the facility for long periods of time. Interventions include staff are to intervene as necessary to protect the rights and safety of others by diverting attention and removing from situation which includes taking to alternate location as needed. A behavioral progress note dated June 8, 2025 at 5:56 p.m., revealed that Resident (# 22) in her motorized chair wheeled herself out of the front door of the facility. A Medication Administration note dated June 9, 2025 at 12:50 a.m. regarding the removal of her 'carrot' splint to left upper extremity was not completed due to Resident (# 22) not in the building. A behavioral progress note dated June 9, 2025 at 5:12 a.m. indicated that Resident (# 22) returned to the Facility at approximately 3:15 a.m., talking nonsensically. Resident (# 22) told staff that she was smoking methamphetamine while she was out of the Facility. A behavioral progress note dated June 10, 2025 at 11:11 a.m. written by Director of Nursing (DON/Staff # 17) indicated that Resident (# 22) continued to talk nonsensical throughout morning and she continued to have delusions and hallucinations. The progress note also indicated that Resident (# 22) had an altercation with another resident and Police were called with the crisis team and Resident (# 22) was transferred to a Behavioral Health Center. -Regarding Resident (# 16) Resident (# 16) was admitted to the facility on [DATE] with diagnoses of cerebral infarct, schizoaffective disorder bipolar type. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating mild cognitive impairment. The assessment also indicated verbal behaviors directed toward others. Review of a facility investigation report, which was not dated, revealed that on June 9, 2025 at approximately 10:00 a.m. activity staff responded to Resident (# 16) and Resident (# 22) having a verbal altercation in the activity room and observed Resident (# 22) swing her ankle foot orthosis (AFO) brace at Resident (# 16). The report also revealed that the Crisis team was called to the Facility for Resident (# 22), who was taken to a Behavioral Health Center and has been discharged from the facility. A Skin Assessment was performed on June 9, 2025, on Resident (# 16) which indicated that he had no new skin issues at the time. Observation of Resident (# 16) was conducted on June 18, 2025 at 2:38 p.m. revealed resident sleeping in bed comfortably with no marks on resident's face. Bed is clean and room is clean. Resident (# 16) did not appear in any distress. An attempt to interview Resident #16 was made, but resident declined and went back to sleep. An interview was conducted with Activities Assistant (Staff #5) on June 18, 2025 at 2:52 p.m., who stated that while she was getting ready for an activity, she heard Resident (# 16) calling derogatory names at Resident (# 22) and Resident (# 22) yelling back at him. Staff (# 5) immediately separated the residents within the activity room and calmed down the situation. Staff (# 5) did not report the initial verbal altercation and returned to prepping for activities and began to hear the commotion start again, when she went back to activity room Staff (# 5) saw Resident (# 22) swing something metal from her wheelchair, hitting Resident (# 16) in the head knocking his head back. Staff (# 5) stated that she swung the metal object using her right hand. Staff (# 5) immediately took Resident (# 22) to her room and notified Staff's (# 5) direct report of the incident. During an interview conducted with DON (#17) on June 18, 2025 at 3:32 p.m., he stated that he was immediately notified of the incident and the residents were already separated and he notified the Administrator and started to make other notifications, including the Police Department. DON (# 17) stated Resident (# 16) was assessed, and no injuries or redness were discovered. DON stated that when Police Department came to the Facility, Resident (# 22) had requested to be sent out to Behavioral Health Hospital, despite the fact that it was documented that Resident (# 22) was nonsensical at this time. DON stated that the crisis team came out and Resident (# 22) was transferred to a Behavioral Health Center. A Policy and Procedure titled, Abuse, Exploitation and Misappropriation Prevention Program, revised April 2021, stated that residents have the right to be free from abuse which includes verbal and physical abuse. The Policy also indicates that the facility is committed to protect residents from abuse by other residents.

Based on clinical record review, interviews, and review of facility policies, the facility failed to ensure six of six sampled residents (#2, #3, #4, #5, #6 and #8) were free from sexual or physical abuse from one resident #1. The deficient practice could lead to sexual, physical and psychosocial harm to the residents. Findings include: -Regarding residents #1 and #2: -Resident #1 was admitted to the facility December 21, 2021 with dysphagia following cerebral infarction, unspecified dementia, mild, with agitation, schizophrenia, unspecified. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 completed a Brief Interview for Mental Status (BIMS) score of 08 indicating moderate cognitive impairment. Further review of the MDS revealed no indicators for mood, but will self-isolate. Indicators for physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, other behavioral symptoms not directed towards others and wandering. These assessments occurred 1-3 days of the lookback period. Review of the care plan, date-initiated December 22, 2024 revealed a focus for elopement; resident at risk for elopement/exit seeking; wandering related to dementia and other cognitive behaviors. Further review of the care plan revealed focus for behavior problems, agitation related to depression and schizophrenia, likes to follow female residents around to help them with things, per family and the potential to be physically aggressive related to dementia, poor impulse control; citing incident on April 13, 2025 with another resident due to resident not getting out of his desired chair; verbal aggression. Interventions include administer medications as ordered, intervene as necessary to protect the rights and safety of others. Review of the physicians orders dated April 15, 2025 revealed monitoring episodes of restlessness, agitation every shift and record every shift, Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) Give 125 mg by mouth two times a day for Mood/AEB Impulsivity, Mirtazapine Tablet 15 MG Give 1 tablet by mouth in the evening for Depression as exhibited by poor by mouth intake; Quetiapine Fumarate Oral Tablet 50 MG (Quetiapine Fumarate) Give 1 tablet by mouth in the morning for as exhibited by mood. Review of the Medication Administration Record for April 15, 2025 revealed a change in the number of times dosage administered for antipsychotic due to elevated behaviors. Review of a Nurse Practitioners Note dated April 14, 2025 at 8:16 p.m. revealed -Patient seen sitting up in activities room eating breakfast without difficulty nurse reports patient with aggressive behavior towards females and other residents. POC discussed with nursing. PMH NP was also alerted to patient behavioral issues at this time. Patient denies any chest pain shortness of breath and has pleasant affect at time of assessment. NAD. Review of the nurse's progress notes dated April 14, 2025 at 3:25 p.m. revealed a note text: During a verbal disagreement between two resident #1 approached and began yelling at the male resident. He then began threatening the male resident and staff had to step between to calm the situation. Resident was escorted back to his room, while also threatening nurses and using vulgar language. A progress note dated April 14, 2025 at 1:31 p.m. revealed a nurse's note text: This writer spoke with CNA who witnessed the alleged res to res. CNA clarified that when she was passing out trays, she heard two residents talking loudly to each other, she turned around to see resident #1 contact resident #8 trying to get him to move chairs. At that time two CNA's stepped in to separate the two residents. A progress note dated April 13, 2025 at 4:46 p.m. revealed a nurse's note text; Nurse summoned to dining room per certified nursing assistant (CNA) reported per CNA resident #1 punched resident #8 because he would not get out of his desired chair. CNA reported hearing a sound when physical contact was made. This nurse attempted to escort resident #1 to his room. Resident #1 is resistive to redirection and had to be redirected X 4 before returning to his bedroom. Resident #8 assessed by other nurse on duty. Representative notified. Manager on duty notified. Nurse Practitioner notified. New order for Hydroxyzine 25mg by mouth every 6 hours as needed for Anxiety X 14days.Representative contacted regarding new order, she declined to initiate Hydroxyzine. Nurse Practitioner notified. A behavior progress note dated April 12, 2025 at 5:37 p.m. states reported per CNA resident #1 required redirection multiple times throughout the day. Resident #1 noted rubbing resident #4 leg. When redirected resident #1 stated, That's my girl. becoming visibly upset when asked to leave the area near resident #4. Frequent visual checks continue to maintain distance of resident #1 and resident #4. Nurse Practitioner notified. A behavior progress note dated April 5, 2025 at 4:31 p.m. revealed resident #1 had an eventful day exhibiting increased sexual tendencies towards female peers. resident #1 noted touching resident #6 legs several times while in the dining room. When redirected resident #1 becomes visibly angered and posturing. Resident #1 stated, I'm gonna do it again. resident #1 had to be redirected from propelling resident #4 female peer per wheelchair from dining room. resident #1 walked away but later returned visibly upset. Attempts to redirect, distract and calm resident #1 were unsuccessful. Resident #5 female peer was found lying in resident #1 room with resident #1 at bedside. When attempting to remove resident #5, resident #1 stated. It's ok, leave her alone, she's with me. A behavior progress note dated March 28, 2025 at 5:25 p.m. revealed resident #1 has been talking to a female resident and trying to get her to walk with him to his room all afternoon. He was walking the female resident in the direction of his room about 30 minutes ago when this nurse intercepted and started walking the resident back towards the activities room, and he swung a punch at this nurse. Resident is also entering the rooms of female residents continuously, and when staff ask him to leave the room, he does but then goes and enters another female resident's room very shortly thereafter. Will continue to monitor. A behavior progress note dated March 22, 2025 at 2:27 p.m. revealed Reported per CNA resident #1 noted slapping the buttocks of resident #3 The sister of resident #3 was present at the time. Nurse Practitioner notified of incident. New order for Depakote 125mg by mouth twice daily for Mood/AEB. A behavior progress note dated March 21, 2025 at 2:28 p.m. revealed resident #1 increased sexual tendencies towards his female peers. Resident #1 noted leading resident #2. to his bedroom. This nurse attempted to redirect and intervene the situation, this only further angers the resident #1 This nurse leading resident #2 by hand to the common area but resident #1 became visibly upset stating, She's coming with me. Resident #1 grabbed her hand tighter and continued to walk towards his bedroom. This nurse acting as a barrier standing between residents #1 and #2. Resident #1 dropped her hand and walked away to his bedroom. Resident #1 family came to visit shortly after and is aware of the incident. Will notify Primary Care Physician. Resident observation on April 18, 2025 at 8:18 a.m. resident #1 provided with 1:1 intervention for 12 hours by Certified Nursing Assistant (CNA/Staff #18). Stated she was informed April 17, 2025 that she would be providing 1:1 care for resident #1 and to monitor his behaviors due to aggression and sexualized behaviors, she stated this was the first time resident #1 has been provided with 1:1 care. Residents #2 and resident 6 were observed seated in recliners in the dining room. There were two CNA's present. -Regarding Resident #2 -Resident #2 was admitted to the facility February 8, 2025 with diagnosis that included metabolic encephalopathy, cognitive communication deficit and altered mental status, unspecified. A review of the Part A Discharge MDS dated [DATE] revealed Resident #2 completed a Brief Interview for Mental Status (BIMS) score of 02 indicating severe cognitive impairment. Review of the care plan date-initiated February 9 2025 and a revision on April 4, 2025 revealed a focus for psychosocial behaviors; exhibits or is at risk for behavioral symptoms delusions, hallucinations, anxiety, SI without a plan, agitation, disrobing, wandering into others rooms. Interventions included Administer medication as ordered, document and record behavioral episodes and manage environmental factors to optimize comfort. Review of the progress notes revealed a behavior note dated April 4, 2025 at 1:27 p.m. Note Text: Resident was found in another resident's room. Resident was easily directed out of room. Skin check was performed. No abnormal findings. An interview was conducted on April 17, 2025 at 12:46 p.m. with Licensed Practical Nurse (LPN/Staff #93). Stated resident #1 has sexual tendencies mostly touching and kissing, rubbing of female residents' legs and those who are ambulatory. Stated resident #1 is fixated on two of them, resident's #4 and #2. Stated resident #1 has be separated from her before and tried to take resident #2 to his room. Staff #93 stated resident #1 had taken a female resident to his room approximately six weeks ago. The resident was resident #4. Staff #93 stated resident #4 was in his room in her wheelchair and resident #1 was standing up pacing the room. Staff #93 stated resident #1 has kissed resident 2 and #4, he's touched them by rubbing their legs, and he grabbed both of resident #3 buttocks, Staff #93 stated resident #1 paces the unit and staff keep a visual with 15-minute checks on resident #1. Staff #93 stated resident #1 has not been provided with 1:1 intervention and that he is unpredictable with physical aggression and posturing. An interview was conducted on April 17, 2025 at 1:22 p.m. with Certified Nursing Assistant (CAN/Staff #59. She stated she was informed that LPN/Staff #93 resident went to go get resident #1 for dinner when she saw resident #2 laying in the bed, she stated resident #1- he was sitting in a chair in his room. she stated resident #2 paces and wanders and had not seen her for about 30 minutes. Staff #59 stated we have to watch out for resident #1 he touches the females. An interview was conducted on April 17, 2025 at 1:28p.m. with certified nursing assistant (CNA/Staff #51) CAN #51 stated she first became aware of the incident when the nurse (LPN/Staff #93) called out for help to resident #1 room. She stated both (LPN/Staff #29) went to the room to find resident #2 lying on top of resident #1 bed naked with no clothing on. Staff #51 stated resident #1 was seated at the bedside with his shirt off and had put on a coat jacket, further stating his pants were on, but could not recall if his shoes were on. Staff#51 stated staff #29 assisted with getting resident #2 dressed. Staff #51 stated she documented the incident in Point Click Care and assumed LPN# 93 and #29 had reported the incident to the Director of Nursing. Staff #93 stated the doctor; family and the DON are aware of resident #1 sexualized behaviors with the other residents. An interview was conducted on April 17, 2025 at 2:18p.m. with housekeeper (staff #80). Staff #80 stated she has observed resident #1 with two female residents on two different occasions. Staff #80 stated On Saturday April 5, 2025, sometime in the morning while cleaning resident rooms she observed resident #1 had resident #2 laying on his bed covered with a blanket. Staff #80 stated resident #1 had his hands underneath the blanket and was rubbing her body. Staff #80 stated it looked like he was rubbing her up and down from her upper thighs to her chest area and touching her legs. Staff #80 stated she immediately informed the CNA that works on the weekends (did not know her name) and also informed her supervisor, Director of Housekeeping (Staff # 42). Staff #80 stated she was hesitant as to what to do with what she had observed, but stated I knew it was the right thing to do. An interview was conducted on April 17, 2025 at 3:37 p.m. with Operations Manager/ Abuse Coordinator (Staff #62). Staff #62 stated he did not file a report with the state agency because he had not been informed that resident #2 was disrobed and was told that resident #1 was sitting on the other side of the room when found. Staff #62 stated based on the report he received from his staff that there was nothing reportable. An interview was conducted on April 18, 2025 at 10:25 a.m. with Director of Housekeeping (Staff # 42). Staff #42 stated that his expectations are that his staff notify and report what they see immediately. He also stated his staff are instructed to notify him immediately as to what they observed and what happened. Staff #80 stated he will then immediately notify the person in charge of that department and the unit manager for ay type of abuse. Staff #42 stated staff #80 telephoned him on Saturday April 5, 2025 at 9:32 a.m. informing him that she had observed resident #1 touching one of the female residents on the thighs in his room. He stated she also informed hm that the female resident was lying on his bed and was rubbing the female resident. Staff #42 stated that staff #80 informed him that she had told resident #1 to leave and had told one of the CNA's. Staff #42 stated he informed her she did the right thing and that he would handle it from there. Staff #42 stated he immediately called the Unit Manger (Staff #79). Staff #42 stated he told her that he was notified by one of the housekeepers that resident #1 was rubbing one of the residents on the thigh. Staff #42 stated he did not inform her that the female resident was observed lying on the bed in resident #1 room. Staff #42 stated he did not inform the Director of Nursing (DON/Staff #86) or the Abuse Coordinator (Staff #62). An interview was conducted April 18, 2025 at 11:00 a.m. with Register Nurse Unit Manager (RN/UM/Staff #79). Staff # 79 stated she has been in the position as RN/UUM since March 2025 and that her responsibilities are to ensure everything is running ok and to make sure that unit is kept clean- residents are safe, family phone calls, log books updated- meds. Staff #79 stated staff report to her anything out of the norm. this would be anything that could lead to possible concerns, including inappropriate behaviors. Staff #79 stated inappropriate behaviors are reported to the DON, depending what is reported to her and if it is something that can be re-directed and no one is hurt from the behavior, then she feels no need to call the DON- Staff #79 stated she would notify the DON if a resident is hurt or imposing harm to another resident. Staff # 79 stated she notified on a Saturday morning that one of the housekeepers had seen a resident touching another resident. She stated it was on a Saturday-morning. She stated I just called the floor and told them to make sure that he [resident #1] is not around the girls. Further stating I did not feel that it warranted me calling the DON at that time. No one was hurt or in distress at that time. Staff #79 stated she was never informed of the residents sexualized behaviors and had that anything like that would warrant me to call my DON. Staff #79 stated does not take part in report with the nursing staff. -Regarding Resident #3 -Resident #3 was admitted to the facility March 7, 2025 with diagnosis that included vascular dementia, unspecified severity, with other behavioral disturbance, Alzheimer's disease, unspecified depression, unspecified, cerebral infarction, unspecified. A review of the admission MDS revealed a BIMS score of 7, indicating severe cognitive impairment. Further review revealed no indicators for mood or behaviors. There were indicators for wandering that occurred 1-3 days in the lookback period. Review of the care plan date-initiated March 19 2025 revealed a focus for risk for elopement and wandering related to disoriented to place and impaired safety awareness and impaired cognitive function, dementia or impaired thought processes related to dementia, difficulty making decisions and psychotropic drug use. Interventions included distracting the resident from wandering by offering pleasant diversions, intervene as appropriate and administer medications as ordered. Review of the progress notes revealed no documentation regarding the resident's buttocks being grabbed by resident #1. An interview was conducted April 17, 2025 at approximately 3:00 p.m. Resident #3 interviewed alone and in private in her room- pleasant and able to communicate and make needs knows- resident #3was able to recall being touched inappropriately by another resident. Stated yeah [NAME] has a bad habit of doing inappropriate things- I think he likes the ladies he grabbed my bottom. I didn't like him doing that, I try to keep away from him. I don't think he means any harm, but it's not nice for him to do that. Resident #3 stated I don't feel safe in my room, men come in all the time. I was changing my clothes and had just put on my bra when [NAME] came in. Sometimes I'll find people in my bed or they walk in your room at night. I had pushed the dresser against my door to keep them from coming in but they told me I couldn't. I don't remember if my sister was her with me, I can call and ask her if she was- (resident tried to call sister from cell phone no response. A male resident entered the resident's room during interview. later identified by staff as resident #10. Resident #10 was observed wandering around aimlessly going into different resident's rooms, no intervention observed by staff during observation on the unit. -Resident # 4 Resident was admitted to the facility December 8, 2023 with diagnosis that included unspecified dementia, unspecified severity, with agitation, restlessness and agitation, anxiety disorder, unspecified, impulsiveness, major depressive disorder, recurrent, unspecified. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating moderate cognitive impairment. The resident was assessed with a mild mood score of 10 with concerns with self-isolation and depression. There were also indicators for verbal behavioral symptoms directed towards others, e.g., threatening, screaming cursing at others, wandering and rejection of care with presence and frequency of this type occurred 1-3 days. Resident has no impairment of the upper or lower extremities and uses a wheelchair for mobility. Review of the care plan date-initiated December 15, 2023 and revised March 18, 2025 revealed a focus for elopement at risk for elopement, exit seeking, wandering related to dementia or other cognitive behavior and cognitive impairment loss related to Alzheimer's disease or other dementias. Interventions included allow wandering in safe areas within the facility, administering medication as ordered and anticipating the residents needs and met promptly. Review of the progress notes revealed no documentation regarding inappropriate touching or kissing of the resident by resident #4, An interview was conducted on April 17, 2025 at 12:46 p.m. with Licensed Practical Nurse (LPN/Staff #93). Stated resident #1 is fixated on two of them, resident's #4 and #2. Stated resident #1 has been separated from her before and tried to take resident #2 to his room. Staff #93 stated resident #1 had taken a female resident to his room approximately six weeks ago. The resident was resident #4. Staff #93 stated resident #1 has been observed kissing, touching and rubbing on resident #4 legs. An interview was conducted on April 17, 2025 at 1:28p.m. with certified nursing assistant (CNA/Staff #51) CNA #51 stated I know resident #1 touches residents #6 and #4, he will whisper in their ear; I don't know what he is saying. CNA #51 stated resident #1 will touch resident #4 and #6 on their arms and legs, stating it appears sexual when he touches them. -Regarding Resident #5 - Resident was admitted to the facility February 8, 2024 with diagnosis including cardiomyopathy, unspecified, altered mental status, unspecified, dementia in other diseases classified elsewhere, mild, with other behavioral disturbance cognitive communication deficit unspecified dementia, unspecified severity, with other behavioral disturbances. Review of the annual MDS dated [DATE] revealed a BIMS score of 03, indicating severe cognitive impairment. Resident not assessed for mood, unable to respond. Assessment for behaviors revealed other behavioral symptoms not directed toward others, places the resident at significant risk for physical illness or injury, interferes with the resident's care, interferes with the resident's participation in activities or social interactions, and significantly intrude on the privacy or activity of others. Further review of the MDS revealed the resident uses a wheelchair for mobility. Review of the care plan revealed a focus for cognitive impairment related to altered Alzheimer's disease or other dementias and the risk for elopement and wandering related to dementia and other cognitive behaviors, Interventions included administer medications as ordered, allow to wander in safe areas within the facility. Review of the progress notes revealed no documentation of and observation alleged incident involving resident #1 taking resident #5 to his room by the hand and attempting to lay her on his bed. The incident was reported to a certified nursing assistant who was able to intervene and remove resident #5 from resident #1 room. An interview was conducted on April 17, 2025 at 2:18p.m. with housekeeper (staff #80). Staff #80 stated she has observed resident #1 on two different occasions. Staff #80 stated I saw him in his room with her trying to lay her on his bed- I saw him take her by the hand to his room (Staff #80 did not know the residents name but was able to point the resident out- identified as [NAME]) Staff #80 stated I told the CNA who went in the room to get her. -Regarding Resident #6 Resident was admitted to the facility April 11, 2023 with diagnosis including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, cognitive communication deficit, Wernicke's encephalopathy Review of the quarterly MDS dated [DATE] revealed a BIMS score of o5, indicating severe cognitive impairment, no indicators for mood or behaviors. Uses walker and wheelchair for mobility. Review of the care plan revealed a focus for impaired cognitive function and thought processes related to vascular dementia, Wernicke's encephalopathy, and unspecified psychosis. Date Initiated: 04/23/2023 Revision on: 05/04/2023. Interventions included stress key words and present just one thought, question or command at a time. A behavior progress note dated April 5, 2025 at 4:31 p.m. revealed resident #1 had an eventful day exhibiting increased sexual tendencies towards female peers. resident #1 noted touching resident #6 legs several times while in the dining room. When redirected resident #1 becomes visibly angered and posturing. Resident #1 stated, I'm gonna do it again. -Regarding Resident #8 Resident #8 was admitted to the facility August 16, 2024 with diagnosis including unspecified dementia, severe, with psychotic disturbance, altered mental status, unspecified, depression, unspecified, anxiety disorder, unspecified. Review of the significant change of cognitive impairment MDS dated [DATE] revealed a BIMS score pf 03 indicating severe cognitive impairment, no indicators for [NAME] or behaviors, wandering with no impact on others, diagnosis for Anxiety disorder, Depression (other than bipolar), altered mental status, unspecified. Received Antipsychotic, Antidepressant, - gradual dose reduction (GDR) was attempted 11/30/2024- Physician documented GDR as clinically contraindicated 11/30/2024. Review of the care plan date-initiated August 22, 2024 revealed a focus for Psychosocial- Emotional/Trauma: At risk for decreased psychosocial well-being physical, social, or spiritual wellbeing related to alleged incident with peer on April 13, 2025. Date Initiated: April 15, 2025 Revision on: April 15, 2025, Interventions: included contact resident representative/friend for comfort and support. Date Initiated April 15, 2025. Review of eINTERACT Change in Condition Evaluation dated April 13, 2025 at 6:02 p.m. revealed pain in side remains, No signs of bruising/abrasion on skin of left side, pain with movement. Open cyst on upper mid back, cleaned and applied dry dressing. Pain medications administered PRN, dressing change daily on upper back till healed. The change in condition and notifications reported to primary care clinician Review of Treatment Administration Record for April 2025 revealed new orders for treatment for ruptured cyst with a start date of April 14, 2025. Review of the physician order summary dated April 13, 2025 revealed a STAT order for an x-ray ribs left side for trauma during altercation, however the examination results dated April 14, 2025 at 1:39pm and reported date April 14, 2025 at 1:41 p.m. revealed significant findings of unilateral left ribs x-ray. The impression revealed an acute hairline of the left lower rib fracture. Review of the nurses progress noted dated April 13, 2025 at 6:38 p.m. revealed a note text of the following detail; Informed of altercation in dining room, resident states he came out of nowhere and hit me, it was hard enough to push me back in my chair. Skin assessment performed, cyst on upper mid back ruptured and wound care performed, pain in left side ribs under arm no bruising or open skin in that area. Pain reported level 7/10, PRN medication administered. NP [NAME] notified, x-ray ordered and wound care to cyst. An interview was conducted on April 17, 2025 at 12:46 p.m. with Licensed Practical Nurse (LPN/Staff #93). Stated there was an incident involving resident #1 and resident #8, Staff #93 stated it was time to serve dinner came and resident #1 came from his room. Staff #93 stated she was at the med cart. She stated she was told by staff resident #1 told resident #8 to get out of his chair and resident #8 said no and resident #1 struck resident #8 on the upper right back to mid area. Staff #93 stated a weekend intervened and there were lots of lots of commotion. Staff #93 stated resident #1 was standing away from the table and resident #8 was standing at the other side of the table. She stated she had to ask resident #1 to leave the area multiple time- he refused- She stated it took four attempts to get the resident #1 to leave. Staff #93 stated LPN/Staff#9 came and completed a skin check for resident #8. She stated resident #8 complained of pain on the side he had a ruptured cyst, located on the left near his scapula where resident #1 hit him- the ruptured cyst was noted at the time of the assessment. Staff #93 stated an assessment was not done for resident #1 since he had not been hit. An attempt to interview resident #8 was made on April 18, 2025 at 8:35 a.m. due to the resident's severe cognition, he could not recall the incident in detail. Resident was walking the hallways- pleasant mood. An interview was conducted on April 18, 2025 at 1:09 p.m. with Abuse Coordinator (Staff #62) regarding residents #1 and #8. Staff #62 stated he was informed by the DON (Staff #86) of the alleged incident on Sunday, April 13, 2025. Staff #62 stated he was informed there was an altercation between residents #1 and #8 who were fighting over a chair in the dining room and staff intervened and removed resident #1 from the dining room. Staff #62 stated he informed the DON to follow-up with staff on duty and get their statements and made some call to initiate the two-hour required investigation report for the state agency. Staff #62 stated following the investigation injuries reported for resident #8 with an oozing cyst and x-rays taken revealed a hairline fracture of his ribs and that the resident had complained of pain. Staff #62 stated the facility unsubstantiated their investigation based on follow-up with the staff at the time; that it appeared two residents and argued over the chair and staff were able to intervene before anything escalated. Staff #62 stated resident #1 and #8 were pleasant with each other following the incident. An interview was conducted on April 18, 2025 at 1:29 p.m. with Director of Nursing (DON/Staff #86) stated the process for reporting alleged abuse is reporting to the different agencies as soon as they are aware. He stated he provides his staff with as much training as possible and during the facility monthly all-staff meetings. He stated they are told to immediately report to their supervisor or to the abuse coordinator. The DON stated he monitors for potential abuse by rounding the units, keeping up with daily nursing notes and being in front with his teams. The DON stated actions taken to protect the residents and other residents from abuse during the investigation process for resident #1 and #8 were that they were immediately separated and provided with frequent checks. He stated Resident #1 is being monitored 1:1 and will be moving the resident to an all-male unit to protect the females on the unit and the other residents. He stated he was not informed of what had happened with resident #! Nor of the other incidents with the other females on the unit. He stated he is very upset with this information. The DON stated staff #79 is new to her role as unit manager and staff #93 is a new floor nurse, that they report the incidents to me immediately. It is not expected that they make that decision on their own. I will be providing some additional training and education for my new staff. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program states Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to freedom from corporate punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to implement their abuse policy, by failing to report an allegation of sexual abuse involving five residents (#2, # 3, #4, #5 and #6) to the State Agency. The deficient practice could result in continued resident to resident sexual abuse Findings include: -Regarding residents #1 and #2: -Resident #1 was admitted to the facility December 21, 2021 with dysphagia following cerebral infarction, unspecified dementia, mild, with agitation, schizophrenia, unspecified. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 completed a Brief Interview for Mental Status (BIMS) score of 08 indicating moderate cognitive impairment. Further review of the MDS revealed no indicators for mood, but will self-isolate. Indicators for physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, other behavioral symptoms not directed towards others and wandering. These assessments occurred 1-3 days of the lookback period. Review of the care plan, date-initiated December 22, 2024 revealed a focus for elopement; resident at risk for elopement/exit seeking; wandering related to dementia and other cognitive behaviors. Further review of the care plan revealed focus for behavior problems, agitation related to depression and schizophrenia, likes to follow female residents around to help them with things, per family and the potential to be physically aggressive related to dementia, poor impulse control; citing incident on April 13, 2025 with another resident due to resident not getting out of his desired chair; verbal aggression. Interventions include administer medications as ordered, intervene as necessary to protect the rights and safety of others. Review of the physicians orders dated April 15, 2025 revealed monitoring episodes of restlessness, agitation every shift and record every shift, Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) Give 125 mg by mouth two times a day for Mood/AEB Impulsivity, Mirtazapine Tablet 15 MG Give 1 tablet by mouth in the evening for Depression as exhibited by poor by mouth intake; Quetiapine Fumarate Oral Tablet 50 MG (Quetiapine Fumarate) Give 1 tablet by mouth in the morning for as exhibited by mood. Review of the Medication Administration Record for April 15, 2025 revealed a change in the number of times dosage administered for antipsychotic due to elevated behaviors. Review of a Nurse Practitioners Note dated April 14, 2025 at 8:16 p.m. revealed -Patient seen sitting up in activities room eating breakfast without difficulty nurse reports patient with aggressive behavior towards females and other residents. POC discussed with nursing. PMH NP was also alerted to patient behavioral issues at this time. Patient denies any chest pain shortness of breath and has pleasant affect at time of assessment. NAD. Review of the nurse's progress notes dated April 14, 2025 at 3:25 p.m. revealed a note text: During a verbal disagreement between two resident #1 approached and began yelling at the male resident. He then began threatening the male resident and staff had to step between to calm the situation. Resident was escorted back to his room, while also threatening nurses and using vulgar language. A progress note dated April 14, 2025 at 1:31 p.m. revealed a nurse's note text: This writer spoke with CNA who witnessed the alleged res to res. CNA clarified that when she was passing out trays, she heard two residents talking loudly to each other, she turned around to see resident #1 contact resident #8 trying to get him to move chairs. At that time two CNA's stepped in to separate the two residents. A progress note dated April 13, 2025 at 4:46 p.m. revealed a nurse's note text; Nurse summoned to dining room per certified nursing assistant (CNA) reported per CNA resident #1 punched resident #8 because he would not get out of his desired chair. CNA reported hearing a sound when physical contact was made. This nurse attempted to escort resident #1 to his room. Resident #1 is resistive to redirection and had to be redirected X 4 before returning to his bedroom. Resident #8 assessed by other nurse on duty. Representative notified. Manager on duty notified. Nurse Practitioner notified. New order for Hydroxyzine 25mg by mouth every 6 hours as needed for Anxiety X 14days.Representative contacted regarding new order, she declined to initiate Hydroxyzine. Nurse Practitioner notified. A behavior progress note dated April 12, 2025 at 5:37 p.m. states reported per CNA resident #1 required redirection multiple times throughout the day. Resident #1 noted rubbing resident #4 leg. When redirected resident #1 stated, That's my girl. becoming visibly upset when asked to leave the area near resident #4. Frequent visual checks continue to maintain distance of resident #1 and resident #4. Nurse Practitioner notified. A behavior progress note dated April 5, 2025 at 4:31 p.m. revealed resident #1 had an eventful day exhibiting increased sexual tendencies towards female peers. resident #1 noted touching resident #6 legs several times while in the dining room. When redirected resident #1 becomes visibly angered and posturing. Resident #1 stated, I'm gonna do it again. resident #1 had to be redirected from propelling resident #4 female peer per wheelchair from dining room. resident #1 walked away but later returned visibly upset. Attempts to redirect, distract and calm resident #1 were unsuccessful. Resident #5 female peer was found lying in resident #1 room with resident #1 at bedside. When attempting to remove resident #5, resident #1 stated. It's ok, leave her alone, she's with me. A behavior progress note dated March 28, 2025 at 5:25 p.m. revealed resident #1 has been talking to a female resident and trying to get her to walk with him to his room all afternoon. He was walking the female resident in the direction of his room about 30 minutes ago when this nurse intercepted and started walking the resident back towards the activities room, and he swung a punch at this nurse. Resident is also entering the rooms of female residents continuously, and when staff ask him to leave the room, he does but then goes and enters another female resident's room very shortly thereafter. Will continue to monitor. A behavior progress note dated March 22, 2025 at 2:27 p.m. revealed Reported per CNA resident #1 noted slapping the buttocks of resident #3 The sister of resident #3 was present at the time. Nurse Practitioner notified of incident. New order for Depakote 125mg by mouth twice daily for Mood/AEB. A behavior progress note dated March 21, 2025 at 2:28 p.m. revealed resident #1 increased sexual tendencies towards his female peers. Resident #1 noted leading resident #2. to his bedroom. This nurse attempted to redirect and intervene the situation, this only further angers the resident #1 This nurse leading resident #2 by hand to the common area but resident #1 became visibly upset stating, She's coming with me. Resident #1 grabbed her hand tighter and continued to walk towards his bedroom. This nurse acting as a barrier standing between residents #1 and #2. Resident #1 dropped her hand and walked away to his bedroom. Resident #1 family came to visit shortly after and is aware of the incident. Will notify Primary Care Physician. Resident Observation on April 18, 2025 at 8:18 a.m. resident #1 provided with 1:1 intervention for 12 hours by Certified Nursing Assistant (CNA/Staff #18). Stated she was informed April 17, 2025 that she would be providing 1:1 care for resident #1 and to monitor his behaviors due to aggression and sexualized behaviors, she stated this was the first time resident #1 has been provided with 1:1 care. Residents #2 and resident 6 were observed seated in recliners in the dining room. There were two CNA's present. -Regarding Resident #2 -Resident #2 was admitted to the facility February 8, 2025 with diagnosis that included metabolic encephalopathy, cognitive communication deficit and altered mental status, unspecified. A review of the Part A Discharge MDS dated [DATE] revealed Resident #2 completed a Brief Interview for Mental Status (BIMS) score of 02 indicating severe cognitive impairment. Review of the care plan date-initiated February 9 2025 and a revision on April 4, 2025 revealed a focus for psychosocial behaviors; exhibits or is at risk for behavioral symptoms delusions, hallucinations, anxiety, SI without a plan, agitation, disrobing, wandering into others rooms. Interventions included Administer medication as ordered, document and record behavioral episodes and manage environmental factors to optimize comfort. Review of the progress notes revealed a behavior note dated April 4, 2025 at 1:27 p.m. Note Text: Resident was found in another resident's room. Resident was easily directed out of room. Skin check was performed. No abnormal findings. An interview was conducted on April 17, 2025 at 12:46 p.m. with Licensed Practical Nurse (LPN/Staff #93). Stated resident #1 has sexual tendencies mostly touching and kissing, rubbing of female residents' legs and those who are ambulatory. Stated resident #1 is fixated on two of them, resident's #4 and #2. Stated resident #1 has be separated from her before and tried to take resident #2 to his room. Staff #93 stated resident #1 had taken a female resident to his room approximately six weeks ago. The resident was resident #4. Staff #93 stated resident #4 was in his room in her wheelchair and resident #1 was standing up pacing the room. Staff #93 stated resident #1 has kissed resident 2 and #4, he's touched them by rubbing their legs, and he grabbed both of resident #3 buttocks, Staff #93 stated resident #1 paces the unit and staff keep a visual with 15-minute checks on resident #1. Staff #93 stated resident #1 has not been provided with 1:1 intervention and that he is unpredictable with physical aggression and posturing. An interview was conducted on April 17, 2025 at 1:22 p.m. with Certified Nursing Assistant (CAN/Staff #59. She stated she was informed that LPN/Staff #93 resident went to go get resident #1 for dinner when she saw resident #2 laying in the bed, she stated resident #1- he was sitting in a chair in his room. she stated resident #2 paces and wanders and had not seen her for about 30 minutes. Staff #59 stated we have to watch out for resident #1 he touches the females. An interview was conducted on April 17, 2025 at 1:28p.m. with certified nursing assistant (CNA/Staff #51) CAN #51 stated she first became aware of the incident when the nurse (LPN/Staff #93) called out for help to resident #1 room. She stated both (LPN/Staff #29) went to the room to find resident #2 lying on top of resident #1 bed naked with no clothing on. Staff #51 stated resident #1 was seated at the bedside with his shirt off and had put on a coat jacket, further stating his pants were on, but could not recall if his shoes were on. Staff#51 stated staff #29 assisted with getting resident #2 dressed. Staff #51 stated she documented the incident in Point Click Care and assumed LPN# 93 and #29 had reported the incident to the Director of Nursing. Staff #93 stated the doctor; family and the DON are aware of resident #1 sexualized behaviors with the other residents. An interview was conducted on April 17, 2025 at 2:18p.m. with housekeeper (staff #80). Staff #80 stated she has observed resident #1 with two female residents on two different occasions. Staff #80 stated On Saturday April 5, 2025, sometime in the morning while cleaning resident rooms she observed resident #1 had resident #2 laying on his bed covered with a blanket. Staff #80 stated resident #1 had his hands underneath the blanket and was rubbing her body. Staff #80 stated it looked like he was rubbing her up and down from her upper thighs to her chest area and touching her legs. Staff #80 stated she immediately informed the CNA that works on the weekends (did not know her name) and also informed her supervisor, Director of Housekeeping (Staff # 42). Staff #80 stated she was hesitant as to what to do with what she had observed, but stated I knew it was the right thing to do. An interview was conducted on April 17, 2025 at 3:37 p.m. with Operations Manager/ Abuse Coordinator (Staff #62). Staff #62 stated he did not file a report with the state agency because he had not been informed that resident #2 was disrobed and was told that resident #1 was sitting on the other side of the room when found. Staff #62 stated based on the report he received from his staff that there was nothing reportable. An interview was conducted on April 18, 2025 at 10:25 a.m. with Director of Housekeeping (Staff # 42). Staff #42 stated that his expectations are that his staff notify and report what they see immediately. He also stated his staff are instructed to notify him immediately as to what they observed and what happened. Staff #80 stated he will then immediately notify the person in charge of that department and the unit manager for ay type of abuse. Staff #42 stated staff #80 telephoned him on Saturday April 5, 2025 at 9:32 a.m. informing him that she had observed resident #1 touching one of the female residents on the thighs in his room. He stated she also informed hm that the female resident was lying on his bed and was rubbing the female resident. Staff #42 stated that staff #80 informed him that she had told resident #1 to leave and had told one of the CNA's. Staff #42 stated he informed her she did the right thing and that he would handle it from there. Staff #42 stated he immediately called the Unit Manger (Staff #79). Staff #42 stated he told her that he was notified by one of the housekeepers that resident #1 was rubbing one of the residents on the thigh. Staff #42 stated he did not inform her that the female resident was observed lying on the bed in resident #1 room. Staff #42 stated he did not inform the Director of Nursing (DON/Staff #86) or the Abuse Coordinator (Staff #62). An interview was conducted April 18, 2025 at 11:00 a.m. with Register Nurse Unit Manager (RN/UM/Staff #79). Staff # 79 stated she has been in the position as RN/UUM since March 2025 and that her responsibilities are to ensure everything is running ok and to make sure that unit is kept clean- residents are safe, family phone calls, log books updated- meds. Staff #79 stated staff report to her anything out of the norm. this would be anything that could lead to possible concerns, including inappropriate behaviors. Staff #79 stated inappropriate behaviors are reported to the DON, depending what is reported to her and if it is something that can be re-directed and no one is hurt from the behavior, then she feels no need to call the DON- Staff #79 stated she would notify the DON if a resident is hurt or imposing harm to another resident. Staff # 79 stated she notified on a Saturday morning that one of the housekeepers had seen a resident touching another resident. She stated it was on a Saturday-morning. She stated I just called the floor and told them to make sure that he [resident #1] is not around the girls. Further stating I did not feel that it warranted me calling the DON at that time. No one was hurt or in distress at that time. Staff #79 stated she was never informed of the residents sexualized behaviors and had that anything like that would warrant me to call my DON. Staff #79 stated does not take part in report with the nursing staff. -Regarding Resident #3 -Resident #3 was admitted to the facility March 7, 2025 with diagnosis that included vascular dementia, unspecified severity, with other behavioral disturbance, Alzheimer's disease, unspecified depression, unspecified, cerebral infarction, unspecified. A review of the admission MDS revealed a BIMS score of 7, indicating severe cognitive impairment. Further review revealed no indicators for mood or behaviors. There were indicators for wandering that occurred 1-3 days in the lookback period. Review of the care plan date-initiated March 19 2025 revealed a focus for risk for elopement and wandering related to disoriented to place and impaired safety awareness and impaired cognitive function, dementia or impaired thought processes related to dementia, difficulty making decisions and psychotropic drug use. Interventions included distracting the resident from wandering by offering pleasant diversions, intervene as appropriate and administer medications as ordered. Review of the progress notes revealed no documentation regarding the resident's buttocks being grabbed by resident #1. An interview was conducted April 17, 2025 at approximately 3:00 p.m. Resident #3 interviewed alone and in private in her room- pleasant and able to communicate and make needs knows- resident #3was able to recall being touched inappropriately by another resident. Stated yeah [NAME] has a bad habit of doing inappropriate things- I think he likes the ladies he grabbed my bottom. I didn't like him doing that, I try to keep away from him. I don't think he means any harm, but it's not nice for him to do that. Resident #3 stated I don't feel safe in my room, men come in all the time. I was changing my clothes and had just put on my bra when [NAME] came in. Sometimes I'll find people in my bed or they walk in your room at night. I had pushed the dresser against my door to keep them from coming in but they told me I couldn't. I don't remember if my sister was her with me, I can call and ask her if she was- (resident tried to call sister from cell phone no response. A male resident entered the resident's room during interview. later identified by staff as resident #10. Resident #10 was observed wandering around aimlessly going into different resident's rooms, no intervention observed by staff during observation on the unit. -Resident # 4 Resident was admitted to the facility December 8, 2023 with diagnosis that included unspecified dementia, unspecified severity, with agitation, restlessness and agitation, anxiety disorder, unspecified, impulsiveness, major depressive disorder, recurrent, unspecified. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating moderate cognitive impairment. The resident was assessed with a mild mood score of 10 with concerns with self-isolation and depression. There were also indicators for verbal behavioral symptoms directed towards others, e.g., threatening, screaming cursing at others, wandering and rejection of care with presence and frequency of this type occurred 1-3 days. Resident has no impairment of the upper or lower extremities and uses a wheelchair for mobility. Review of the care plan date-initiated December 15, 2023 and revised March 18, 2025 revealed a focus for elopement at risk for elopement, exit seeking, wandering related to dementia or other cognitive behavior and cognitive impairment loss related to Alzheimer's disease or other dementias. Interventions included allow wandering in safe areas within the facility, administering medication as ordered and anticipating the residents needs and met promptly. Review of the progress notes revealed no documentation regarding inappropriate touching or kissing of the resident by resident #4, An interview was conducted on April 17, 2025 at 12:46 p.m. with Licensed Practical Nurse (LPN/Staff #93). Stated resident #1 is fixated on two of them, resident's #4 and #2. Stated resident #1 has been separated from her before and tried to take resident #2 to his room. Staff #93 stated resident #1 had taken a female resident to his room approximately six weeks ago. The resident was resident #4. Staff #93 stated resident #1 has been observed kissing, touching and rubbing on resident #4 legs. An interview was conducted on April 17, 2025 at 1:28p.m. with certified nursing assistant (CNA/Staff #51) CNA #51 stated I know resident #1 touches residents #6 and #4, he will whisper in their ear; I don't know what he is saying. CNA #51 stated resident #1 will touch resident #4 and #6 on their arms and legs, stating it appears sexual when he touches them. -Regarding Resident #5 - Resident was admitted to the facility February 8, 2024 with diagnosis including cardiomyopathy, unspecified, altered mental status, unspecified, dementia in other diseases classified elsewhere, mild, with other behavioral disturbance cognitive communication deficit unspecified dementia, unspecified severity, with other behavioral disturbances. Review of the annual MDS dated [DATE] revealed a BIMS score of 03, indicating severe cognitive impairment. Resident not assessed for mood, unable to respond. Assessment for behaviors revealed other behavioral symptoms not directed toward others, places the resident at significant risk for physical illness or injury, interferes with the resident's care, interferes with the resident's participation in activities or social interactions, and significantly intrude on the privacy or activity of others. Further review of the MDS revealed the resident uses a wheelchair for mobility. Review of the care plan revealed a focus for cognitive impairment related to altered Alzheimer's disease or other dementias and the risk for elopement and wandering related to dementia and other cognitive behaviors, Interventions included administer medications as ordered, allow to wander in safe areas within the facility. Review of the progress notes revealed no documentation of and observation alleged incident involving resident #1 taking resident #5 to his room by the hand and attempting to lay her on his bed. The incident was reported to a certified nursing assistant who was able to intervene and remove resident #5 from resident #1 room. An interview was conducted on April 17, 2025 at 2:18p.m. with housekeeper (staff #80). Staff #80 stated she has observed resident #1 on two different occasions. Staff #80 stated I saw him in his room with her trying to lay her on his bed- I saw him take her by the hand to his room (Staff #80 did not know the residents name but was able to point the resident out- identified as [NAME]) Staff #80 stated I told the CNA who went in the room to get her. -Regarding Resident #6 Resident was admitted to the facility April 11, 2023 with diagnosis including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, cognitive communication deficit, Wernicke's encephalopathy Review of the quarterly MDS dated [DATE] revealed a BIMS score of o5, indicating severe cognitive impairment, no indicators for mood or behaviors. Uses walker and wheelchair for mobility. Review of the care plan revealed a focus for impaired cognitive function and thought processes related to vascular dementia, Wernicke's encephalopathy, and unspecified psychosis. Date Initiated: 04/23/2023 Revision on: 05/04/2023. Interventions included stress key words and present just one thought, question or command at a time. A behavior progress note dated April 5, 2025 at 4:31 p.m. revealed resident #1 had an eventful day exhibiting increased sexual tendencies towards female peers. resident #1 noted touching resident #6 legs several times while in the dining room. When redirected resident #1 becomes visibly angered and posturing. Resident #1 stated, I'm gonna do it again. -Regarding Resident #8 Resident #8 was admitted to the facility August 16, 2024 with diagnosis including unspecified dementia, severe, with psychotic disturbance, altered mental status, unspecified, depression, unspecified, anxiety disorder, unspecified. Review of the significant change of cognitive impairment MDS dated [DATE] revealed a BIMS score pf 03 indicating severe cognitive impairment, no indicators for [NAME] or behaviors, wandering with no impact on others, diagnosis for Anxiety disorder, Depression (other than bipolar), altered mental status, unspecified. Received Antipsychotic, Antidepressant, - gradual dose reduction (GDR) was attempted 11/30/2024- Physician documented GDR as clinically contraindicated 11/30/2024. Review of the care plan date-initiated August 22, 2024 revealed a focus for Psychosocial- Emotional/Trauma: At risk for decreased psychosocial well-being physical, social, or spiritual wellbeing related to alleged incident with peer on April 13, 2025. Date Initiated: April 15, 2025 Revision on: April 15, 2025, Interventions: included contact resident representative/friend for comfort and support. Date Initiated April 15, 2025. Review of eINTERACT Change in Condition Evaluation dated April 13, 2025 at 6:02 p.m. revealed pain in side remains, No signs of bruising/abrasion on skin of left side, pain with movement. Open cyst on upper mid back, cleaned and applied dry dressing. Pain medications administered PRN, dressing change daily on upper back till healed. The change in condition and notifications reported to primary care clinician Review of Treatment Administration Record for April 2025 revealed new orders for treatment for ruptured cyst with a start date of April 14, 2025. Review of the physician order summary dated April 13, 2025 revealed a STAT order for an x-ray ribs left side for trauma during altercation, however the examination results dated April 14, 2025 at 1:39pm and reported date April 14, 2025 at 1:41 p.m. revealed significant findings of unilateral left ribs x-ray. The impression revealed an acute hairline of the left lower rib fracture. Review of the nurses progress noted dated April 13, 2025 at 6:38 p.m. revealed a note text of the following detail; Informed of altercation in dining room, resident states he came out of nowhere and hit me, it was hard enough to push me back in my chair. Skin assessment performed, cyst on upper mid back ruptured and wound care performed, pain in left side ribs under arm no bruising or open skin in that area. Pain reported level 7/10, PRN medication administered. NP [NAME] notified, x-ray ordered and wound care to cyst. An interview was conducted on April 17, 2025 at 12:46 p.m. with Licensed Practical Nurse (LPN/Staff #93). Stated there was an incident involving resident #1 and resident #8, Staff #93 stated it was time to serve dinner came and resident #1 came from his room. Staff #93 stated she was at the med cart. She stated she was told by staff resident #1 told resident #8 to get out of his chair and resident #8 said no and resident #1 struck resident #8 on the upper right back to mid area. Staff #93 stated a weekend intervened and there were lots of lots of commotion. Staff #93 stated resident #1 was standing away from the table and resident #8 was standing at the other side of the table. She stated she had to ask resident #1 to leave the area multiple time- he refused- She stated it took four attempts to get the resident #1 to leave. Staff #93 stated LPN/Staff#9 came and completed a skin check for resident #8. She stated resident #8 complained of pain on the side he had a ruptured cyst, located on the left near his scapula where resident #1 hit him- the ruptured cyst was noted at the time of the assessment. Staff #93 stated an assessment was not done for resident #1 since he had not been hit. An attempt to interview resident #8 was made on April 18, 2025 at 8:35 a.m. due to the resident's severe cognition, he could not recall the incident in detail. Resident was walking the hallways- pleasant mood. An interview was conducted on April 18, 2025 at 1:09 p.m. with Abuse Coordinator (Staff #62) regarding residents #1 and #8. Staff #62 stated he was informed by the DON (Staff #86) of the alleged incident on Sunday, April 13, 2025. Staff #62 stated he was informed there was an altercation between residents #1 and #8 who were fighting over a chair in the dining room and staff intervened and removed resident #1 from the dining room. Staff #62 stated he informed the DON to follow-up with staff on duty and get their statements and made some call to initiate the two-hour required investigation report for the state agency. Staff #62 stated following the investigation injuries reported for resident #8 with an oozing cyst and x-rays taken revealed a hairline fracture of his ribs and that the resident had complained of pain. Staff #62 stated the facility unsubstantiated their investigation based on follow-up with the staff at the time; that it appeared two residents and argued over the chair and staff were able to intervene before anything escalated. Staff #62 stated resident #1 and #8 were pleasant with each other following the incident. An interview was conducted on April 18, 2025 at 1:29 p.m. with Director of Nursing (DON/Staff #86) stated the process for reporting alleged abuse is reporting to the different agencies as soon as they are aware. He stated he provides his staff with as much training as possible and during the facility monthly all-staff meetings. He stated they are told to immediately report to their supervisor or to the abuse coordinator. The DON stated he monitors for potential abuse by rounding the units, keeping up with daily nursing notes and being in front with his teams. The DON stated actions taken to protect the residents and other residents from abuse during the investigation process for resident #1 and #8 were that they were immediately separated and provided with frequent checks. He stated Resident #1 is being monitored 1:1 and will be moving the resident to an all-male unit to protect the females on the unit and the other residents. He stated he was not informed of what had happened with resident #! Nor of the other incidents with the other females on the unit. He stated he is very upset with this information. The DON stated staff #79 is new to her role as unit manager and staff #93 is a new floor nurse, that they report the incidents to me immediately. It is not expected that they make that decision on their own. I will be providing some additional training and education for my new staff. Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, with a revision date of April 2021 revealed a policy statement All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Reporting allegations to the Administrator and authorities (2) The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. the resident's representative; d. Adult protective services; i.e. law enforcement officials; f. The resident's attending physician; and g. the facility's medical director. (3) Immediately is defined as: a. within two hours of an allegation involving abuse.

Based on clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure that an allegation of sexual abuse for five residents (#2, # 3, #4, #5 and #6) was reported to the State Agency. Findings include: -Regarding residents #1 and #2: -Resident #1 was admitted to the facility December 21, 2021 with dysphagia following cerebral infarction, unspecified dementia, mild, with agitation, schizophrenia, unspecified. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 completed a Brief Interview for Mental Status (BIMS) score of 08 indicating moderate cognitive impairment. Further review of the MDS revealed no indicators for mood, but will self-isolate. Indicators for physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, other behavioral symptoms not directed towards others and wandering. These assessments occurred 1-3 days of the lookback period. Review of the care plan, date-initiated December 22, 2024 revealed a focus for elopement; resident at risk for elopement/exit seeking; wandering related to dementia and other cognitive behaviors. Further review of the care plan revealed focus for behavior problems, agitation related to depression and schizophrenia, likes to follow female residents around to help them with things, per family and the potential to be physically aggressive related to dementia, poor impulse control; citing incident on April 13, 2025 with another resident due to resident not getting out of his desired chair; verbal aggression. Interventions include administer medications as ordered, intervene as necessary to protect the rights and safety of others. Review of the physicians orders dated April 15, 2025 revealed monitoring episodes of restlessness, agitation every shift and record every shift, Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) Give 125 mg by mouth two times a day for Mood/AEB Impulsivity, Mirtazapine Tablet 15 MG Give 1 tablet by mouth in the evening for Depression as exhibited by poor by mouth intake; Quetiapine Fumarate Oral Tablet 50 MG (Quetiapine Fumarate) Give 1 tablet by mouth in the morning for as exhibited by mood. Review of the Medication Administration Record for April 15, 2025 revealed a change in the number of times dosage administered for antipsychotic due to elevated behaviors. Review of a Nurse Practitioners Note dated April 14, 2025 at 8:16 p.m. revealed -Patient seen sitting up in activities room eating breakfast without difficulty nurse reports patient with aggressive behavior towards females and other residents. POC discussed with nursing. PMH NP was also alerted to patient behavioral issues at this time. Patient denies any chest pain shortness of breath and has pleasant affect at time of assessment. NAD. Review of the nurse's progress notes dated April 14, 2025 at 3:25 p.m. revealed a note text: During a verbal disagreement between two resident #1 approached and began yelling at the male resident. He then began threatening the male resident and staff had to step between to calm the situation. Resident was escorted back to his room, while also threatening nurses and using vulgar language. A progress note dated April 14, 2025 at 1:31 p.m. revealed a nurse's note text: This writer spoke with CNA who witnessed the alleged res to res. CNA clarified that when she was passing out trays, she heard two residents talking loudly to each other, she turned around to see resident #1 contact resident #8 trying to get him to move chairs. At that time two CNA's stepped in to separate the two residents. A progress note dated April 13, 2025 at 4:46 p.m. revealed a nurse's note text; Nurse summoned to dining room per certified nursing assistant (CNA) reported per CNA resident #1 punched resident #8 because he would not get out of his desired chair. CNA reported hearing a sound when physical contact was made. This nurse attempted to escort resident #1 to his room. Resident #1 is resistive to redirection and had to be redirected X 4 before returning to his bedroom. Resident #8 assessed by other nurse on duty. Representative notified. Manager on duty notified. Nurse Practitioner notified. New order for Hydroxyzine 25mg by mouth every 6 hours as needed for Anxiety X 14days.Representative contacted regarding new order, she declined to initiate Hydroxyzine. Nurse Practitioner notified. A behavior progress note dated April 12, 2025 at 5:37 p.m. states reported per CNA resident #1 required redirection multiple times throughout the day. Resident #1 noted rubbing resident #4 leg. When redirected resident #1 stated, That's my girl. becoming visibly upset when asked to leave the area near resident #4. Frequent visual checks continue to maintain distance of resident #1 and resident #4. Nurse Practitioner notified. A behavior progress note dated April 5, 2025 at 4:31 p.m. revealed resident #1 had an eventful day exhibiting increased sexual tendencies towards female peers. resident #1 noted touching resident #6 legs several times while in the dining room. When redirected resident #1 becomes visibly angered and posturing. Resident #1 stated, I'm gonna do it again. resident #1 had to be redirected from propelling resident #4 female peer per wheelchair from dining room. resident #1 walked away but later returned visibly upset. Attempts to redirect, distract and calm resident #1 were unsuccessful. Resident #5 female peer was found lying in resident #1 room with resident #1 at bedside. When attempting to remove resident #5, resident #1 stated. It's ok, leave her alone, she's with me. A behavior progress note dated March 28, 2025 at 5:25 p.m. revealed resident #1 has been talking to a female resident and trying to get her to walk with him to his room all afternoon. He was walking the female resident in the direction of his room about 30 minutes ago when this nurse intercepted and started walking the resident back towards the activities room, and he swung a punch at this nurse. Resident is also entering the rooms of female residents continuously, and when staff ask him to leave the room, he does but then goes and enters another female resident's room very shortly thereafter. Will continue to monitor. A behavior progress note dated March 22, 2025 at 2:27 p.m. revealed Reported per CNA resident #1 noted slapping the buttocks of resident #3 The sister of resident #3 was present at the time. Nurse Practitioner notified of incident. New order for Depakote 125mg by mouth twice daily for Mood/AEB. A behavior progress note dated March 21, 2025 at 2:28 p.m. revealed resident #1 increased sexual tendencies towards his female peers. Resident #1 noted leading resident #2. to his bedroom. This nurse attempted to redirect and intervene the situation, this only further angers the resident #1 This nurse leading resident #2 by hand to the common area but resident #1 became visibly upset stating, She's coming with me. Resident #1 grabbed her hand tighter and continued to walk towards his bedroom. This nurse acting as a barrier standing between residents #1 and #2. Resident #1 dropped her hand and walked away to his bedroom. Resident #1 family came to visit shortly after and is aware of the incident. Will notify Primary Care Physician. Resident Observation on April 18, 2025 at 8:18 a.m. resident #1 provided with 1:1 intervention for 12 hours by Certified Nursing Assistant (CNA/Staff #18). Stated she was informed April 17, 2025 that she would be providing 1:1 care for resident #1 and to monitor his behaviors due to aggression and sexualized behaviors, she stated this was the first time resident #1 has been provided with 1:1 care. Residents #2 and resident 6 were observed seated in recliners in the dining room. There were two CNA's present. -Regarding Resident #2 -Resident #2 was admitted to the facility February 8, 2025 with diagnosis that included metabolic encephalopathy, cognitive communication deficit and altered mental status, unspecified. A review of the Part A Discharge MDS dated [DATE] revealed Resident #2 completed a Brief Interview for Mental Status (BIMS) score of 02 indicating severe cognitive impairment. Review of the care plan date-initiated February 9 2025 and a revision on April 4, 2025 revealed a focus for psychosocial behaviors; exhibits or is at risk for behavioral symptoms delusions, hallucinations, anxiety, SI without a plan, agitation, disrobing, wandering into others rooms. Interventions included Administer medication as ordered, document and record behavioral episodes and manage environmental factors to optimize comfort. Review of the progress notes revealed a behavior note dated April 4, 2025 at 1:27 p.m. Note Text: Resident was found in another resident's room. Resident was easily directed out of room. Skin check was performed. No abnormal findings. An interview was conducted on April 17, 2025 at 12:46 p.m. with Licensed Practical Nurse (LPN/Staff #93). Stated resident #1 has sexual tendencies mostly touching and kissing, rubbing of female residents' legs and those who are ambulatory. Stated resident #1 is fixated on two of them, resident's #4 and #2. Stated resident #1 has be separated from her before and tried to take resident #2 to his room. Staff #93 stated resident #1 had taken a female resident to his room approximately six weeks ago. The resident was resident #4. Staff #93 stated resident #4 was in his room in her wheelchair and resident #1 was standing up pacing the room. Staff #93 stated resident #1 has kissed resident 2 and #4, he's touched them by rubbing their legs, and he grabbed both of resident #3 buttocks, Staff #93 stated resident #1 paces the unit and staff keep a visual with 15-minute checks on resident #1. Staff #93 stated resident #1 has not been provided with 1:1 intervention and that he is unpredictable with physical aggression and posturing. An interview was conducted on April 17, 2025 at 1:22 p.m. with Certified Nursing Assistant (CAN/Staff #59. She stated she was informed that LPN/Staff #93 resident went to go get resident #1 for dinner when she saw resident #2 laying in the bed, she stated resident #1- he was sitting in a chair in his room. she stated resident #2 paces and wanders and had not seen her for about 30 minutes. Staff #59 stated we have to watch out for resident #1 he touches the females. An interview was conducted on April 17, 2025 at 1:28p.m. with certified nursing assistant (CNA/Staff #51) CAN #51 stated she first became aware of the incident when the nurse (LPN/Staff #93) called out for help to resident #1 room. She stated both (LPN/Staff #29) went to the room to find resident #2 lying on top of resident #1 bed naked with no clothing on. Staff #51 stated resident #1 was seated at the bedside with his shirt off and had put on a coat jacket, further stating his pants were on, but could not recall if his shoes were on. Staff#51 stated staff #29 assisted with getting resident #2 dressed. Staff #51 stated she documented the incident in Point Click Care and assumed LPN# 93 and #29 had reported the incident to the Director of Nursing. Staff #93 stated the doctor; family and the DON are aware of resident #1 sexualized behaviors with the other residents. An interview was conducted on April 17, 2025 at 2:18p.m. with housekeeper (staff #80). Staff #80 stated she has observed resident #1 with two female residents on two different occasions. Staff #80 stated On Saturday April 5, 2025, sometime in the morning while cleaning resident rooms she observed resident #1 had resident #2 laying on his bed covered with a blanket. Staff #80 stated resident #1 had his hands underneath the blanket and was rubbing her body. Staff #80 stated it looked like he was rubbing her up and down from her upper thighs to her chest area and touching her legs. Staff #80 stated she immediately informed the CNA that works on the weekends (did not know her name) and also informed her supervisor, Director of Housekeeping (Staff # 42). Staff #80 stated she was hesitant as to what to do with what she had observed, but stated I knew it was the right thing to do. An interview was conducted on April 17, 2025 at 3:37 p.m. with Operations Manager/ Abuse Coordinator (Staff #62). Staff #62 stated he did not file a report with the state agency because he had not been informed that resident #2 was disrobed and was told that resident #1 was sitting on the other side of the room when found. Staff #62 stated based on the report he received from his staff that there was nothing reportable. An interview was conducted on April 18, 2025 at 10:25 a.m. with Director of Housekeeping (Staff # 42). Staff #42 stated that his expectations are that his staff notify and report what they see immediately. He also stated his staff are instructed to notify him immediately as to what they observed and what happened. Staff #80 stated he will then immediately notify the person in charge of that department and the unit manager for ay type of abuse. Staff #42 stated staff #80 telephoned him on Saturday April 5, 2025 at 9:32 a.m. informing him that she had observed resident #1 touching one of the female residents on the thighs in his room. He stated she also informed hm that the female resident was lying on his bed and was rubbing the female resident. Staff #42 stated that staff #80 informed him that she had told resident #1 to leave and had told one of the CNA's. Staff #42 stated he informed her she did the right thing and that he would handle it from there. Staff #42 stated he immediately called the Unit Manger (Staff #79). Staff #42 stated he told her that he was notified by one of the housekeepers that resident #1 was rubbing one of the residents on the thigh. Staff #42 stated he did not inform her that the female resident was observed lying on the bed in resident #1 room. Staff #42 stated he did not inform the Director of Nursing (DON/Staff #86) or the Abuse Coordinator (Staff #62). An interview was conducted April 18, 2025 at 11:00 a.m. with Register Nurse Unit Manager (RN/UM/Staff #79). Staff # 79 stated she has been in the position as RN/UUM since March 2025 and that her responsibilities are to ensure everything is running ok and to make sure that unit is kept clean- residents are safe, family phone calls, log books updated- meds. Staff #79 stated staff report to her anything out of the norm. this would be anything that could lead to possible concerns, including inappropriate behaviors. Staff #79 stated inappropriate behaviors are reported to the DON, depending what is reported to her and if it is something that can be re-directed and no one is hurt from the behavior, then she feels no need to call the DON- Staff #79 stated she would notify the DON if a resident is hurt or imposing harm to another resident. Staff # 79 stated she notified on a Saturday morning that one of the housekeepers had seen a resident touching another resident. She stated it was on a Saturday-morning. She stated I just called the floor and told them to make sure that he [resident #1] is not around the girls. Further stating I did not feel that it warranted me calling the DON at that time. No one was hurt or in distress at that time. Staff #79 stated she was never informed of the residents sexualized behaviors and had that anything like that would warrant me to call my DON. Staff #79 stated does not take part in report with the nursing staff. -Regarding Resident #3 -Resident #3 was admitted to the facility March 7, 2025 with diagnosis that included vascular dementia, unspecified severity, with other behavioral disturbance, Alzheimer's disease, unspecified depression, unspecified, cerebral infarction, unspecified. A review of the admission MDS revealed a BIMS score of 7, indicating severe cognitive impairment. Further review revealed no indicators for mood or behaviors. There were indicators for wandering that occurred 1-3 days in the lookback period. Review of the care plan date-initiated March 19 2025 revealed a focus for risk for elopement and wandering related to disoriented to place and impaired safety awareness and impaired cognitive function, dementia or impaired thought processes related to dementia, difficulty making decisions and psychotropic drug use. Interventions included distracting the resident from wandering by offering pleasant diversions, intervene as appropriate and administer medications as ordered. Review of the progress notes revealed no documentation regarding the resident's buttocks being grabbed by resident #1. An interview was conducted April 17, 2025 at approximately 3:00 p.m. Resident #3 interviewed alone and in private in her room- pleasant and able to communicate and make needs knows- resident #3was able to recall being touched inappropriately by another resident. Stated yeah [NAME] has a bad habit of doing inappropriate things- I think he likes the ladies he grabbed my bottom. I didn't like him doing that, I try to keep away from him. I don't think he means any harm, but it's not nice for him to do that. Resident #3 stated I don't feel safe in my room, men come in all the time. I was changing my clothes and had just put on my bra when [NAME] came in. Sometimes I'll find people in my bed or they walk in your room at night. I had pushed the dresser against my door to keep them from coming in but they told me I couldn't. I don't remember if my sister was her with me, I can call and ask her if she was- (resident tried to call sister from cell phone no response. A male resident entered the resident's room during interview. later identified by staff as resident #10. Resident #10 was observed wandering around aimlessly going into different resident's rooms, no intervention observed by staff during observation on the unit. -Resident # 4 Resident was admitted to the facility December 8, 2023 with diagnosis that included unspecified dementia, unspecified severity, with agitation, restlessness and agitation, anxiety disorder, unspecified, impulsiveness, major depressive disorder, recurrent, unspecified. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating moderate cognitive impairment. The resident was assessed with a mild mood score of 10 with concerns with self-isolation and depression. There were also indicators for verbal behavioral symptoms directed towards others, e.g., threatening, screaming cursing at others, wandering and rejection of care with presence and frequency of this type occurred 1-3 days. Resident has no impairment of the upper or lower extremities and uses a wheelchair for mobility. Review of the care plan date-initiated December 15, 2023 and revised March 18, 2025 revealed a focus for elopement at risk for elopement, exit seeking, wandering related to dementia or other cognitive behavior and cognitive impairment loss related to Alzheimer's disease or other dementias. Interventions included allow wandering in safe areas within the facility, administering medication as ordered and anticipating the residents needs and met promptly. Review of the progress notes revealed no documentation regarding inappropriate touching or kissing of the resident by resident #4, An interview was conducted on April 17, 2025 at 12:46 p.m. with Licensed Practical Nurse (LPN/Staff #93). Stated resident #1 is fixated on two of them, resident's #4 and #2. Stated resident #1 has been separated from her before and tried to take resident #2 to his room. Staff #93 stated resident #1 had taken a female resident to his room approximately six weeks ago. The resident was resident #4. Staff #93 stated resident #1 has been observed kissing, touching and rubbing on resident #4 legs. An interview was conducted on April 17, 2025 at 1:28p.m. with certified nursing assistant (CNA/Staff #51) CNA #51 stated I know resident #1 touches residents #6 and #4, he will whisper in their ear; I don't know what he is saying. CNA #51 stated resident #1 will touch resident #4 and #6 on their arms and legs, stating it appears sexual when he touches them. -Regarding Resident #5 - Resident was admitted to the facility February 8, 2024 with diagnosis including cardiomyopathy, unspecified, altered mental status, unspecified, dementia in other diseases classified elsewhere, mild, with other behavioral disturbance cognitive communication deficit unspecified dementia, unspecified severity, with other behavioral disturbances. Review of the annual MDS dated [DATE] revealed a BIMS score of 03, indicating severe cognitive impairment. Resident not assessed for mood, unable to respond. Assessment for behaviors revealed other behavioral symptoms not directed toward others, places the resident at significant risk for physical illness or injury, interferes with the resident's care, interferes with the resident's participation in activities or social interactions, and significantly intrude on the privacy or activity of others. Further review of the MDS revealed the resident uses a wheelchair for mobility. Review of the care plan revealed a focus for cognitive impairment related to altered Alzheimer's disease or other dementias and the risk for elopement and wandering related to dementia and other cognitive behaviors, Interventions included administer medications as ordered, allow to wander in safe areas within the facility. Review of the progress notes revealed no documentation of and observation alleged incident involving resident #1 taking resident #5 to his room by the hand and attempting to lay her on his bed. The incident was reported to a certified nursing assistant who was able to intervene and remove resident #5 from resident #1 room. An interview was conducted on April 17, 2025 at 2:18p.m. with housekeeper (staff #80). Staff #80 stated she has observed resident #1 on two different occasions. Staff #80 stated I saw him in his room with her trying to lay her on his bed- I saw him take her by the hand to his room (Staff #80 did not know the residents name but was able to point the resident out- identified as [NAME]) Staff #80 stated I told the CNA who went in the room to get her. -Regarding Resident #6 Resident was admitted to the facility April 11, 2023 with diagnosis including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, cognitive communication deficit, Wernicke's encephalopathy Review of the quarterly MDS dated [DATE] revealed a BIMS score of o5, indicating severe cognitive impairment, no indicators for mood or behaviors. Uses walker and wheelchair for mobility. Review of the care plan revealed a focus for impaired cognitive function and thought processes related to vascular dementia, Wernicke's encephalopathy, and unspecified psychosis. Date Initiated: 04/23/2023 Revision on: 05/04/2023. Interventions included stress key words and present just one thought, question or command at a time. A behavior progress note dated April 5, 2025 at 4:31 p.m. revealed resident #1 had an eventful day exhibiting increased sexual tendencies towards female peers. resident #1 noted touching resident #6 legs several times while in the dining room. When redirected resident #1 becomes visibly angered and posturing. Resident #1 stated, I'm gonna do it again. -Regarding Resident #8 Resident #8 was admitted to the facility August 16, 2024 with diagnosis including unspecified dementia, severe, with psychotic disturbance, altered mental status, unspecified, depression, unspecified, anxiety disorder, unspecified. Review of the significant change of cognitive impairment MDS dated [DATE] revealed a BIMS score pf 03 indicating severe cognitive impairment, no indicators for [NAME] or behaviors, wandering with no impact on others, diagnosis for Anxiety disorder, Depression (other than bipolar), altered mental status, unspecified. Received Antipsychotic, Antidepressant, - gradual dose reduction (GDR) was attempted 11/30/2024- Physician documented GDR as clinically contraindicated 11/30/2024. Review of the care plan date-initiated August 22, 2024 revealed a focus for Psychosocial- Emotional/Trauma: At risk for decreased psychosocial well-being physical, social, or spiritual wellbeing related to alleged incident with peer on April 13, 2025. Date Initiated: April 15, 2025 Revision on: April 15, 2025, Interventions: included contact resident representative/friend for comfort and support. Date Initiated April 15, 2025. Review of eINTERACT Change in Condition Evaluation dated April 13, 2025 at 6:02 p.m. revealed pain in side remains, No signs of bruising/abrasion on skin of left side, pain with movement. Open cyst on upper mid back, cleaned and applied dry dressing. Pain medications administered PRN, dressing change daily on upper back till healed. The change in condition and notifications reported to primary care clinician Review of Treatment Administration Record for April 2025 revealed new orders for treatment for ruptured cyst with a start date of April 14, 2025. Review of the physician order summary dated April 13, 2025 revealed a STAT order for an x-ray ribs left side for trauma during altercation, however the examination results dated April 14, 2025 at 1:39pm and reported date April 14, 2025 at 1:41 p.m. revealed significant findings of unilateral left ribs x-ray. The impression revealed an acute hairline of the left lower rib fracture. Review of the nurses progress noted dated April 13, 2025 at 6:38 p.m. revealed a note text of the following detail; Informed of altercation in dining room, resident states he came out of nowhere and hit me, it was hard enough to push me back in my chair. Skin assessment performed, cyst on upper mid back ruptured and wound care performed, pain in left side ribs under arm no bruising or open skin in that area. Pain reported level 7/10, PRN medication administered. NP [NAME] notified, x-ray ordered and wound care to cyst. An interview was conducted on April 17, 2025 at 12:46 p.m. with Licensed Practical Nurse (LPN/Staff #93). Stated there was an incident involving resident #1 and resident #8, Staff #93 stated it was time to serve dinner came and resident #1 came from his room. Staff #93 stated she was at the med cart. She stated she was told by staff resident #1 told resident #8 to get out of his chair and resident #8 said no and resident #1 struck resident #8 on the upper right back to mid area. Staff #93 stated a weekend intervened and there were lots of lots of commotion. Staff #93 stated resident #1 was standing away from the table and resident #8 was standing at the other side of the table. She stated she had to ask resident #1 to leave the area multiple time- he refused- She stated it took four attempts to get the resident #1 to leave. Staff #93 stated LPN/Staff#9 came and completed a skin check for resident #8. She stated resident #8 complained of pain on the side he had a ruptured cyst, located on the left near his scapula where resident #1 hit him- the ruptured cyst was noted at the time of the assessment. Staff #93 stated an assessment was not done for resident #1 since he had not been hit. An attempt to interview resident #8 was made on April 18, 2025 at 8:35 a.m. due to the resident's severe cognition, he could not recall the incident in detail. Resident was walking the hallways- pleasant mood. An interview was conducted on April 18, 2025 at 1:09 p.m. with Abuse Coordinator (Staff #62) regarding residents #1 and #8. Staff #62 stated he was informed by the DON (Staff #86) of the alleged incident on Sunday, April 13, 2025. Staff #62 stated he was informed there was an altercation between residents #1 and #8 who were fighting over a chair in the dining room and staff intervened and removed resident #1 from the dining room. Staff #62 stated he informed the DON to follow-up with staff on duty and get their statements and made some call to initiate the two-hour required investigation report for the state agency. Staff #62 stated following the investigation injuries reported for resident #8 with an oozing cyst and x-rays taken revealed a hairline fracture of his ribs and that the resident had complained of pain. Staff #62 stated the facility unsubstantiated their investigation based on follow-up with the staff at the time; that it appeared two residents and argued over the chair and staff were able to intervene before anything escalated. Staff #62 stated resident #1 and #8 were pleasant with each other following the incident. An interview was conducted on April 18, 2025 at 1:29 p.m. with Director of Nursing (DON/Staff #86) stated the process for reporting alleged abuse is reporting to the different agencies as soon as they are aware. He stated he provides his staff with as much training as possible and during the facility monthly all-staff meetings. He stated they are told to immediately report to their supervisor or to the abuse coordinator. The DON stated he monitors for potential abuse by rounding the units, keeping up with daily nursing notes and being in front with his teams. The DON stated actions taken to protect the residents and other residents from abuse during the investigation process for resident #1 and #8 were that they were immediately separated and provided with frequent checks. He stated Resident #1 is being monitored 1:1 and will be moving the resident to an all-male unit to protect the females on the unit and the other residents. He stated he was not informed of what had happened with resident #! Nor of the other incidents with the other females on the unit. He stated he is very upset with this information. The DON stated staff #79 is new to her role as unit manager and staff #93 is a new floor nurse, that they report the incidents to me immediately. It is not expected that they make that decision on their own. I will be providing some additional training and education for my new staff. Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, with a revision date of April 2021 revealed a policy statement All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Reporting allegations to the Administrator and authorities (2) The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. the resident's representative; d. Adult protective services; i.e. law enforcement officials; f. The resident's attending physician; and g. the facility's medical director. (3) Immediately is defined as: a. within two hours of an allegation involving abuse.

Based on clinical record reviews, staff interviews, review of facility records, and review of policies and procedures, the facility failed to have evidence that an alleged violation involving sexual abuse regarding five residents (#2, # 3, #4, #5 and #6) was thoroughly investigated. The deficient practice could result in additional alleged violations involving abuse not being investigated Findings include: -Regarding residents #1 and #2: -Resident #1 was admitted to the facility December 21, 2021 with dysphagia following cerebral infarction, unspecified dementia, mild, with agitation, schizophrenia, unspecified. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 completed a Brief Interview for Mental Status (BIMS) score of 08 indicating moderate cognitive impairment. Further review of the MDS revealed no indicators for mood, but will self-isolate. Indicators for physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, other behavioral symptoms not directed towards others and wandering. These assessments occurred 1-3 days of the lookback period. Review of the care plan, date-initiated December 22, 2024 revealed a focus for elopement; resident at risk for elopement/exit seeking; wandering related to dementia and other cognitive behaviors. Further review of the care plan revealed focus for behavior problems, agitation related to depression and schizophrenia, likes to follow female residents around to help them with things, per family and the potential to be physically aggressive related to dementia, poor impulse control; citing incident on April 13, 2025 with another resident due to resident not getting out of his desired chair; verbal aggression. Interventions include administer medications as ordered, intervene as necessary to protect the rights and safety of others. Review of the physicians orders dated April 15, 2025 revealed monitoring episodes of restlessness, agitation every shift and record every shift, Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) Give 125 mg by mouth two times a day for Mood/AEB Impulsivity, Mirtazapine Tablet 15 MG Give 1 tablet by mouth in the evening for Depression as exhibited by poor by mouth intake; Quetiapine Fumarate Oral Tablet 50 MG (Quetiapine Fumarate) Give 1 tablet by mouth in the morning for as exhibited by mood. Review of the Medication Administration Record for April 15, 2025 revealed a change in the number of times dosage administered for antipsychotic due to elevated behaviors. Review of a Nurse Practitioners Note dated April 14, 2025 at 8:16 p.m. revealed -Patient seen sitting up in activities room eating breakfast without difficulty nurse reports patient with aggressive behavior towards females and other residents. POC discussed with nursing. PMH NP was also alerted to patient behavioral issues at this time. Patient denies any chest pain shortness of breath and has pleasant affect at time of assessment. NAD. Review of the nurse's progress notes dated April 14, 2025 at 3:25 p.m. revealed a note text: During a verbal disagreement between two resident #1 approached and began yelling at the male resident. He then began threatening the male resident and staff had to step between to calm the situation. Resident was escorted back to his room, while also threatening nurses and using vulgar language. A progress note dated April 14, 2025 at 1:31 p.m. revealed a nurse's note text: This writer spoke with CNA who witnessed the alleged res to res. CNA clarified that when she was passing out trays, she heard two residents talking loudly to each other, she turned around to see resident #1 contact resident #8 trying to get him to move chairs. At that time two CNA's stepped in to separate the two residents. A progress note dated April 13, 2025 at 4:46 p.m. revealed a nurse's note text; Nurse summoned to dining room per certified nursing assistant (CNA) reported per CNA resident #1 punched resident #8 because he would not get out of his desired chair. CNA reported hearing a sound when physical contact was made. This nurse attempted to escort resident #1 to his room. Resident #1 is resistive to redirection and had to be redirected X 4 before returning to his bedroom. Resident #8 assessed by other nurse on duty. Representative notified. Manager on duty notified. Nurse Practitioner notified. New order for Hydroxyzine 25mg by mouth every 6 hours as needed for Anxiety X 14days.Representative contacted regarding new order, she declined to initiate Hydroxyzine. Nurse Practitioner notified. A behavior progress note dated April 12, 2025 at 5:37 p.m. states reported per CNA resident #1 required redirection multiple times throughout the day. Resident #1 noted rubbing resident #4 leg. When redirected resident #1 stated, That's my girl. becoming visibly upset when asked to leave the area near resident #4. Frequent visual checks continue to maintain distance of resident #1 and resident #4. Nurse Practitioner notified. A behavior progress note dated April 5, 2025 at 4:31 p.m. revealed resident #1 had an eventful day exhibiting increased sexual tendencies towards female peers. resident #1 noted touching resident #6 legs several times while in the dining room. When redirected resident #1 becomes visibly angered and posturing. Resident #1 stated, I'm gonna do it again. resident #1 had to be redirected from propelling resident #4 female peer per wheelchair from dining room. resident #1 walked away but later returned visibly upset. Attempts to redirect, distract and calm resident #1 were unsuccessful. Resident #5 female peer was found lying in resident #1 room with resident #1 at bedside. When attempting to remove resident #5, resident #1 stated. It's ok, leave her alone, she's with me. A behavior progress note dated March 28, 2025 at 5:25 p.m. revealed resident #1 has been talking to a female resident and trying to get her to walk with him to his room all afternoon. He was walking the female resident in the direction of his room about 30 minutes ago when this nurse intercepted and started walking the resident back towards the activities room, and he swung a punch at this nurse. Resident is also entering the rooms of female residents continuously, and when staff ask him to leave the room, he does but then goes and enters another female resident's room very shortly thereafter. Will continue to monitor. A behavior progress note dated March 22, 2025 at 2:27 p.m. revealed Reported per CNA resident #1 noted slapping the buttocks of resident #3 The sister of resident #3 was present at the time. Nurse Practitioner notified of incident. New order for Depakote 125mg by mouth twice daily for Mood/AEB. A behavior progress note dated March 21, 2025 at 2:28 p.m. revealed resident #1 increased sexual tendencies towards his female peers. Resident #1 noted leading resident #2. to his bedroom. This nurse attempted to redirect and intervene the situation, this only further angers the resident #1 This nurse leading resident #2 by hand to the common area but resident #1 became visibly upset stating, She's coming with me. Resident #1 grabbed her hand tighter and continued to walk towards his bedroom. This nurse acting as a barrier standing between residents #1 and #2. Resident #1 dropped her hand and walked away to his bedroom. Resident #1 family came to visit shortly after and is aware of the incident. Will notify Primary Care Physician. Resident Observation on April 18, 2025 at 8:18 a.m. resident #1 provided with 1:1 intervention for 12 hours by Certified Nursing Assistant (CNA/Staff #18). Stated she was informed April 17, 2025 that she would be providing 1:1 care for resident #1 and to monitor his behaviors due to aggression and sexualized behaviors, she stated this was the first time resident #1 has been provided with 1:1 care. Residents #2 and resident 6 were observed seated in recliners in the dining room. There were two CNA's present. -Regarding Resident #2 -Resident #2 was admitted to the facility February 8, 2025 with diagnosis that included metabolic encephalopathy, cognitive communication deficit and altered mental status, unspecified. A review of the Part A Discharge MDS dated [DATE] revealed Resident #2 completed a Brief Interview for Mental Status (BIMS) score of 02 indicating severe cognitive impairment. Review of the care plan date-initiated February 9 2025 and a revision on April 4, 2025 revealed a focus for psychosocial behaviors; exhibits or is at risk for behavioral symptoms delusions, hallucinations, anxiety, SI without a plan, agitation, disrobing, wandering into others rooms. Interventions included Administer medication as ordered, document and record behavioral episodes and manage environmental factors to optimize comfort. Review of the progress notes revealed a behavior note dated April 4, 2025 at 1:27 p.m. Note Text: Resident was found in another resident's room. Resident was easily directed out of room. Skin check was performed. No abnormal findings. An interview was conducted on April 17, 2025 at 12:46 p.m. with Licensed Practical Nurse (LPN/Staff #93). Stated resident #1 has sexual tendencies mostly touching and kissing, rubbing of female residents' legs and those who are ambulatory. Stated resident #1 is fixated on two of them, resident's #4 and #2. Stated resident #1 has be separated from her before and tried to take resident #2 to his room. Staff #93 stated resident #1 had taken a female resident to his room approximately six weeks ago. The resident was resident #4. Staff #93 stated resident #4 was in his room in her wheelchair and resident #1 was standing up pacing the room. Staff #93 stated resident #1 has kissed resident 2 and #4, he's touched them by rubbing their legs, and he grabbed both of resident #3 buttocks, Staff #93 stated resident #1 paces the unit and staff keep a visual with 15-minute checks on resident #1. Staff #93 stated resident #1 has not been provided with 1:1 intervention and that he is unpredictable with physical aggression and posturing. An interview was conducted on April 17, 2025 at 1:22 p.m. with Certified Nursing Assistant (CAN/Staff #59. She stated she was informed that LPN/Staff #93 resident went to go get resident #1 for dinner when she saw resident #2 laying in the bed, she stated resident #1- he was sitting in a chair in his room. she stated resident #2 paces and wanders and had not seen her for about 30 minutes. Staff #59 stated we have to watch out for resident #1 he touches the females. An interview was conducted on April 17, 2025 at 1:28p.m. with certified nursing assistant (CNA/Staff #51) CAN #51 stated she first became aware of the incident when the nurse (LPN/Staff #93) called out for help to resident #1 room. She stated both (LPN/Staff #29) went to the room to find resident #2 lying on top of resident #1 bed naked with no clothing on. Staff #51 stated resident #1 was seated at the bedside with his shirt off and had put on a coat jacket, further stating his pants were on, but could not recall if his shoes were on. Staff#51 stated staff #29 assisted with getting resident #2 dressed. Staff #51 stated she documented the incident in Point Click Care and assumed LPN# 93 and #29 had reported the incident to the Director of Nursing. Staff #93 stated the doctor; family and the DON are aware of resident #1 sexualized behaviors with the other residents. An interview was conducted on April 17, 2025 at 2:18p.m. with housekeeper (staff #80). Staff #80 stated she has observed resident #1 with two female residents on two different occasions. Staff #80 stated On Saturday April 5, 2025, sometime in the morning while cleaning resident rooms she observed resident #1 had resident #2 laying on his bed covered with a blanket. Staff #80 stated resident #1 had his hands underneath the blanket and was rubbing her body. Staff #80 stated it looked like he was rubbing her up and down from her upper thighs to her chest area and touching her legs. Staff #80 stated she immediately informed the CNA that works on the weekends (did not know her name) and also informed her supervisor, Director of Housekeeping (Staff # 42). Staff #80 stated she was hesitant as to what to do with what she had observed, but stated I knew it was the right thing to do. An interview was conducted on April 17, 2025 at 3:37 p.m. with Operations Manager/ Abuse Coordinator (Staff #62). Staff #62 stated he did not file a report with the state agency because he had not been informed that resident #2 was disrobed and was told that resident #1 was sitting on the other side of the room when found. Staff #62 stated based on the report he received from his staff that there was nothing reportable. An interview was conducted on April 18, 2025 at 10:25 a.m. with Director of Housekeeping (Staff # 42). Staff #42 stated that his expectations are that his staff notify and report what they see immediately. He also stated his staff are instructed to notify him immediately as to what they observed and what happened. Staff #80 stated he will then immediately notify the person in charge of that department and the unit manager for ay type of abuse. Staff #42 stated staff #80 telephoned him on Saturday April 5, 2025 at 9:32 a.m. informing him that she had observed resident #1 touching one of the female residents on the thighs in his room. He stated she also informed hm that the female resident was lying on his bed and was rubbing the female resident. Staff #42 stated that staff #80 informed him that she had told resident #1 to leave and had told one of the CNA's. Staff #42 stated he informed her she did the right thing and that he would handle it from there. Staff #42 stated he immediately called the Unit Manger (Staff #79). Staff #42 stated he told her that he was notified by one of the housekeepers that resident #1 was rubbing one of the residents on the thigh. Staff #42 stated he did not inform her that the female resident was observed lying on the bed in resident #1 room. Staff #42 stated he did not inform the Director of Nursing (DON/Staff #86) or the Abuse Coordinator (Staff #62). An interview was conducted April 18, 2025 at 11:00 a.m. with Register Nurse Unit Manager (RN/UM/Staff #79). Staff # 79 stated she has been in the position as RN/UUM since March 2025 and that her responsibilities are to ensure everything is running ok and to make sure that unit is kept clean- residents are safe, family phone calls, log books updated- meds. Staff #79 stated staff report to her anything out of the norm. this would be anything that could lead to possible concerns, including inappropriate behaviors. Staff #79 stated inappropriate behaviors are reported to the DON, depending what is reported to her and if it is something that can be re-directed and no one is hurt from the behavior, then she feels no need to call the DON- Staff #79 stated she would notify the DON if a resident is hurt or imposing harm to another resident. Staff # 79 stated she notified on a Saturday morning that one of the housekeepers had seen a resident touching another resident. She stated it was on a Saturday-morning. She stated I just called the floor and told them to make sure that he [resident #1] is not around the girls. Further stating I did not feel that it warranted me calling the DON at that time. No one was hurt or in distress at that time. Staff #79 stated she was never informed of the residents sexualized behaviors and had that anything like that would warrant me to call my DON. Staff #79 stated does not take part in report with the nursing staff. -Regarding Resident #3 -Resident #3 was admitted to the facility March 7, 2025 with diagnosis that included vascular dementia, unspecified severity, with other behavioral disturbance, Alzheimer's disease, unspecified depression, unspecified, cerebral infarction, unspecified. A review of the admission MDS revealed a BIMS score of 7, indicating severe cognitive impairment. Further review revealed no indicators for mood or behaviors. There were indicators for wandering that occurred 1-3 days in the lookback period. Review of the care plan date-initiated March 19 2025 revealed a focus for risk for elopement and wandering related to disoriented to place and impaired safety awareness and impaired cognitive function, dementia or impaired thought processes related to dementia, difficulty making decisions and psychotropic drug use. Interventions included distracting the resident from wandering by offering pleasant diversions, intervene as appropriate and administer medications as ordered. Review of the progress notes revealed no documentation regarding the resident's buttocks being grabbed by resident #1. An interview was conducted April 17, 2025 at approximately 3:00 p.m. Resident #3 interviewed alone and in private in her room- pleasant and able to communicate and make needs knows- resident #3was able to recall being touched inappropriately by another resident. Stated yeah [NAME] has a bad habit of doing inappropriate things- I think he likes the ladies he grabbed my bottom. I didn't like him doing that, I try to keep away from him. I don't think he means any harm, but it's not nice for him to do that. Resident #3 stated I don't feel safe in my room, men come in all the time. I was changing my clothes and had just put on my bra when [NAME] came in. Sometimes I'll find people in my bed or they walk in your room at night. I had pushed the dresser against my door to keep them from coming in but they told me I couldn't. I don't remember if my sister was her with me, I can call and ask her if she was- (resident tried to call sister from cell phone no response. A male resident entered the resident's room during interview. later identified by staff as resident #10. Resident #10 was observed wandering around aimlessly going into different resident's rooms, no intervention observed by staff during observation on the unit. -Resident # 4 Resident was admitted to the facility December 8, 2023 with diagnosis that included unspecified dementia, unspecified severity, with agitation, restlessness and agitation, anxiety disorder, unspecified, impulsiveness, major depressive disorder, recurrent, unspecified. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating moderate cognitive impairment. The resident was assessed with a mild mood score of 10 with concerns with self-isolation and depression. There were also indicators for verbal behavioral symptoms directed towards others, e.g., threatening, screaming cursing at others, wandering and rejection of care with presence and frequency of this type occurred 1-3 days. Resident has no impairment of the upper or lower extremities and uses a wheelchair for mobility. Review of the care plan date-initiated December 15, 2023 and revised March 18, 2025 revealed a focus for elopement at risk for elopement, exit seeking, wandering related to dementia or other cognitive behavior and cognitive impairment loss related to Alzheimer's disease or other dementias. Interventions included allow wandering in safe areas within the facility, administering medication as ordered and anticipating the residents needs and met promptly. Review of the progress notes revealed no documentation regarding inappropriate touching or kissing of the resident by resident #4, An interview was conducted on April 17, 2025 at 12:46 p.m. with Licensed Practical Nurse (LPN/Staff #93). Stated resident #1 is fixated on two of them, resident's #4 and #2. Stated resident #1 has been separated from her before and tried to take resident #2 to his room. Staff #93 stated resident #1 had taken a female resident to his room approximately six weeks ago. The resident was resident #4. Staff #93 stated resident #1 has been observed kissing, touching and rubbing on resident #4 legs. An interview was conducted on April 17, 2025 at 1:28p.m. with certified nursing assistant (CNA/Staff #51) CNA #51 stated I know resident #1 touches residents #6 and #4, he will whisper in their ear; I don't know what he is saying. CNA #51 stated resident #1 will touch resident #4 and #6 on their arms and legs, stating it appears sexual when he touches them. -Regarding Resident #5 - Resident was admitted to the facility February 8, 2024 with diagnosis including cardiomyopathy, unspecified, altered mental status, unspecified, dementia in other diseases classified elsewhere, mild, with other behavioral disturbance cognitive communication deficit unspecified dementia, unspecified severity, with other behavioral disturbances. Review of the annual MDS dated [DATE] revealed a BIMS score of 03, indicating severe cognitive impairment. Resident not assessed for mood, unable to respond. Assessment for behaviors revealed other behavioral symptoms not directed toward others, places the resident at significant risk for physical illness or injury, interferes with the resident's care, interferes with the resident's participation in activities or social interactions, and significantly intrude on the privacy or activity of others. Further review of the MDS revealed the resident uses a wheelchair for mobility. Review of the care plan revealed a focus for cognitive impairment related to altered Alzheimer's disease or other dementias and the risk for elopement and wandering related to dementia and other cognitive behaviors, Interventions included administer medications as ordered, allow to wander in safe areas within the facility. Review of the progress notes revealed no documentation of and observation alleged incident involving resident #1 taking resident #5 to his room by the hand and attempting to lay her on his bed. The incident was reported to a certified nursing assistant who was able to intervene and remove resident #5 from resident #1 room. An interview was conducted on April 17, 2025 at 2:18p.m. with housekeeper (staff #80). Staff #80 stated she has observed resident #1 on two different occasions. Staff #80 stated I saw him in his room with her trying to lay her on his bed- I saw him take her by the hand to his room (Staff #80 did not know the residents name but was able to point the resident out- identified as [NAME]) Staff #80 stated I told the CNA who went in the room to get her. -Regarding Resident #6 Resident was admitted to the facility April 11, 2023 with diagnosis including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, cognitive communication deficit, Wernicke's encephalopathy Review of the quarterly MDS dated [DATE] revealed a BIMS score of o5, indicating severe cognitive impairment, no indicators for mood or behaviors. Uses walker and wheelchair for mobility. Review of the care plan revealed a focus for impaired cognitive function and thought processes related to vascular dementia, Wernicke's encephalopathy, and unspecified psychosis. Date Initiated: 04/23/2023 Revision on: 05/04/2023. Interventions included stress key words and present just one thought, question or command at a time. A behavior progress note dated April 5, 2025 at 4:31 p.m. revealed resident #1 had an eventful day exhibiting increased sexual tendencies towards female peers. resident #1 noted touching resident #6 legs several times while in the dining room. When redirected resident #1 becomes visibly angered and posturing. Resident #1 stated, I'm gonna do it again. -Regarding Resident #8 Resident #8 was admitted to the facility August 16, 2024 with diagnosis including unspecified dementia, severe, with psychotic disturbance, altered mental status, unspecified, depression, unspecified, anxiety disorder, unspecified. Review of the significant change of cognitive impairment MDS dated [DATE] revealed a BIMS score pf 03 indicating severe cognitive impairment, no indicators for [NAME] or behaviors, wandering with no impact on others, diagnosis for Anxiety disorder, Depression (other than bipolar), altered mental status, unspecified. Received Antipsychotic, Antidepressant, - gradual dose reduction (GDR) was attempted 11/30/2024- Physician documented GDR as clinically contraindicated 11/30/2024. Review of the care plan date-initiated August 22, 2024 revealed a focus for Psychosocial- Emotional/Trauma: At risk for decreased psychosocial well-being physical, social, or spiritual wellbeing related to alleged incident with peer on April 13, 2025. Date Initiated: April 15, 2025 Revision on: April 15, 2025, Interventions: included contact resident representative/friend for comfort and support. Date Initiated April 15, 2025. Review of eINTERACT Change in Condition Evaluation dated April 13, 2025 at 6:02 p.m. revealed pain in side remains, No signs of bruising/abrasion on skin of left side, pain with movement. Open cyst on upper mid back, cleaned and applied dry dressing. Pain medications administered PRN, dressing change daily on upper back till healed. The change in condition and notifications reported to primary care clinician Review of Treatment Administration Record for April 2025 revealed new orders for treatment for ruptured cyst with a start date of April 14, 2025. Review of the physician order summary dated April 13, 2025 revealed a STAT order for an x-ray ribs left side for trauma during altercation, however the examination results dated April 14, 2025 at 1:39pm and reported date April 14, 2025 at 1:41 p.m. revealed significant findings of unilateral left ribs x-ray. The impression revealed an acute hairline of the left lower rib fracture. Review of the nurses progress noted dated April 13, 2025 at 6:38 p.m. revealed a note text of the following detail; Informed of altercation in dining room, resident states he came out of nowhere and hit me, it was hard enough to push me back in my chair. Skin assessment performed, cyst on upper mid back ruptured and wound care performed, pain in left side ribs under arm no bruising or open skin in that area. Pain reported level 7/10, PRN medication administered. NP [NAME] notified, x-ray ordered and wound care to cyst. An interview was conducted on April 17, 2025 at 12:46 p.m. with Licensed Practical Nurse (LPN/Staff #93). Stated there was an incident involving resident #1 and resident #8, Staff #93 stated it was time to serve dinner came and resident #1 came from his room. Staff #93 stated she was at the med cart. She stated she was told by staff resident #1 told resident #8 to get out of his chair and resident #8 said no and resident #1 struck resident #8 on the upper right back to mid area. Staff #93 stated a weekend intervened and there were lots of lots of commotion. Staff #93 stated resident #1 was standing away from the table and resident #8 was standing at the other side of the table. She stated she had to ask resident #1 to leave the area multiple time- he refused- She stated it took four attempts to get the resident #1 to leave. Staff #93 stated LPN/Staff#9 came and completed a skin check for resident #8. She stated resident #8 complained of pain on the side he had a ruptured cyst, located on the left near his scapula where resident #1 hit him- the ruptured cyst was noted at the time of the assessment. Staff #93 stated an assessment was not done for resident #1 since he had not been hit. An attempt to interview resident #8 was made on April 18, 2025 at 8:35 a.m. due to the resident's severe cognition, he could not recall the incident in detail. Resident was walking the hallways- pleasant mood. An interview was conducted on April 18, 2025 at 1:09 p.m. with Abuse Coordinator (Staff #62) regarding residents #1 and #8. Staff #62 stated he was informed by the DON (Staff #86) of the alleged incident on Sunday, April 13, 2025. Staff #62 stated he was informed there was an altercation between residents #1 and #8 who were fighting over a chair in the dining room and staff intervened and removed resident #1 from the dining room. Staff #62 stated he informed the DON to follow-up with staff on duty and get their statements and made some call to initiate the two-hour required investigation report for the state agency. Staff #62 stated following the investigation injuries reported for resident #8 with an oozing cyst and x-rays taken revealed a hairline fracture of his ribs and that the resident had complained of pain. Staff #62 stated the facility unsubstantiated their investigation based on follow-up with the staff at the time; that it appeared two residents and argued over the chair and staff were able to intervene before anything escalated. Staff #62 stated resident #1 and #8 were pleasant with each other following the incident. An interview was conducted on April 18, 2025 at 1:29 p.m. with Director of Nursing (DON/Staff #86) stated the process for reporting alleged abuse is reporting to the different agencies as soon as they are aware. He stated he provides his staff with as much training as possible and during the facility monthly all-staff meetings. He stated they are told to immediately report to their supervisor or to the abuse coordinator. The DON stated he monitors for potential abuse by rounding the units, keeping up with daily nursing notes and being in front with his teams. The DON stated actions taken to protect the residents and other residents from abuse during the investigation process for resident #1 and #8 were that they were immediately separated and provided with frequent checks. He stated Resident #1 is being monitored 1:1 and will be moving the resident to an all-male unit to protect the females on the unit and the other residents. He stated he was not informed of what had happened with resident #! Nor of the other incidents with the other females on the unit. He stated he is very upset with this information. The DON stated staff #79 is new to her role as unit manager and staff #93 is a new floor nurse, that they report the incidents to me immediately. It is not expected that they make that decision on their own. I will be providing some additional training and education for my new staff. Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, with a revision date of April 2021 revealed a policy statement All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Reporting allegations to the Administrator and authorities (2) The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. the resident's representative; d. Adult protective services; i.e. law enforcement officials; f. The resident's attending physician; and g. the facility's medical director. (3) Immediately is defined as: a. within two hours of an allegation involving abuse

Based on staff interviews, facility documentation and policy review, the facility failed to implement their abuse policy, by failing to report and investigate an allegation of abuse involving one resident (#1) to the State Agency. The deficient practice could result in further incidents of abuse. Findings include: Resident #1 was admitted to the facility on [DATE], with diagnoses of senile degeneration of brain, unspecified dementia and major depressive disorder. Review of Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6.0 indicating severe impairement. Record revealed resident #1 was admitted to hospice services on January 3, 2025. An interview was conducted on January 13, 2025 at 1:58 pm with a certified nursing assistant (CNA)/Staff #124. Staff #124 identified resident #1 who was observed sitting in a reclining chair with her feet elevated, eyes close, dressed in pants and sweat shirt. Staff #124 stated that resident #1 is newly admitted under hospice services. And while resident is receiving hospice care, a hospice aid comes to give resident her shower. Staff #124 stated that resident still answers questions, can pivot for transferring in and out of bed, and resident requires prompting and assistance with toileting. An interview was conducted on January 13, 2025 at 2:11 pm with a licensed practical nurse (LPN)/Staff #134. Staff #134 stated that she works in the dementia unit, she helps with activities of daily living (ADLs), and assist with feeding residents. She stated that regarding resident #1, resident was recently placed on hospice care, resident can follow directions, resident walks a little bit less than compared a week ago, and staff #134 stated that she has no knowledge of any allegations of abuse. Staff #134 stated that resident is by herself in the room without a roommate. Staff #134 stated that the blinds in the resident's room are torn up, they hang a sheet over the window to cover the window. She reiterated that she has no knowledge of allegation of abuse to any of her residents. And for any allegation that she is made aware of, she will report it to her supervisor right away. In addition, she stated that she receives abuse training yearly. Furthermore, staff #134 stated that the care of resident #1 involves a hospice nurse that comes and a hospice CNA that gives resident a bath. Staff #134 showed the surveyors resident's hospice medical record paper copy in a binder located in the nurses station which included hospice contact number, hospice nurse/Staff #232 and the hospice aid/Staff #240. On January 13, 2025 at 3:17 pm, operation manager/staff #300 stated that they received an allegation of abuse from adult protective services (APS) today at 12:45 pm, and he stated that he had submitted a facility report at 2:30 pm. The Department's Complaints/Incident Tracking System revealed the facility reported the allegation of abuse on January 13, 2025 at 2:38 pm to the State Agency. An interview was conducted on January 13, 2025 at 4:04 pm with a CNA/Staff #240. Staff #240 stated that she saw resident #1 on Monday which is January 6, on Wednesday which is January 8, and Monday which is January 13. Staff #240 stated that she help resident with her showers and the resident did not refuse any of her showers. She stated that on Monday, January 6, during her initial visit to resident #1, staff #240 stated that resident kept repeating that she was raped and would like to press charges. In addition, Staff #240 stated that the resident has bruise redness on her left side of the neck which looks like a choked mark or something like a hand placed on the neck, bruising on top of both hands and bruise on the left above resident's wrist. The bruise is purple and greenish in color. The resident's left upper arm inside the elbow has dark purple bruising. Staff #240 stated that after giving the resident her shower, she informed her nurse Staff #232 and a female social worker which she showed her the pictures. Staff #240 stated that she asked her nurse at that time if they have a sheet for her to document her skin assessment and she was told no. An interview was conducted on January 13, 2025 at 4:20 pm with a registered nurse (RN)/Staff #232. Staff #232 stated that she initially met the resident on January 6. She stated that Staff #240 gave resident a shower, and Staff #240 asked resident about the bruise on her wrist, and then the resident told her that she has been raped by a big black male. Staff#232 stated that the bruise and allegation of rape was reported to her by Staff #240 after she had finished giving resident her shower. Staff #232 stated that after being made aware of the allegation, she did a head to toe assessment, and she found bruise on resident's both wrist, resident only alert to self, the bruising did not look like grab marks, she ask the resident questions and the resident was unable to provide her details. Staff #232 stated that she then spoke with Staff #302 who is the social worker of the facility, and Staff #232 also reported the allegation to her director of nursing (DON). Staff #232 stated that she saw resident again on January 8th and resident made same statement that she has been raped. She saw the resident Monday, January 13, and resident did not say anything about rape. An interview was conducted on January 13, 2025 at 5:01 pm with social service director/Staff #302. Staff #302 stated that his role as a social worker involves follow up with grievances. Staff #302 stated that he has no knowledge of any allegation of abuse not until this morning when APS came in. He stated that he works Monday thru Friday from 08:30 to 5:00 pm. He stated that one of the hospice nurse reported to him that one of their resident, resident #1, who is in their memory care unit, that there was something reported to nursing and at that time he was in the nursing station, and he stated that one of their resident was saying weird things, referring in the past about something happened to her, that the resident was saying random things like having hallucination or delusion, and that the resident was saying that stuff was missing in the past. Staff #302 stated that the resident was doing very well and then she turns for the worst, her health declined, and on January 2, 2025 he called hospice to evaluate her because resident was not acting like her usual self, and not talking to every body like her normal self. He added that normally the resident was walking, talking, and making phone calls, then on January 2nd when he saw the resident, the resident was not walking, talking or calling anyone. Staff #302 stated that he spoke with a female nurse between 8:00 am to 5:00 pm, who spoke with the hospice nurse, who staff #302 stated he does not remember the name of the nurse he spoke with. Staff #302 stated that when something is reported to him like grievance, he will bring it to their morning meetings or stand up meeting with the IDT (interdisciplinary team) department which is composed of the administrator, DON, nurse managers, housekeeping manager, MDS nurse, the whole management team. His responsibility when an allegation of abuse is reported to him is to report to his administrator or the DON. An interview was conducted on January 13, 2025 at 5:39 pm with resident #1. During the interview, resident verbally stated her name, stated she has been here couple years, stated that she has been hurt, she has been raped, she stated she does not like being raped, she was raped twice, she has 2 rapes here, and it is not a pleasant situation. She stated that they pin you down, person is big guy three times her size, it happened right in her room, they are aware of it, it happens in the morning in a hurry, you have two people , big guys, both males, her clothes comes off, one is not a big guy but the other guy is a bigger guy, he pulls her aside, next thing she knew her underwear is pulled, she is having nightmare, she does not know how to explain it, it usually happens in her room, like he is changing her diaper, he gets her pants and underwear off, he changes her, so she gets a clean start for the day, the next thing she knew he puts a new diaper on, this big guy can just hold you down, then he puts her in a different clothes, it is scary and spooky. Resident pointed down below her mid waist area and stated that he doesn't put it inside but it is humiliating. Surveyor observe bruise, light purple bluish on top of resident's right hand, and bruise upper left wrist. The surveyors returned in the resident's room at 6:07 pm on January 13, 2025 after resident had a male and a female CNAs perform patient care. The interview with resident continued. The resident stated that the rape is in his apartment, the big guy came one time in the morning, a huge black man wears a blue uniform, the alleged perpetrator #400 is an older guy, huge shoulders, can't miss him because he is so big, alleged perpetrator #400 hurt her in her shoulder, lower back, did not enter her, he held her down. An interview was conducted on January 13, 2025 at 6:50 pm with the DON/Staff #305. The DON stated that for reporting allegation of abuse, they have a two-hour window. Their staff receive annual training on abuse. The DON stated that he was made aware of the allegation of abuse at 12:45 pm from APS for possible sexual assault and bruising. Then, he spoke with his administrator and reported it to the Department of Health (DHS) only. The DON stated that he refers to the policy and procedure to who he reports to for possible sexual assault, and he added to report to the state licensing, ombudsman, resident representative, APS, law enforcement officials, resident attending physician/medical director. At 6:58 pm on January 13, 2025, Staff #300 stated that he does not know if it was reported to the law enforcement because the social service does it. At 7:03 pm on January 13, 2025, Staff #302 joined the interview and stated that the law enforcement was notified today, and stated that once the state surveyors conclude today then they will notify the ombudsman and the case manager. At 7:09 pm on January 13, 2025, LPN/unit manager/Staff #310 stated that she called the law enforcement and informed them of the allegation of rape at 6:30 pm. Review of record revealed a social service note dated January 14, 2025 that the ombudsman and case manager were notified about the allegation that the resident's family reported to APS and State. Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, with a revision date of April 2021 revealed a policy statement All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Reporting allegations to the Administrator and authorities (2) The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/cerificaation agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. the resident's representative; d. Adult protective services; e. law enforcement officials; f. The resident's attending physician; and g. the facility's medical director. (3) Immediately is defined as: a. within two hours of an allegation involving abuse.

Based on staff interviews, facility documentation and policy review, the facility failed to ensure that an allegation of abuse for one resident (#1) was reported to the State Agency. The deficient practice can result in further incidents of abuse not being reported in accordance with professional standards. Findings include: Resident #1 was admitted to the facility on [DATE], with diagnoses of senile degeneration of brain, unspecified dementia and major depressive disorder. Review of Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6.0 indicating severe impairement. Record revealed resident #1 was admitted to hospice services on January 3, 2025. An interview was conducted on January 13, 2025 at 1:58 pm with a certified nursing assistant (CNA)/Staff #124. Staff #124 identified resident #1 who was observed sitting in a reclining chair with her feet elevated, eyes close, dressed in pants and sweat shirt. Staff #124 stated that resident #1 is newly admitted under hospice services. And while resident is receiving hospice care, a hospice aid comes to give resident her shower. Staff #124 stated that resident still answers questions, can pivot for transferring in and out of bed, and resident requires prompting and assistance with toileting. An interview was conducted on January 13, 2025 at 2:11 pm with a licensed practical nurse (LPN)/Staff #134. Staff #134 stated that she works in the dementia unit, she helps with activities of daily living (ADLs), and assist with feeding residents. She stated that regarding resident #1, resident was recently placed on hospice care, resident can follow directions, resident walks a little bit less than compared a week ago, and staff #134 stated that she has no knowledge of any allegations of abuse. Staff #134 stated that resident is by herself in the room without a roommate. Staff #134 stated that the blinds in the resident's room are torn up, they hang a sheet over the window to cover the window. She reiterated that she has no knowledge of allegation of abuse to any of her residents. And for any allegation that she is made aware of, she will report it to her supervisor right away. In addition, she stated that she receives abuse training yearly. Furthermore, staff #134 stated that the care of resident #1 involves a hospice nurse that comes and a hospice CNA that gives resident a bath. Staff #134 showed the surveyors resident's hospice medical record paper copy in a binder located in the nurses station which included hospice contact number, hospice nurse/Staff #232 and the hospice aid/Staff #240. On January 13, 2025 at 3:17 pm, operation manager/staff #300 stated that they received an allegation of abuse from adult protective services (APS) today at 12:45 pm, and he stated that he had submitted a facility report at 2:30 pm. The Department's Complaints/Incident Tracking System revealed the facility reported the allegation of abuse on January 13, 2025 at 2:38 pm to the State Agency. An interview was conducted on January 13, 2025 at 4:04 pm with a CNA/Staff #240. Staff #240 stated that she saw resident #1 on Monday which is January 6, on Wednesday which is January 8, and Monday which is January 13. Staff #240 stated that she help resident with her showers and the resident did not refuse any of her showers. She stated that on Monday, January 6, during her initial visit to resident #1, staff #240 stated that resident kept repeating that she was raped and would like to press charges. In addition, Staff #240 stated that the resident has bruise redness on her left side of the neck which looks like a choked mark or something like a hand placed on the neck, bruising on top of both hands and bruise on the left above resident's wrist. The bruise is purple and greenish in color. The resident's left upper arm inside the elbow has dark purple bruising. Staff #240 stated that after giving the resident her shower, she informed her nurse Staff #232 and a female social worker which she showed her the pictures. Staff #240 stated that she asked her nurse at that time if they have a sheet for her to document her skin assessment and she was told no. An interview was conducted on January 13, 2025 at 4:20 pm with a registered nurse (RN)/Staff #232. Staff #232 stated that she initially met the resident on January 6. She stated that Staff #240 gave resident a shower, and Staff #240 asked resident about the bruise on her wrist, and then the resident told her that she has been raped by a big black male. Staff#232 stated that the bruise and allegation of rape was reported to her by Staff #240 after she had finished giving resident her shower. Staff #232 stated that after being made aware of the allegation, she did a head to toe assessment, and she found bruise on resident's both wrist, resident only alert to self, the bruising did not look like grab marks, she ask the resident questions and the resident was unable to provide her details. Staff #232 stated that she then spoke with Staff #302 who is the social worker of the facility, and Staff #232 also reported the allegation to her director of nursing (DON). Staff #232 stated that she saw resident again on January 8th and resident made same statement that she has been raped. She saw the resident Monday, January 13, and resident did not say anything about rape. An interview was conducted on January 13, 2025 at 5:01 pm with social service director/Staff #302. Staff #302 stated that his role as a social worker involves follow up with grievances. Staff #302 stated that he has no knowledge of any allegation of abuse not until this morning when APS came in. He stated that he works Monday thru Friday from 08:30 to 5:00 pm. He stated that one of the hospice nurse reported to him that one of their resident, resident #1, who is in their memory care unit, that there was something reported to nursing and at that time he was in the nursing station, and he stated that one of their resident was saying weird things, referring in the past about something happened to her, that the resident was saying random things like having hallucination or delusion, and that the resident was saying that stuff was missing in the past. Staff #302 stated that the resident was doing very well and then she turns for the worst, her health declined, and on January 2, 2025 he called hospice to evaluate her because resident was not acting like her usual self, and not talking to every body like her normal self. He added that normally the resident was walking, talking, and making phone calls, then on January 2nd when he saw the resident, the resident was not walking, talking or calling anyone. Staff #302 stated that he spoke with a female nurse between 8:00 am to 5:00 pm, who spoke with the hospice nurse, who staff #302 stated he does not remember the name of the nurse he spoke with. Staff #302 stated that when something is reported to him like grievance, he will bring it to their morning meetings or stand up meeting with the IDT (interdisciplinary team) department which is composed of the administrator, DON, nurse managers, housekeeping manager, MDS nurse, the whole management team. His responsibility when an allegation of abuse is reported to him is to report to his administrator or the DON. An interview was conducted on January 13, 2025 at 5:39 pm with resident #1. During the interview, resident verbally stated her name, stated she has been here couple years, stated that she has been hurt, she has been raped, she stated she does not like being raped, she was raped twice, she has 2 rapes here, and it is not a pleasant situation. She stated that they pin you down, person is big guy three times her size, it happened right in her room, they are aware of it, it happens in the morning in a hurry, you have two people , big guys, both males, her clothes comes off, one is not a big guy but the other guy is a bigger guy, he pulls her aside, next thing she knew her underwear is pulled, she is having nightmare, she does not know how to explain it, it usually happens in her room, like he is changing her diaper, he gets her pants and underwear off, he changes her, so she gets a clean start for the day, the next thing she knew he puts a new diaper on, this big guy can just hold you down, then he puts her in a different clothes, it is scary and spooky. Resident pointed down below her mid waist area and stated that he doesn't put it inside but it is humiliating. Surveyor observe bruise, light purple bluish on top of resident's right hand, and bruise upper left wrist. The surveyors returned in the resident's room at 6:07 pm on January 13, 2025 after resident had a male and a female CNAs perform patient care. The interview with resident continued. The resident stated that the rape is in his apartment, the big guy came one time in the morning, a huge black man wears a blue uniform, the alleged perpetrator #400 is an older guy, huge shoulders, can't miss him because he is so big, alleged perpetrator #400 hurt her in her shoulder, lower back, did not enter her, he held her down. An interview was conducted on January 13, 2025 at 6:50 pm with the DON/Staff #305. The DON stated that for reporting allegation of abuse, they have a two-hour window. Their staff receive annual training on abuse. The DON stated that he was made aware of the allegation of abuse at 12:45 pm from APS for possible sexual assault and bruising. Then, he spoke with his administrator and reported it to the Department of Health (DHS) only. The DON stated that he refers to the policy and procedure to who he reports to for possible sexual assault, and he added to report to the state licensing, ombudsman, resident representative, APS, law enforcement officials, resident attending physician/medical director. At 6:58 pm on January 13, 2025, Staff #300 stated that he does not know if it was reported to the law enforcement because the social service does it. At 7:03 pm on January 13, 2025, Staff #302 joined the interview and stated that the law enforcement was notified today, and stated that once the state surveyors conclude today then they will notify the ombudsman and the case manager. At 7:09 pm on January 13, 2025, LPN/unit manager/Staff #310 stated that she called the law enforcement and informed them of the allegation of rape at 6:30 pm. Review of record revealed a social service note dated January 14, 2025 that the ombudsman and case manager were notified about the allegation that the resident's family reported to APS and State. Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, with a revision date of April 2021 revealed a policy statement All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Reporting allegations to the Administrator and authorities (2) The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/cerificaation agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. the resident's representative; d. Adult protective services; e. law enforcement officials; f. The resident's attending physician; and g. the facility's medical director. (3) Immediately is defined as: a. within two hours of an allegation involving abuse.

Based on interviews and review of the facility policy, the facility failed to investigate and correct alleged violations of abuse for resident #1. The deficient practice could lead to residents suffering from psychosocial harm and further abuse of residents. Findings include: Resident #1 was admitted to the facility on [DATE], with diagnoses of senile degeneration of brain, unspecified dementia and major depressive disorder. Review of Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6.0 indicating severe impairement. Record revealed resident #1 was admitted to hospice services on January 3, 2025. An interview was conducted on January 13, 2025 at 1:58 pm with a certified nursing assistant (CNA)/Staff #124. Staff #124 identified resident #1 who was observed sitting in a reclining chair with her feet elevated, eyes close, dressed in pants and sweat shirt. Staff #124 stated that resident #1 is newly admitted under hospice services. And while resident is receiving hospice care, a hospice aid comes to give resident her shower. Staff #124 stated that resident still answers questions, can pivot for transferring in and out of bed, and resident requires prompting and assistance with toileting. An interview was conducted on January 13, 2025 at 2:11 pm with a licensed practical nurse (LPN)/Staff #134. Staff #134 stated that she works in the dementia unit, she helps with activities of daily living (ADLs), and assist with feeding residents. She stated that regarding resident #1, resident was recently placed on hospice care, resident can follow directions, resident walks a little bit less than compared a week ago, and staff #134 stated that she has no knowledge of any allegations of abuse. Staff #134 stated that resident is by herself in the room without a roommate. Staff #134 stated that the blinds in the resident's room are torn up, they hang a sheet over the window to cover the window. She reiterated that she has no knowledge of allegation of abuse to any of her residents. And for any allegation that she is made aware of, she will report it to her supervisor right away. In addition, she stated that she receives abuse training yearly. Furthermore, staff #134 stated that the care of resident #1 involves a hospice nurse that comes and a hospice CNA that gives resident a bath. Staff #134 showed the surveyors resident's hospice medical record paper copy in a binder located in the nurses station which included hospice contact number, hospice nurse/Staff #232 and the hospice aid/Staff #240. On January 13, 2025 at 3:17 pm, operation manager/staff #300 stated that they received an allegation of abuse from adult protective services (APS) today at 12:45 pm, and he stated that he had submitted a facility report at 2:30 pm. The Department's Complaints/Incident Tracking System revealed the facility reported the allegation of abuse on January 13, 2025 at 2:38 pm to the State Agency. An interview was conducted on January 13, 2025 at 4:04 pm with a CNA/Staff #240. Staff #240 stated that she saw resident #1 on Monday which is January 6, on Wednesday which is January 8, and Monday which is January 13. Staff #240 stated that she help resident with her showers and the resident did not refuse any of her showers. She stated that on Monday, January 6, during her initial visit to resident #1, staff #240 stated that resident kept repeating that she was raped and would like to press charges. In addition, Staff #240 stated that the resident has bruise redness on her left side of the neck which looks like a choked mark or something like a hand placed on the neck, bruising on top of both hands and bruise on the left above resident's wrist. The bruise is purple and greenish in color. The resident's left upper arm inside the elbow has dark purple bruising. Staff #240 stated that after giving the resident her shower, she informed her nurse Staff #232 and a female social worker which she showed her the pictures. Staff #240 stated that she asked her nurse at that time if they have a sheet for her to document her skin assessment and she was told no. An interview was conducted on January 13, 2025 at 4:20 pm with a registered nurse (RN)/Staff #232. Staff #232 stated that she initially met the resident on January 6. She stated that Staff #240 gave resident a shower, and Staff #240 asked resident about the bruise on her wrist, and then the resident told her that she has been raped by a big black male. Staff#232 stated that the bruise and allegation of rape was reported to her by Staff #240 after she had finished giving resident her shower. Staff #232 stated that after being made aware of the allegation, she did a head to toe assessment, and she found bruise on resident's both wrist, resident only alert to self, the bruising did not look like grab marks, she ask the resident questions and the resident was unable to provide her details. Staff #232 stated that she then spoke with Staff #302 who is the social worker of the facility, and Staff #232 also reported the allegation to her director of nursing (DON). Staff #232 stated that she saw resident again on January 8th and resident made same statement that she has been raped. She saw the resident Monday, January 13, and resident did not say anything about rape. An interview was conducted on January 13, 2025 at 5:01 pm with social service director/Staff #302. Staff #302 stated that his role as a social worker involves follow up with grievances. Staff #302 stated that he has no knowledge of any allegation of abuse not until this morning when APS came in. He stated that he works Monday thru Friday from 08:30 to 5:00 pm. He stated that one of the hospice nurse reported to him that one of their resident, resident #1, who is in their memory care unit, that there was something reported to nursing and at that time he was in the nursing station, and he stated that one of their resident was saying weird things, referring in the past about something happened to her, that the resident was saying random things like having hallucination or delusion, and that the resident was saying that stuff was missing in the past. Staff #302 stated that the resident was doing very well and then she turns for the worst, her health declined, and on January 2, 2025 he called hospice to evaluate her because resident was not acting like her usual self, and not talking to every body like her normal self. He added that normally the resident was walking, talking, and making phone calls, then on January 2nd when he saw the resident, the resident was not walking, talking or calling anyone. Staff #302 stated that he spoke with a female nurse between 8:00 am to 5:00 pm, who spoke with the hospice nurse, who staff #302 stated he does not remember the name of the nurse he spoke with. Staff #302 stated that when something is reported to him like grievance, he will bring it to their morning meetings or stand up meeting with the IDT (interdisciplinary team) department which is composed of the administrator, DON, nurse managers, housekeeping manager, MDS nurse, the whole management team. His responsibility when an allegation of abuse is reported to him is to report to his administrator or the DON. An interview was conducted on January 13, 2025 at 5:39 pm with resident #1. During the interview, resident verbally stated her name, stated she has been here couple years, stated that she has been hurt, she has been raped, she stated she does not like being raped, she was raped twice, she has 2 rapes here, and it is not a pleasant situation. She stated that they pin you down, person is big guy three times her size, it happened right in her room, they are aware of it, it happens in the morning in a hurry, you have two people , big guys, both males, her clothes comes off, one is not a big guy but the other guy is a bigger guy, he pulls her aside, next thing she knew her underwear is pulled, she is having nightmare, she does not know how to explain it, it usually happens in her room, like he is changing her diaper, he gets her pants and underwear off, he changes her, so she gets a clean start for the day, the next thing she knew he puts a new diaper on, this big guy can just hold you down, then he puts her in a different clothes, it is scary and spooky. Resident pointed down below her mid waist area and stated that he doesn't put it inside but it is humiliating. Surveyor observe bruise, light purple bluish on top of resident's right hand, and bruise upper left wrist. The surveyors returned in the resident's room at 6:07 pm on January 13, 2025 after resident had a male and a female CNAs perform patient care. The interview with resident continued. The resident stated that the rape is in his apartment, the big guy came one time in the morning, a huge black man wears a blue uniform, the alleged perpetrator #400 is an older guy, huge shoulders, can't miss him because he is so big, alleged perpetrator #400 hurt her in her shoulder, lower back, did not enter her, he held her down. An interview was conducted on January 13, 2025 at 6:50 pm with the DON/Staff #305. The DON stated that for reporting allegation of abuse, they have a two-hour window. Their staff receive annual training on abuse. The DON stated that he was made aware of the allegation of abuse at 12:45 pm from APS for possible sexual assault and bruising. Then, he spoke with his administrator and reported it to the Department of Health (DHS) only. The DON stated that he refers to the policy and procedure to who he reports to for possible sexual assault, and he added to report to the state licensing, ombudsman, resident representative, APS, law enforcement officials, resident attending physician/medical director. At 6:58 pm on January 13, 2025, Staff #300 stated that he does not know if it was reported to the law enforcement because the social service does it. At 7:03 pm on January 13, 2025, Staff #302 joined the interview and stated that the law enforcement was notified today, and stated that once the state surveyors conclude today then they will notify the ombudsman and the case manager. At 7:09 pm on January 13, 2025, LPN/unit manager/Staff #310 stated that she called the law enforcement and informed them of the allegation of rape at 6:30 pm. Review of record revealed a social service note dated January 14, 2025 that the ombudsman and case manager were notified about the allegation that the resident's family reported to APS and State. Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, with a revision date of April 2021 revealed a policy statement All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Reporting allegations to the Administrator and authorities (2) The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/cerificaation agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. the resident's representative; d. Adult protective services; e. law enforcement officials; f. The resident's attending physician; and g. the facility's medical director. (3) Immediately is defined as: a. within two hours of an allegation involving abuse.

Based on clinical record review, interviews, review of Hoyer lift manual and facility policies, the facility failed to use a two-person transfer, as identified by the equipment manual, when transferring a resident. This resulted in resident #3 sustaining a major injury. Findings include: Resident #3 was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), heart failure, closed fracture of the right lower leg with routine healing and stage 1 kidney disease. The activities of daily living (ADLs) care plan dated August 13, 2020 revealed that the resident required assistance with ADLs/mobility secondary to multiple chronic conditions, morbid obesity and history of foot/leg fractures. Intervenations included extensive assistance of 1-2 staff for bed mobility, toileting and dressing; may use Hoyer lift for transfers; and total dependence for bathing. The care plan dated February 6, 2023 included that the resident was at risk for falls related to history of falls, impaired mobility and diagnosis of visual loss. Intervention included to assist resident/caregiver to organize belongings for a clutter free-environment in the resident's room and consistent furniture arrangement. The physician order dated February 28, 2022 included a Hoyer lift may be used for transfers. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8 indicating resident #3 had moderate cognitive impairment. The MDS also revealed that the the helper does all of the effort with no effort from the resident or the assistance of 2 or more helpers was required for the resident to complete the activity. Further, the MDS included that the resident did not have a fracture and did not have any falls since the previous assessment. The comprehensive skin evaluation/assessment dated [DATE] included that the resident had moderate pain, had discoloration ecchymotic skin and bruise to the right side of the lower extremity. A late entry eINTERACT Summary note dated August 7, 2024 included that there was a change in condition of the resident due to a fall. Per the documentation, the primary care provider recommended new pain medications and x-rays; and that, the resident had a fracture and the family decided not to treat the fracture. A nurse's note dated August 7, 2024 revealed the resident was alert and able to make needs known and was s/p (status post) fall in the morning shift. Per the documentation, the 2 views x-ray done to the right femur had an impression of acute displaced periprosthetic fracture in the distal femoral metaphysis. It also included that the nurse practitioner (NP) and the resident's family was notified of the results. The fall incident report dated August 7, 2024 included that a certified nursing assistant (CNA/staff #17) was transferring resident in the mechanical lift when the right bottom strap came off the lift hook then the resident slid out of the sling onto the floor. Per the documentation, the resident complained of right leg pain and her head was hurting; and that, the Hoyer lift taken out of commission. It also included that the resident was alert and oriented to person, place and situation and had a pain level of 3. Predisposing physiological factor included confusion. Injuries Report Post Incident included fracture of the distal femur. Further, the documentation included staff education on mechanical lift usage and the hoyer was taken out of commission; and that, there were no statements found. The report did not indicate whether there was another staff present in the resident's room during the transfer. The Rehab-Status Post-Fall Screen assessment dated [DATE] revealed that on August 7, 2024 at 11:00 a.m., the resident had a witnessed fall in the resident's room during a hoyer lift transfer. Per the documentation, the strap of the sling of the Hoyer got unhooked and the resident slid out of the sling and onto the floor. Recommendations from therapy included to conduct staff in-service on Hoyer transfers. The documentation did not include whether there was another staff present in the resident's room during the transfer. The fall care plan was revisedon August 10, 2024 to include that on August 7, 2024 the resident slid out of Hoyer sling during transfer. Intervention included to have a spotter in the room when Hoyer lift is in place. The eINTERACT transfer form dated August 11, 2024 included that the resident was sent to the hospital for femural fracture and per family's request. Per the documentation, the resident had a recent fall on August 7, 2024 resulting in a fracture to the femur and that at that time the family did not want the resident to be sent to the hospital. However, the documentation did not include whether there was another staff present in the resident's room during the transfer. The IDT (interdisciplinary team) functional abilities collaboration evaluation dated August 13, 2024 included that the resident had a fall on August 7, 2024 with major injury. The facility's Total Mechanical Lift Competency Checklist and Sit/Stand Mechanical Lift Competency Checklist for their staff with revision date of April 2008 revealed that under section two titled, Mechanical Lift Operation subsection A included to ensure two caregivers are present; and visually inspects sling for signs of wear and tear and not to use any sling that is visually damaged. The Hoyer Lift User Instruction Manual provided to the survey team revealed safety precautions such as not lifting the patient unless trained and competent to do so, always check the sling is suitable for the particular patient and is of the correct size and capacity, always carry out lifting operations according to the instruction in the user manual. Operating instructions included to have someone assist when attempting to transfer a patient. An interview was conducted on December 18, 2024 at 2:10 p.m. with a certified nursing assistant (CNA/staff #100) who stated that she typically do not use a Hoyer lift often because she mostly works in the behavioral unit; and that, today she was providing coverage in the general unit. She stated that when using the Hoyer lift to transfer a resident, she would put the sling on the resident, hook it up to the Hoyer and then lift the resident out of their wheelchair. Further, the CNA said that 2 staff members were required to be present and both staff had to be involved in the actual transfer. The CNA said that a dietary staff cannot be the 2nd staff member when operating the Hoyer because that dietary staff does not know the resident's care. An interview was conducted on December 18, 2024 at 2:19 p.m. with the CNA (staff #17) who was the CNA who assisted the resident with transfer using the Hoyer in August 2024. Staff #17 said that she received training on how to use the Hoyer lift when she was hired and a few months ago. She said that prior to using the Hoyer lift, she tests out the lift by moving it up and down to ensure that it was functioning correctly. She stated that when transferring a resident using the Hoyer lift, she uses a sling and connects them to the handles, then gets the chair ready and safely puts the tresident in the chair. Further, staff #17 said that she also ensures that she has someone with her to help. Regarding the incident with resident #3, she stated that she was helping resident #3 get up and get dressed for the day; and, resident #3 fell when she was using the Hoyer lift. Staff #17 said that the resident fell because one of the sides of the sling was not connected and it came off. She said that the dietary director (DD/staff #127) was helping her by being the spotter that day of the incident. Staff #17 further stated that she was not sure how the sling came off; and that, maybe she did not put the strap/sling all the way and it slid off the hook. In an interview with the Director of Nursing (DON/staff #50) conducted on December 18, 2024 at 2:43 p.m., the DON stated that he was not sure how the strap came off the Hoyer lift as the CNA (staff #17) working with the resident swore she put the strap on. He said that he had tried to replicate the scenario and he could not figure out how the strap came off. The DON stated that the dietary director (staff #127) just happened to walk by when the transfer was in progress and he had assisted as the spotter for the CNA (staff #17) with the Hoyer transfer of resident #3. The DON further stated that anyone can spot the Hoyer transfer but the person operating the Hoyer lift had to be a clinical staff; and, it was not the standard of care that it was required that the second person was the a clinical person to assist with Hoyer transfers. Further, the DON stated that if staff did not received training on Hoyer, it does not mean that they do not know how to operate the Hoyer. The DON also compared using a Hoyer to changing a tire on a car; and that, he did not get training on how to change a tire on a car but he knows how to do it regardless. An interview was conducted on December 18, 2024 at 3:11 p.m. with the dietary director (DD/staff #127) who stated that in his [AGE] years working at the facility he had assisted with Hoyer lift transfers several times. He stated that when assisting with Hoyer transfers, he would get rid of the tables, clear out items in the way or even move wheelchairs around. However, he stated that he does not assist with the actual transfer using the Hoyer lift because he has not been trained on how to do the actual transfer. Regarding the incident with resident #3, the DD said that he was walking down the hallway when the CNA (staff #17) waved him down for assistance; he did but he did not enter the resident's room. He said that he spotted from the hallway. He said that the CNA had elevated the resident using the Hoyer and was starting to bring her off the bed when one of the straps came down and the resident started to slide out of the sling. The DD said that the CNA stopped what she what she was doing and lowered the resident on the Hoyer. He further stated that he could not recall if the straps were in place; and, admitted to not knowing the process of how the straps of the Hoyer should look or work. Further, the DD said that if he was trained on the Hoyer lift transfer, he might have been able to tell if the resident was strapped in correctly. During an interview with a Registered Nurse (RN/Staff #124) conducted on December 18, 2024 at 3:58 p.m., the RN stated that she had helped CNAs when they are transferring residents using the Hoyer lift; and that, two persons were needed to operate a Hoyer lift. The RN said that priori to the incident with resident #3, the CNAs were using the Hoyer lift by themselves; and that, after the incident, facility management sent out a text message to staff that CNAs cannot operate the Hoyer by themselves. Further, the RN stated that a dietary staff could not be the second person operating the Hoyer Lift because they do not know how the Hoyer work and what information was needed to operate it; and that, the second person could either a CNA or another nurse. The RN said that she was not sure if rehab staff could help with the Hoyer transfer; and that, if staff were not trained on the use of Hoyer lift, there was a risk of resident falling. Further, the RN stated that it could also result in resident becoming fearful of the Hoyer and would not trust staff. In an interview conducted with another CNA (staff #161) conducted on December 18, 2024 at 3:47 p.m., the CNA stated that when using a Hoyer, there should be 2 persons doing it. She stated that one person would work the control and the other will be with the resident. She also said that one person will be standing by the Hoyer and the oether person will be with the patient on the bed and guide the resient. The CNA also said that moving the machine always required 2 persons and this could be the CNA and another nurse or CNA or therapy. Further, the CNA siad that she would get their help before moving the resident. An interview was conducted on December 18, 2024 at 4:12 PM with another RN (staff #158) who stated that she recently received training on using the Hoyer lift because of the incident with resident #3. The RN said that prior to the incident with resident #3, there was not a requirement to have two people in the room when using the Hoyer lift. However, The RN said that this was now a requirement; and that, dietary staff were not able to help withHoyer transfers. The RN said that when using the Hoyer for resident transfers, there had to be two CNAs or a CNA and a nurse or two nurses in the room. Further, the RN said that untrained staff using the Hoyer or having only one staff qualified to use the Hoyer could result in a fall of the resident being transferred because the transfer might not be done correctly, or the staff person might not know how to operate the Hoyer lift. During an interview with the admiistrator conducted on December 18, 2024 at 5:15 p.m., the administrator stated that the dietary manager (staff #127) did not have training on use of Hoyer; and that the dietary manager does not operate the Hoyer but would be the spotter during the transfer. Further, the administrator stated that the facility allowed staff such as housekeeping and dietary to spot the Hoyer while it is being used. In another interview with the DON conducted on December 19, 2024 at 8:19 a.m., the DON stated that when tranferring a resident using the Hoyer lift, first person would hook up the sling to the Hoyer while the second person watches the transfer. The first person would operate the transfer only when they were trained to do so; and, the second person would be able to move things out of the way. The DON stated that the second person did not need to be trained on the Hoyer; but, should be inside the resident room during the transfer. The DON said that the User Manual for the Hoyer lift, did not say that the person using the Hoyer must be a licensed or qualified. Further, the DON said on August 7, 2024, the CNA (staff #17) and the dietary director (DD/staff #127) were transferring resident #3 using the Hoyer; and that, this was in line with the manufacturer's instructions of having two people to transfer a resident. The DON further stated that he was not sure how the strap came off the Hoyer during the transfer process and how the incident happened; but, resident #3 sustained a fracture as a result of the fall from the Hoyer. Review of facility policy titled Safe Lifting and Movement of Residents with last revision date of July 2017 included that in order to protect the safety and well-being of staff and residents, and to promote quality care, the facility uses appropriate techniques and devices to lift and move residents. The policy also included that staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. The policy did not include how many staff members are required for the transfer of a resident using a Hoyer lift.

Based on resident and staff interviews, clinical record review, and facility policy, the facility failed to ensure adequate supervision was provided to prevent elopement for one resident (#37). The deficient practice resulted in resident eloping from the facility. Findings include: Resident #37 admitted [DATE] with diagnoses of dementia, diastolic congestive heart failure (CHF), adjustment disorder and anxiety disorders The elopement risk dated January 29, 2024 revealed a score of 10 indicating the resident was at risk for elopement. Another elopement risk dated April 29, 2024 revealed a score of 22 indicating the resident was at risk for elopement. The assessment included that the resident voiced attempt to elope but there was no action made. The initial facility report received on August 26, 2024 revealed that on August 25, 2024 at 7:15 p.m., a certified nurse assistant (CNA) told the on-duty nurse that the resident cannot be located during checks and changes. The documentation included that the resident was saying for the last week that he had been wanting to leave. Per the report, the facility started the elopement procedure. However, review of the clinical record revealed no documentation that resident was expressing to leave the facility; whether the resident was placed in increased monitoring; and that, the resident eloped from the facility on August 25, 2024. Despite documentation that the resident was at risk for risk for elopement, there was no evidence found that a care plan was developed with interventions implemented to address the resident's risk for elopement until August 26, 2024. The care plan dated August 26, 2024 included that the resident was an elopement risk/wandered related to impaired safety awareness. Interventions included providing structured activities such as toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes; and, assessing for fall risk. The elopement and wandering risk observation/assessment dated [DATE] revealed the resident expressed plan to leave but had not attempted to leave the facility. It also included that the resident ambulated independently with or without the use of an assistive device; and, the resident was in the locked memory care unit. Another elopement and wandering risk observation/assessment dated [DATE] revealed a score of 22 indicating the resident was at risk for elopement. Per the assessment, the resident had verbalized a desire to leave the facility, packed their belongings, stood by exit doors, or attempted to open an exit do; had exhibited unsafe wandering or has made one or more attempts to elope prior to admission or in the last year; and exhibited unsafe wandering or elopement attempts and was difficult to redirect. The documentation also included that based on the elopement and wandering risk observation/assessment findings, a wander guard alarm was indicated. The logbook documentation on check operation of door monitors and patient wandering system revealed the following findings: -August 2, 2024 - the back door, chi patio and front door had a pass remark; and, -August 16, 21 and 29, 2024- the front door had a pass remark. The CNA documentation from August 1 through August 30, 2024 revealed that resident had wandering behavior documented on August 8, 9, 20, 21, 23 and 29, 2024. The facility 5-day report submitted on August 30,2024 included that on August 25, 2024 at around 7:00 p.m., the NOC (night) shift nurse was doing rounds for their medication pass when the nurse noticed that the resident was not in his room. Per the documentation, the resident was not found on the unit and the patio; and, an elopement was called and local police department was notified. The documentation also included that the nurse and CNA drove on areas around the facility but was not able to find the resident. On August 26, 2024, Monday, the facility management team and other staff from sister facilities searched different parts of the city following all leads from all sources but still was not able to find the resident. On August 27, 2024 Tuesday, the administrator received a call from a case manager from a hospital who reported that the resident was at the emergency department (ED) of hospital since Monday August 26, 2024. The facility concluded that the resident eloped from the facility on the evening of August 25, 2024; and, the facility executed elopement protocol per facility policy. Plan of action included updating the care plan, staff in-service training on elopement, and all door alarms were serviced on unit that the resident resides. An interview with the nurse manager (staff #77) was conducted on August 30, 2024 at approximately 1:20 p.m. The nurse manager stated she was very familiar with resident #37 and his plan of care. She stated that the resident on the long-term care unit, but approximately 8 months to a year ago, he was moved to the locked unit due to his wandering behavior and decrease in BIMS score. She stated that the facility remained unsure on how the resident eloped from the facility; but, she recalled that she got a call Sunday night from the nurse (LPN/staff #45) who reported that the resident was not in his room, the cafeteria, or anywhere on the unit. The nurse manager said that staff searched the whole building and called police; and, several staff members drove around the neighborhood and were unable to locate the resident. The nurse manager stated that the hospital notified the facility on Tuesday, August 27, 2024 that they had found the resident who was in the hospital. She stated that the resident to the facility on Wednesday, August 28, 2024; and that, since the resident's return, he was placed on every 15-minute checks and the facility had increased Activities engagement so the resident was not isolated. In an interview with resident #37 conducted on August 30, 2024 at 1:26 p.m., the resident stated that he did not recall the incident of his elopement. However, he said that he will figure out how to escape from the facility eventually. An observation of the secured unit was conducted with a CNA (staff #12) on August 30, 2024 at 2:22 p.m. The door to the smoking area was blocked by a wheeled medication cart. When the medication cart was wheeled out of the way, the door was unlocked, opened and the alarm did not sound off. The CNA proceeded going outside to the patio and smoking area and checked the gate which was locked. The CNA stated that the gate was low the gate; and that, some residents who were tall and could get over it easily. In an interview with a licensed practical nurse (LPN/staff #45) conducted on September 3, 2024 at 11:25 a.m., the LPN stated that she was working the day resident #37 went missing. The LPN stated that the resident had a low BIMS score, had no previous elopement, was admitted in the secured unit for 8 months and had been wandering and asking to leave. The LPN said that when she started her rounds, a family member/visitor came up to her saying they had brought a coffee for Resident #37 who was not in his room. She said that she thought the resident stepped outside to smoke; but, when she went outside she did not find the resident. The LPN said that she then went to double check in the resident's room, but the resident was not in there; and, the roommate reported that resident #37 was gone and had left earlier that day at around 4pm. She stated the facility shut down the building, began the search, and informed the local police and supervisor (staff #77). The LPN said that she was not sure how the resident was able to leave since the door to the smoking area required a staff to open it and the alarm would sound off immediately if the door was opened and startle the residents when they open the door. Further, the LPN stated that there had been a flood on the unit in August, and this may be the reason why the door to the smoking area can be opened without the alarm sounding off or why the alarm no longer works. In an interview with the Director of Nursing (DON) conducted on August 30, 2024 at 2:57 p.m., he stated that the facility 5-day investigation report had not found anything of significance; and that, the facility was not able to figure out how the resident had eloped on August 25, 2024. He stated there were no cameras on the secure unit. The DON also stated that the expectation was for staff to do checks and changes to keep resident safe, offer the resident the ability to go outside in the day; and that, staff will do risk assessment on every resident that is admitted and quarterly thereafter. The facility policy on Wandering and Elopements with revision date of March 2019 included that the facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.

Based on resident and staff interviews, review of the clinical record, facility documentation and policy, the facility failed to ensure that code status was accurate and consistent in the medical record for one resident, #16. The deficient practice could result in resident not receiving care consistent with their signed advance directive. Findings include: Resident #16 was admitted on [DATE] with diagnosis including hypertensive heart disease with heart failure, bipolar disorder, schizophrenia, dementia, mood disturbance, anxiety, type 2 diabetes, depression, atherosclerotic heart disease of native coronary arteries, heart failure, Parkinson's disease, and psychotic disturbance. A review of the quarterly MDS (minimum data set) dated [DATE] revealed a BIMS (Brief interview of mental status) score of 14, suggesting the resident was cognitively intact. A review of the physician orders revealed an order dated [DATE] noting a DNR (do not resuscitate). A subsequent order in the electronic health record dated [DATE] revealed a full-code order, signifying that all resuscitation procedures will be provided to keep the resident alive. A review of the electronic health record revealed an advanced directive dated February 25, 2024, which noted that resident #16 is to be resuscitated and hospitalized . The advanced directive was signed and dated by the responsible party and the facility representative on February 26, 2024; however, the physician order was not updated until [DATE]. A review of the care plan, revealed an entry for [DATE] noting NO CPR. An interview was conducted on [DATE] at 12:29 PM with staff #84 CNA (Certified Nursing Assistant). Staff #84 stated that she tries to make sure that she knows whether any of her patients have a DNR in place. Staff #84 reviewed the health record for resident #16 and stated that the resident was a DNR. Staff #84 stated that to her knowledge the DON (Director of Nursing) completes the advanced directives documentation with the residents. An interview was conducted on [DATE] at 12:43 PM with staff #86 RN (Registered Nurse). Staff #86 stated that that advanced directives are completed by the nurse on shift at admission. She further stated that an advanced directive is completed each time a resident gets sent out of the facility and returns. Staff #86 stated that if a resident is coding (cardiopulmonary arrest), staff would first check their code status (resuscitate or do not resuscitate) in the electronic health record. When asked where the code status is noted, staff #86 demonstrated where in the electronic health record she would look. She indicated the resident's profile page. She stated that once the code status was identified, staff would call the code, and notify the nurse practitioner or physician. Staff #86 stated that she knows which of her patients have a DNR in place, but generally does not work in this specific unit/area. Staff #86 pulled up the electronic health record for resident #16 and stated that the resident was a DNR signified on the profile page. When staff #86 was asked to pull up the advanced directive document in the electronic health record, she gasped and stated that this is not good, the resident is a full-code. She stated that the expectation is that the advanced directive documents match the code status on the profile page. She stated that the risk could include someone not being resuscitated when they are designated as a full-code, meaning that they are to receive all life saving measures. An interview was conducted on [DATE] at 12:50 PM with staff #34 DON (Director of Nursing). Staff #34 stated that any of the nurses can complete an advanced directive document with a resident. Staff #34 stated that if a resident is not of sound mind, then 2 physicians could make the necessary elections and sign the advanced directive/ DNR form on behalf of the resident. When staff #34 reviewed the electronic health record, he stated that the advanced directive selection did not match what was displayed on the resident's profile page. He further stated that this did not meet his expectations and that the code status displayed always needs to match the code status on the most current advanced directive form; however, the code status on the profile page for resident #16 did not match the code selection on the advanced directive form. He stated that the risk could include a full-code patient not being resuscitated. A review of the facility policy entitled Advanced Directives, with a revised date of [DATE], revealed that the resident has the right to formulate an advanced directive and that their advanced directives are honored in accordance with state law and facility policy. The policy further stated that resident's wishes are communicated to the resident's direct care staff and physician by placing the advanced directive documents in a prominent location; however, care staff on the unit for resident #16 were not familiar with the resident's wishes and looked up the code status on the resident's profile page, which did not correspond to the resident's elected wishes on the advanced directives form; moreover, the physician had not been notified of the residents current advanced directive election until [DATE], post interview with staff #86.

Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure that one resident, #74 was free from staff abuse. The deficient practice could result in other residents being abused. Findings include: Resident #74 was admitted on [DATE] with diagnosis including chronic obstructive pulmonary disease, hypertension, paraplegia, muscle weakness and idiopathic neuropathy. A review of the quarterly MDS (minimum data set) dated July 20, 2023 revealed a BIMS (brief interview of mental status) score of 15, suggesting the resident was cognitively intact. A review of the care plan for resident #74 revealed no significant behaviors and or applicable findings. A review of the progress notes revealed that a skin assessment was conducted on September 15, 2023 revealing no skin injuries or wounds. The progress notes further revealed a change of condition documentation on September 17, 2023. A review of the facility's investigative report revealed that on September 17, 2023 staff #121 was cleaning the bathroom of resident #74. After staff #121 left the room, resident #74 was noted to have followed her into the hallway. The resident was then noted to have grabbed the broom from the housekeeping cart and began hitting staff #121. It was noted that staff #121 was observed blocking the blows and as a result made contact with the resident. The facility report further revealed that staff #121 was terminated on September 17, 2023 and is not eligible for rehire. The report further revealed that an in-service was conducted post incident. An interview was conducted on March 19, 2024 at 12:32 PM with staff #84 CNA (certified nursing assistant). Staff #84 stated that she in a resident's room, heard commotion outside and went to investigate. She stated that she saw the resident #74 and staff #121 fighting. She stated that she ran over in an effort to protect the resident. She said that she had observed the staff member hitting the resident a few times. Another staff member arrived and assisted with separating the resident and staff #121. She stated that she then proceeded to move resident #74 outside and assess him for injuries as well as help calm him down and reassure him that he was safe. She stated that no injuries were observed. An interview was conducted on March 20, 2024 at 12:12 PM with staff #86 RN (registered nurse). The RN stated that training, regarding resident , is conducted at hire, annually and then as needed throughout the year. An interview was conducted on March 20, 2024 at 2:10 PM with staff #94 CNA (certified nursing assistant). Staff #94 stated that abuse includes not only physical abuse by anyone but also verbal abuse. The CNA stated that staff receive training regarding abuse at least annually but often times more frequently. An attempt was made to contact staff #121 CNA (alleged perpetrator) on March 21, 2024 at 8:38 AM. A message on the phone noted that the person called was unable to receive messages at the time. An interview was conducted on March 21, 2024 at 9:03 AM with staff #43 (licensed practical nurse). Staff #43 stated that she was around the corner when she heard yelling. She stated that when she came around the corner, she saw that resident #74 had a broom and was hitting staff #121. She stated that staff #121 yelled for the resident to stop. She stated that one of the CNA's grabbed the resident and she took the broom out of his hand. She stated that thereafter staff #121 went behind the resident, after he had already been restrained, and started hitting him from behind. She stated that she did not recall where or how often resident #74 was hit by staff #121. She stated that, to her knowledge, resident #74 did not incur any injuries. She stated that all staff received additional abuse training after the incident. Staff #43 stated that the expectation is that resident abuse does not occur; however, it was observed that staff #121 did hit resident #74 willfully. An attempt was made to interview resident #74 on March 21, 2024 at 9:36 AM; however, the resident declined the interview. A review of the Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy revised April 2021 revealed that the objective is to keep residents free from abuse by facility staff or others. A review of the facility policy entitled Resident Rights, revised December 2016, revealed that residents have a right to be free from abuse; however, staff #121 was observed, by other staff, hitting resident #74.

Based on observations, resident and staff interviews, clinical record review, and policies and procedures, the facility failed ensure that oxygen cylinders are not stored directly on the floor for one resident, # 364. The deficient practice could cause the cylinder to tip over, the valve to break off and or the cylinder to potentially explode. Findings include: Resident #364 was admitted on [DATE] with diagnosis including chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, acquired absence of left leg-below the knee, anxiety, and major depressive disorder-recurrent. A review of the MDS (minimum data set) dated March 19, 2024 revealed a BIMS (brief interview of mental status) score of 15, suggesting the resident was cognitively intact. A review of the physician orders revealed an order on March 8, 2024 for 2 liters per minute of oxygen via nasal cannula as needed, per concentrator/ tank for shortness of breath. An observation was conducted on March 20, 2024 at 11:49 AM in the room of resident #364. Resident #364 was observed to be resting in her bed and approximately 2 feet from the foot end of her bed, an oxygen cylinder was observed sitting directly on the floor without carrier/ caddy or other stabilizing support mechanism. An observation was conducted on March 20, 2024 at 2:04 PM. The oxygen cylinder was observed in the same location, situated directly on the floor. An observation was conducted on March 20, 2024 at 2:12 PM, post interview with nursing staff. The oxygen cylinder remained in the resident's room, directly on the floor. An interview was conducted on March 20, 2024 at 2:04 PM with staff #87 (licensed practical nurse). Staff #87 stated that portable oxygen is not stored in resident rooms. She stated that only concentrators were used in the rooms. When asked why oxygen cylinders could not be kept in the resident rooms, she stated that the cylinders could fall over and cause injury or even explode. She stated all cylinders must be kept in a carrier and can never sit directly on the floor. An interview was conducted on March 20, 2024 at 2:10 PM with staff #94 (certified nursing assistant). Staff #94 stated that portable oxygen is only utilized when residents are transported or leaving their room. She stated that oxygen cylinders must always be in a sleeve or caddy and can never sit directly on floor. She stated that the risk for not have a cylinder in a sleeve or caddy could include it falling over and exploding. An interview was conducted on March 20, 2024 at 2:15 PM with staff #81 RN. Staff #81 stated that oxygen containers/ cylinders should always be in a carrier when in a resident's room. Staff #81 was taken to the resident's room, and then observed the oxygen container on the floor. She immediately picked up the container and removed it from the room. She stated that the container shouldn't be there like that. Stating that it needed to be in a a carrier. She stated that the risk could include explosion. An interview was conducted on March 20, 2024 at 2:21 PM with staff #34 DON (director of nursing). Staff #34 stated that oxygen containers are usually stored in oxygen storage rooms, and at times may be located in bottle bags on the resident's wheelchair. Staff # stated that the cylinders/ containers should not be kept in the resident's rooms directly on the floor. Staff #34 stated that the risk could include explosion. A review of the facility policy entitled Oxygen Administration with a revised date of July 2017 revealed that portable oxygen cylinders area strapped to the stand; however, the oxygen cylinder in the room of resident #364 was placed directly on the floor without a stand.

Based on documentation, staff interviews, and facility policy and procedures, the facility failed to ensure that one resident (#14) was free from abuse by other resident (#21). The deficient practice could result in residents being emotionally and physically harmed. Findings include: -Resident (#14) was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included quadriplegia, bipolar disorder, anxiety disorder, and post traumatic disorder. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 15 indicating the resident was cognitively intact. A physician's progress note dated October 23, 2023 at 4:35 PM included that the patient is in bed and states that pain level is 2/10 to his face and nose. Resident had an altercation last night. Review of a 5-day written investigation revealed a statement dated October 23, 2023 by resident #14. He stated that he and resident #21 were both swinging at each other and resident #21 did not hit him first. A progress note dated October 25, 2023 at 4:10 PM revealed that the resident had a verbal/physical altercation with another male resident. A small abrasion remains on each side of residents nose. The resident denies any pain or discomfort to the area. No other injuries were noted. -Resident #21 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis of vertebra, depression, hypertension, and other psychoactive substance abuse, but in remission. The minimum data set (MDS) dated [DATE] did not include a brief interview for mental status (BIMS) score. A physician's note dated October 22, 2023 at 10:01 PM revealed that the patient had a verbal/physical altercation with another resident. Both patients were inebriated. The patient tried to stand up from wheelchair and fell to ground. He did not hit head, so no change in level of consciousness, but did sustained a skin tear to right elbow, and multiple small abrasions to both lower extremities. The areas were cleansed and dressed. Review of a 5-day written investigation revealed a statement dated October 23, 2023 by resident #21. He stated that he and resident #14 were verbally arguing and resident #14 drove by him in his wheelchair and hit him in the head. Resident #21 stated that he then stood up and hit resident #14 in the head with the back of his hand. Resident #14 ran into him with his wheelchair and he sat down and fell out of his wheelchair. -Resident #40 was admitted to the facility on [DATE], with diagnoses that included Type II diabetes, chronic kidney disease, and anxiety. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 13 indicating the resident was cognitively intact. Review of a 5-day written investigation revealed a statement dated October 23, 2023 by resident #40. He stated that resident #21 was on the patio drinking alcohol and the other residents told him that he should not be drinking. Resident #40 stated that he witnessed resident #14 ramming his motorized wheelchair into resident #21 multiple times. Then, resident #21 got up and slapped resident #14 across the face really hard and fell to the ground and resident #14 pinned resident #21 to the ground. Resident #40 stated that both residents had been drinking. -Resident #6 was admitted to the facility on [DATE] with diagnoses that included human immunodeficiency virus, sepsis, and syncope and collapse. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 14 indicating the resident was cognitively intact. Review of a 5-day written investigation revealed a statement dated October 23, 2023 by resident #6. He stated that resident #14 ran over resident #21 with his wheelchair. Then, resident #21 hit resident #14 with an open hand in the face. Resident #21 got up and resident #14 hit him; resident #21 lost his balance and fell back into his wheelchair sideways. Resident #6 stated that he went to get staff. During an interview was conducted on March 4, 2024 at 1:09 PM with the Director of Nursing (DON/staff #116) and the Administrator (staff #165). Staff #165 stated that both residents were cognitively intact and able to make their own decisions. She also stated that there was not a staff supervising the residents on the patio, but staff did go out to the patio area when they heard something happening and did intervene. The facility's policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 states that residents have 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 physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on clinical record review, review of facility records, observations, resident and staff interviews, and review of policies and procedures, the facility failed to ensure that a mode of transport used to transport one resident (#65) through a courtyard was used safely, which resulted in bilateral fractured femurs. The deficient practice could result in additional resident injuries. Findings include: Resident #65 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Date Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) of 14, which indicated that the resident was cognitively intact. The assessment included that the resident required extensive assistance with dressing, hygiene and bathing and required two-person assistance with bed mobility and transfers, and one person assist to use a wheelchair. The assessment also included that the resident used a wheelchair and a walker and had no falls since admission. Review of resident #65's clinical record from March 1, through May 21, 2020 did not reveal that the resident had any falls prior to May 21, 2020. A nurse's note dated May 21, 2020 at 9:38 a.m. included that a CNA (Certified Nursing Assistant) was transporting resident #65 in a shower chair, and the resident fell out of the chair and hit the left side of her head. The note included that resident #65 complained of pain in both knees and the right foot, a nurse practitioner was notified, and x-rays were ordered. A Change in Condition note dated May 21, 2020 at 11:40 a.m. included that resident #65 had fallen that morning, the resident's primary care clinician had been notified, and orders had been obtained for X-ray's. A nurse's note dated May 21, 2020 at 2:00 p.m. included that resident #65 had been sent to the hospital due to increased pain in the right knee. An undated written care plan with a focus that included that resident #65 was at risk for falls due to impaired mobility, muscle spasms, chronic pain, morbid obesity, and wheelchair dependence included that resident #65 was alert and oriented, does not attempt to self-transfer, and fell on [DATE] with bilateral femur fractures, which was an isolated event. The care plans included the following (undated) interventions: -May use shower chair/bed from room to shower room. -Provide resident with total assist of 2 (staff) for transfers using a Hoyer lift. -Hoyer lift for transfers. Review of the MAR (Medication Administration Record) for May, 2020 included an entry for a narcotic pain medication-[MEDICATION(S)] (Hydrochloride) 5 mg. (milligram) capsules, give by mouth every 4 hours as needed for pain. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] An investigative report dated May 26, 2020 included that on May 21, 2020 at approximately 10:00 a.m. resident #65 was being transferred through the facility courtyard in a shower chair by a CNA. The report included that as resident #65 was being transferred by the CNA she slid out of the chair and fell on her knees, and staff was unable to prevent the resident from sliding from the chair. The report included that a mechanical (Hoyer) lift was used to assist the resident from the ground, and she was returned to her room. The report included that resident #65 complained of knee pain, was provided medication, an X-Ray was ordered and resident #65 was sent to the hospital, and that the resident was diagnosed with right and left acute distal femur fractures. The facility investigation included that resident (#65) was interviewed on May 21, and 26, and stated that she did not know what happened to cause her to slide out of her chair and that she always transferred to the shower through the courtyard. The investigative report dated May 26, 2020 included a handwritten (undated and unsigned) statement from a CNA. The statement included that the CNA was transporting resident #65 to a shower and that the resident had asked to go outside to see the (facilities pet) turtles. The statement included that as the CNA and resident #65 were heading outside, there was a bump, and resident #65 slid out of the chair and hit her head on a rail, near a door. Review of the MAR for May, 2020 included the following: -An entry dated May 27, 2020 at 8:34 a.m. Resident #65 received [MEDICATION(S)] 5 mg. capsule for pain with a level of 8 (severe pain). -An entry dated May 27, 2020 at 12:25 p.m. Resident #65 received [MEDICATION(S)] 5 mg. capsule for pain with a level of 10 (severe pain). A physician's progress note dated May 27, 2020 included that the resident had been sent to the hospital after falling while being transported to the shower. The note included that portable X-Ray results showed bilateral femur fractures. The note included that the left femur fracture was acute comminuted and the right femur fracture was a displaced fracture of the distal femur, and also included a recommendation for non-weight bearing on the bilateral lower extremities (legs) for 6 weeks. The note included that resident #65 was unable to move bilateral lower extremities. An entry in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing documentation note dated May 29, 2020 at 7:58 a.m. included that the resident was status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The note included that the resident was alert and oriented and that her reason for stay was teaching and training ortho pain management and that resident #65 did not complain of pain at that time. An entry in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview conducted on February 16, 2021 at 2:32 pm with resident #65, she stated that on the day of the fall she was transferred onto a shower chair by a Hoyer lift, and that the shower chair was high enough that her feet did not touch the ground. Resident #65 stated that she was being transported to the shower through the courtyard, by her request when the chair came to a stop, which caused her to slide off the chair onto the ground, and that she hit her head on the way down and onto her knees. During an interview conducted on February 17, 2021 at 9:05 am with a Unit Manager (Staff #93), she stated that she did not observe resident #65 fall, but was nearby and arrived at the fall shortly after it happened, and that she found the resident on the ground. Staff #65 stated that resident #65 was assessed, then lifted by Hoyer lift into her shower chair and returned to her room. Staff #65 stated resident #65 was in pain only when she was moved. During an interview conducted on February 17, 2021 at 9:41 am with a CNA (Staff #3, she stated that she was the CNA who transported resident #65 in the shower chair when she fell . Staff #3 stated that shower chair hit a bump or something and came to an abrupt stop causing resident #65 to fall forward onto the ground. During an interview conducted on February 17, 2021 at 10:43 am with an LPN (Licensed Practical Nurse/staff#10), she stated that resident #65 was in a shower chair, as per the resident's request, and that the resident is frequently transported to the shower in a shower chair through the courtyard. During an interview with the Rehabilitation Director (Staff #114) on February 17, 2021 at 12:57 pm., the Director stated that the resident should be transferred to the shower room by wheelchair, and that it is not the best-case scenario to transfer the resident through the courtyard in a shower chair. During an interview conducted on February 17, 2021 at 2:28 pm. with an LPN (Staff #96), she stated that she would not have allowed a resident to be transferred through the courtyard by a shower chair because that is unsafe. An observation was conducted on February 17, 2021 of the walkway and courtyard where resident #65 fell on [DATE]. The observation included that there is a metal handrail on the left side of the walkway at the entrance to the courtyard, and a slight ridge which could cause a bump in a wheelchair as it crossed. Review of a policy and procedure titled 1.7 ADL: Shower included that a resident should be transferred to the shower room, then placed into a shower chair next to the shower. Review of a policy and procedure titled Falls Prevention included that all residents will be evaluated for fall risk through routine evaluations and that measures will be taken to reduce the risk of resident falls.

Based on clinical record review, observations, review of the National pressure Ulcer Advisory Panel (NPUAP), staff interview and review of facility policy, the facility failed to ensure that one resident (#158) was provided care and services to prevent the development of an avoidable pressure ulcer and to promote the healing of an existing pressure ulcer. The facility also failed to implement the impaired skin care plan for one resident (#48). The survey sample size was three. Findings include: -Resident #158 was admitted on [DATE], status [REDACTED]. Review of the clinical record revealed a physician history and physical dated February 20, 2010, that did not include presence of decubitus ulcer. The Admission Data Set (ADS) revealed the resident had a "1 x 1 stage 1 pressure ulcer (PU)" described as a "reddened area 6 centimeters (cm) round" on his left buttock. The ADS included a Pressure Ulcer Risk Assessment that identified the resident was at risk for pressure ulcer development. A review of the clinical record and the Admission MDS (Minimum Data Set) dated February 26, 2010, documented that the resident had no pressure ulcers. Section V. of the Resident Assessment Protocol Summary (RAPS), of the MDS, documented that the resident was at risk for pressure ulcers due to dependency on bed mobility, bowel incontinence, and skin desensitized to pain/pressure and directed staff to proceed with a care plan. A care plan was opened on February 17, 2010. The care plan entitled "Potential for Skin Impairment" determined that the resident had potential for impaired skin integrity related to left [MEDICAL CONDITION], Braden scale score greater than 15, impaired mobility, incontinence, noncompliant with turning or other preventative measures and history of bruising. Review of the resident's Quarterly data set dated [DATE], documented that the resident had shearing to the left buttock and was ordered treatment of [REDACTED]. The Pressure Ulcer Risk assessment dated [DATE], reported that the resident was at continued risk for pressure ulcer development. Review of the Quarterly MDS assessment dated [DATE], documented that the resident as not having an unhealed pressure ulcer at stage one or higher. The MDS directed staff to provide a pressure reducing device for chair and bed as skin and ulcer treatments. Review of the Care Plan Conference Summary dated November 11, 2010, documented that the resident at risk for skin breakdown. The care plan did not include that the resident had a pressure ulcer. The Weekly Skin assessment dated [DATE], documented left shearing had resolved. The Monthly Summary for November and December 2010 recorded skin dry and fragile but without documentation that resident had "Broken Areas" or "Pressure Sore". The Weekly Skin Assessments from November 22 through December 27, 2010, recorded that the resident's skin was intact. On January 4, 2011, a nurse's note documented, "skin assessment done to peri/coccyx area with treatment orders noted. Right ischial and right buttocks is shearing and coccyx is a Stage 2. Will reassess treatment in 10 days..." The skin care plan was updated on January 4, 2011, and identified the resident as having treatments to shears located on coccyx, right ischial and the right buttock. Updated approaches included: air overlay mattress on bed, gel cushion to Geri chair when up in bed between meals and treatments as ordered. Review of the Weekly Wound Measurement for Surgical and Other Wounds included a January 4, 2011, entry that documented that the resident had developed a 3 cm x 2 cm shearing site with thick skin build up on his right ischial. Weekly measurement documentation, following the initial wound measurement, described the wound as improving, clean and dry. Review of Weekly Measurement for Pressure Ulcer (Stage 1 to Stage IV) included an entry dated January 4, 2011, that documented the resident had developed a 2.5 cm x 2.0 cm Stage 2 pressure ulcer on his coccyx. On this same date the resident was identified with a shearing site with thickened skin on right buttock but was determined to be healed on January 11, 2011. Review of physician orders [REDACTED]. Apply a thin layer wound gel to site and cover with OpSite. Change every third day and as necessary (PRN). Cleanse coccyx and right ischial site with wound cleanser and pat dry with a 4 x 4 gauze. Apply [MEDICATION NAME] to site. Change every third day and PRN. A Skin Integrity Evaluation dated January 6, 2011, was completed by the Director of Nursing (DON) and included the following documentation: "...On January 4, excoriations and redness cleared but with 2 areas that appear to be shears (ischial, buttock right and a fissure like open area center of buttocks, may be related to frequent peri-care and him resisting (holding buttocks) at coccyx..." On January 31, 2011, the Weekly Wound Measurement for Pressure Ulcers documented the coccyx wound as measured 1.4 cm x 1.0 cm x 0.2 cm and described as worsened and not healing. There were no other descriptions of the pressure ulcer provided. The right ischial wound was measured to be 3.0 cm x 1.8 cm and continued to be described as improved, healing, clean and dry. No other descriptions of wound were provided. On February 1, 2011 at 12:15 PM, an observation was conducted of the right ischial wound and coccyx pressure ulcer with a Licensed Practical Nurse (LPN). The right ischial wound was observed to be black with scant amount of moisture noted at center of black area. The area was measured by the LPN during the observation and was described by the LPN to be a Stage 4 pressure ulcer that measured 3.2 cm x 3.5 cm with black eschar. The coccyx wound was then measured next by the LPN and reported to be a Stage 2 pressure ulcer that measured 3.5 cm x 2.6 cm with white tissue located at center of wound. Three additional wounds were newly identified during the observation with the LPN. The first was located on left buttock and reported by the LPN to be a Stage 2 that measured 1.7 cm x 2.3 cm. The second was located higher on the left buttock and was reported by the LPN to be a shearing wound which measured 2 cm x 1.5 cm. The third was located on the right buttock and reported by the LPN to be a Stage 2 pressure ulcer that measured 5.5 cm x 2.8 cm. The LPN revealed that these three newly identified wounds would require treatment orders, stating, "I will call the doctor right away for treatment orders". During the wound observation on February 1, 2011, the resident's wheel chair pad was observed to be lying on the unoccupied bed in the resident's room. The resident's Geri chair was observed to sit next to the resident's bed with a full chair length cover. An interview was conducted with the certified nursing assistant (CNA) who assisted the nurse with the resident's wound care. When questioned about why the wheelchair pad was on the unoccupied bed and not in the Geri chair, he pointed to the cushion and stated that the cushion had not been in use for a long time because it caused the resident to slide. Further, he explained while pointing to the full length chair cover, "we use this down cushion now". Review of Nurse's Note dated February 1, 2011, included the following documentation regarding the LPN's wound observations that "...treatment completed after assessment noted left upper buttock shearing approximately 2 x 1.5 without drainage or odor noted. Left buttocks has a 1.7 x 2.3 Stage 2 edges pinkish with no drainage. Coccyx has a 3.5 x 2.6 open area with pinkish edges with bright redness surrounding a whitish approximately 1 x 1 without drainage or odor noted. Right buttocks has a 5 x 5 x 2.8 open area with pink edges and reddened area surrounding a whitish area and 3 darkened red areas noted lower part of open areas. Ischial area has 3 x 3.5 open area with 2 x 2.5 darkened center (Eschar). Will place call to Dr. for new treatment orders to this area no drainage or odor..." The nurse failed to document the centimeters of each wound observed. Following the wound observation an interview was conducted with the director of nursing (DON) who revealed that the LPN's assessment of the resident's pressure ulcers and wounds had not been certified in wound care. Review of the Weekly Wound Measurement For Pressure Ulcer (Stage 1 to Stage IV) dated February 1, 2011, documented a second assessment and measurement conducted by the DON and included the following: Coccyx with Stage 2 measuring 3.0 cm x 2.8, depth less than .1 cm with yellow area measuring 1.4 cm x 1.0 cm with granulating edges describing wound as worsened. Right buttock stage 2 measuring 5.0 cm x 2.8 cm depth less than .1 cm with granulating edges and worse. Right buttock ischial area UTD (unable to determine) measuring 3.5 cm x 2.8 cm depth less than .1 cm described as 90% eschar pink border surrounds dark skin outer with eschar area 3.2 cm x 2.2 cm feels thin described as worse. Also, review of Weekly Wound Measurement for Surgical and Other Wounds included a left sacral shear measured as 2.0 cm x 1.5 cm superficial depth. On February 1, 2011 at 2:00 PM, the resident was observed in his room and sitting up in the Geri chair. The wheel chair cushion/pad was still lying on the unoccupied bed in the resident's room. The resident was sitting on the chair with the "down cushion" between the resident and the chair. An interview was conducted with the LPN following the observation. The LPN revealed that the resident should be sitting on the gel cushion in his Geri chair. She stated that failure to place the cushion in his Geri chair by staff may have resulted because the resident had made several transfers to and from the Geri chair in order to measure wounds a second time. -Resident #48 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The ADS, dated November 3, 2010, revealed a Pressure ulcer risk assessment, which had documented a score of 13. According to the pressure ulcer risk assessment, the score of 13 indicated high risk for pressure ulcers and the need to develop a care plan. The ADS also documented that a full body skin inspection, revealed multiple wounds. The resident's skin assessment had listed the following locations: The coccyx measured 10 x 9 x 10 cm with a small amount of bleeding. The posterior left lower extremity measured 10 x 4 x 0 cm with small amount of serosanguinous drainage. The posterior right lower extremity measured 7 x 4 x 0 cm with serosanguinous drainage. The heels were black with eschar. However, there were no measurements documented for the heels. A care plan was developed for Actual Impaired Skin dated November 3, 2010, related to stage 1 to UTD (unable to determine), pressure ulcer sites such as coccyx, bilateral posterior calves, right and left heels. The resident's goals had included to have no further skin breakdown, show healing of impaired areas, and no complications by next review. The approaches consisted of medication and treatment as ordered, to notify physician for changes or lack of response to treatment, monitor for infections, complications, and pain, skin checks every week, low air loss mattress, gel cushion, assist to turn every two hours, measure and assess wound every week. Physician orders [REDACTED]. The order further documented to now apply skin prep to eschar sites and cover with a 4 x 4 gauze and to secure with kling wrap every day for the heels bilaterally times 14 days, then to reassess. A care plan conference summary sheet dated November 18, 2010, documented that the resident was at risk for further skin breakdown. In addition, the summary revealed that the resident was slow healing. Another physician order [REDACTED]. However, the clinical record had no documentation of a reassessment or a physician order [REDACTED]. The review of the clinical record was conducted, which included another physician's orders [REDACTED]. According to the order, the treatment was to gently cleanse with normal saline (ns), pat dry with a 4 x 4 gauze. Apply wound gel (healing) to open areas, cover with a 4 x 4 gauze with ABD pad. Wrap with kling and secure with tape bid (twice a day) x (times) 14 days, then reassess, which was documented on December 24, 2010, to continue the treatment order. The Treatment Administration Record for January 2011 had no transcribed orders for wound gel to be applied to the posterior calf wounds. According to the documentation, the treatment orders for the bilateral calf wounds did not reflect the previous physician's orders [REDACTED]. However, per the resident's care plan for "Actual Impaired Skin," documented to notify the physician for any changes or lack of response to treatment. However, the LPN failed to contact the resident's physician to obtain further treatment or interventions, as needed. A wound observation was conducted on January 31, 2011. The resident had two sites, which had changed. The area on the right heel measured 4.2 x 3 cm. The heel area had an eschar cap, but had a new area at the lower edge of the wound. The right calf wound measured 6 x 3.8 cm had a black area, which was in the center of the wound. There was no documentation that the primary physician was notified of the wound changes. An interview was conducted with the LPN, during the wound observation on January 31, 2011. The LPN stated, the area on the heel and posterior calf are new, and the physician should be notified of the wound changes. The LPN further stated that the resident may need further interventions. Although, the resident's wound changes were placed in the 24 hour report, there was no documentation that the physician was notified. An interview was conducted with the MDS nurse February 1, 2011. The MDS nurse stated, after review of the clinical record no documentation was found concerning the resident's physician being notified of the wound changes, which would be needed for further treatment. In addition, there was no documentation that the Hospice (wound nurse) was notified to obtain further instructions, interventions, or treatments, per Hospice's physician. The interview conducted with the DON on February 1, 2011, at 11:30 a.m. The DON stated, the facility's protocol for wound management included a reassessment of the pressure ulcer wounds and further instructions for interventions and develop and/or update the plan of care as needed. The DON further stated, pressure ulcer wounds may have different reassessment times or intervals according to the needs. Some wounds may have five days, seven days, or 14 days reassessments, but no longer than 14 days. Also, the DON stated, the resident's physician should have been notified of any changes in the resident's wound to ensure proper treatment. The "Care, Treatment, and Documentation of Skin Issues,"...Purpose: To promote the wellness, health and safety of residents within the facility. To provide adequate documentation of pressure ulcers...thus allowing for preventative intervention and treatment...If an area of pressure ulcer or other unusual skin occurrence was observed the Licensed Nurse would contact the physician and arrange for an appropriate treatment order...Pressure ulcers...which are not demonstrating healing per the measurements documented on the...wound sheet within 14 days would result in the physician being contacted for possible change in the treatment orders. The DON or designee would monitor the Weekly Skin Assessment...to ensure adequate documentation and follow-up has been completed by the Licensed Nurse. According to the NPUAP, "...Consider all bed-bound and chair bound persons, or those whose ability to reposition is impaired, to be at risk for pressure ulcers...Identify all individual risk factors...Modify care according to the individual factors...Perform a head to toe skin assessment at least daily, expecially checking pressure points such as sacrum, ischium, trochanters, heels, elbows, and the back of the head..."