Every finding on record at Sistersville Center

Based on medical record review, observation, and staff interview, the facility failed to ensure Resident's received treatment and care in accordance with professional standards of practice. Specifically, physician's orders were not followed for Neurological checks (neuro checks) . This practice affected one (1) of one (1) residents reviewed, during the Long-Term Care Survey Process (LTCSP). Resident identifier #13. Facility census: 60. a) Resident #13 The facility's policy titled Falls Management, with effective date 09/15/01 and revision date 01/15/26, stated any resident who had a fall unwitnessed by staff would be observed for neurological abnormalities by performing neurological checks per policy. The facility's policy titled, Neurological Evaluation, with effective date 03/01/98 and revision date 01/15/26, stated when a resident has an unwitnessed fall, neurological evaluations would be performed every 15 minutes for two (2) hours, then every 30 minutes for two (2) hours, then every hour for four (4) hours, and then every eight (8) hours for at least 72 hours. Review of Resident #13's progress notes showed the resident had an unwitnessed fall on 12/26/25. A progress note written on 12/26/25 at 10:15 PM stated, This nurse heard resident yelling Help me from hallway. Upon entering room, resident was on her hands and knees beside of her bed. She stated, I was trying to get comfortable in the bed and somehow ended up in the floor. Assessed resident for injuries, no injuries observed. PERRLA [pupils equal, round, reactive to light and accommodation]. VSS [vital signs stable] and WNL [within normal limits]. Denies any pain or discomfort. No change in ROM [range of motion]. Resident able to move all extremities without difficulty. Resident denies hitting her head. Assisted resident back to bed x2 assist. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Neuro checks per facility protocol. Other than the initial neurological evaluation documented in the note above, no neurological evaluations were found in the medical record. On 04/02/2026 at 10:57 AM, Administrator #47 confirmed no neurological evaluations could be located for Resident #13's fall on 12/26/25. Administrator #47 also confirmed Resident #13's fall on 12/26/25 was unwitnessed by staff. No further information was provided through the completion of the survey process.

Based on staff interview and surveyor intervention, the facility failed to provide feeding of meals in a timely manner after serving the trays to residents with no drink or meal assistance. This was true for two (2) of two (2) residents in the care area of Resident Rights/Exercise of Rights. Resident Identifiers: Resident #55 and Resident # 57. Facility census: 60. Findings include: a) Resident # 55 Review of Resident # 55's records show Regular/Liberalized Puree Thick liquids- Honey with 240 ml of cranberry juice with all meals. On 03/31/26 at 12:39 PM, Resident # 55 was served lunch tray with no drink or utensils. Utensils include large maroon spoon. The meals were sitting, uncovered, in trays for eleven (11) minutes before a staff member came over to check what drinks were needed and to start assisting resident with feeding. At 12:53 PM, Registered Nurse Clinical Lead Staff # 45 was asked if it is common for residents to have to wait to be fed or assisted with dining room meals for over ten minutes to which her reply was, absolutely not! This is not a practice we like to see. b) Resident # 57 Review of Resident # 57's records show Regular/Liberalized Puree diet with 2 % milk (eight ounces) and assorted beverage (eight ounces). The pureed food in tray was served at 12:39 PM on 03/31/26 in the dining room and resident was in reclined position by table until Staff #45 came over at 12:53 PM to start with feeding. Staff member was asked if waiting ten minutes was common for residents to start being fed after the uncovered trays have been sitting at table and the reply was Absolutely not! This is not a practice we like to see. The Nursing Home Administrator was not working on this day to discuss this item so the corporate staff member was the main contact for this discussion.

Based on record review and staff interview, the facility failed to implement their abuse prohibition policy regarding the reporting of allegations of potential verbal abuse. This was true for one (1) of four (4) residents reviewed for the care area of abuse. Additionally, a random opportunity for discovery showed other allegations of potential verbal abuse had not been reported. Resident Identifier: #7. Facility Census: 60. Findings included: a) Policy Review The facility's policy titled, Abuse Prohibition, with effective date 07/01/13 and revision date 11/14/25, stated allegations involving abuse with no serious bodily injury would be reported immediately but no later than 24 hours after forming the suspicion of abuse. b) Resident #7 On 03/16/26, an allegation of potential verbal abuse was reported to the Office of Health Facility Licensure and Certification. The incident occurred on 02/13/26 at 7:45 PM. The initial reporting of allegations stated, Resident thought she heard the CNA [certified nursing assistant] calling her a mumbled word that sounded like bitch. Resident told her father and he asked the CNA if it was true .The resident's father asked the CNA not to report it, so no immediate steps were taken. According to the initial reporting of allegations, the incident was discovered during the investigation of an unrelated concern on 03/16/26 and was reported to all required entities at that time. Following this, an investigation was conducted. The five (5) day follow-up, which unsubstantiated the allegation, was submitted on 03/20/26. According to a typed statement on 03/16/26 by Nurse Aide (NA) #1, who was involved in the allegation, the incident had been reported to former Director of Nursing (DON) #88 and former Administrator #89 at the time of the incident. The former DON and Administrator stated the incident did not need reported because it was a muttered word. On 04/01/26 at 1:00 PM, Administrator #47 confirmed the incident involving an allegation of potential verbal abuse that occurred on 02/13/26 was not reported until 03/16/26. No further information was reported through the completion of the survey. c) NA #57 and NA #1 On 04/01/26, the surveyor asked to review the investigation for the allegation of potential verbal abuse described above. In the file was a typed statement. The statement indicated it was from google.com mail and was sent from an iPhone. However, there was no information regarding the writer of the statement. The statement read as follows: I have worked with [Nurse Aide (NA) #53] in this facility for almost three years. She does come in and do her job, and does not call off ever. Our job is far more than just showing up though. I have seen residents trying to talk to her, and her just walk off. Many residents have told me they know she's mad at them. I have heard her call a certain resident pissy pants, and told him he needed to start using a urinal. That was reported by a nurse at one time also. She has also made the comment about it stinking in there while she was changing him. I know that resident was afraid to use his call light at one point because he didn't want her coming in to change him. Multiple residents have told me she's mean and calls them names. I know she has a nickname for everyone she doesn't like. Working with her got so tense, and hostile You never know what kind of mood she's going to be in, and she doesn't just take it out on her coworkers it is with the residents also. I would work with a resident on one side of the curtain, and [NA #53] on the other side with the other resident. There was multiple times residents would yell out and tell her to be easy, and she would say well roll. I would finish up and go help her so I know what was going on. I never witnessed her physically hurting anyone, but she is mean, and always in a horrible mood. She's shut call lights off without answering them multiple times. I also know that she has reported us to state before. She's the one that went online and reported sexual activitu on red hall. She has told many people about doing it. [NA #1] has told so many lies to so many there. She is as mean as [NA #53]. She's always complaining about having to do her job. Complaining about her coworkers, and how no one ever does their jobs. I've heard her calling the residents nicknames also. She does it at the nurses station talking to other coworkers. I don't hang around and listen to her much. I don't have too much interaction with her. I have had a few residents call her the mean one. I know they are talking about her because they say it's the pregnant one. On 04/01/26 at 1:00 PM, Administrator #47 was asked if the allegations of abuse contained in this statement had been reported and investigated. She was unaware of the source of this statement. On 04/01/26 at 1:27 PM, Administrator #47 stated the allegations of abuse contained in this statement had not been previously reported and investigated. However, the matter had just been reported to the required entities. Additionally, the NAs involved had just been suspended pending investigation. No further information was provided through the completion of the survey process.

Based on record review and staff interview, the facility failed to investigate allegations of potential abuse. This was a random opportunity for discovery. Facility Census: 60. Findings included:c) NA #57 and NA #1esOn 04/01/26, the surveyor asked to review the investigation for the allegation of potential verbal abuse toward Resident #7 that had been reported to the Office of Health Facility Licensure and Certification (OHFLAC) on 03/16/26. The allegation of verbal abuse toward Resident #7 had been investigated and was determined to be unsubstantiated. In the finvestigation file was a typed statement. The statement indicated it was from google.com mail and was sent from an iPhone. However, there was no information regarding the writer of the statement. The statement read as follows: I have worked with [Nurse Aide (NA) #53] in this facility for almost three years. She does come in and do her job, and does not call off ever. Our job is far more than just showing up though. I have seen residents trying to talk to her, and her just walk off. Many residents have told me they know she's mad at them. I have heard her call a certain resident pissy pants, and told him he needed to start using a urinal. That was reported by a nurse at one time also. She has also made the comment about it stinking in there while she was changing him. I know that resident was afraid to use his call light at one point because he didn't want her coming in to change him. Multiple residents have told me she's mean and calls them names. I know she has a nickname for everyone she doesn't like. Working with her got so tense, and hostile You never know what kind of mood she's going to be in, and she doesn't just take it out on her coworkers it is with the residents also. I would work with a resident on one side of the curtain, and [NA #53] on the other side with the other resident. There was multiple times residents would yell out and tell her to be easy, and she would say well roll. I would finish up and go help her so I know what was going on. I never witnessed her physically hurting anyone, but she is mean, and always in a horrible mood. She's shut call lights off without answering them multiple times. I also know that she has reported us to state before. She's the one that went online and reported sexual activitu on red hall. She has told many people about doing it. [NA #1] has told so many lies to so many there. She is as mean as [NA #53]. She's always complaining about having to do her job. Complaining about her coworkers, and how no one ever does their jobs. I've heard her calling the residents nicknames also. She does it at the nurses station talking to other coworkers. I don't hang around and listen to her much. I don't have too much interaction with her. I have had a few residents call her the mean one. I know they are talking about her because they say it's the pregnant one. On 04/01/26 at 1:27 PM, Administrator #47 stated the allegations of abuse contained in this statement had not been previously investigated. She stated the matter would be investigated. No further information was provided through the completion of the survey process.

Based on record review and staff interview, the facility failed to report allegations of potential verbal abuse within a timely manner. This was true for one (1) of four (4) residents reviewed for the care area of abuse. Additionally, a random opportunity for discovery showed other allegations of potential verbal abuse had not been reported. Resident Identifier: #7. Facility Census: 60. Findings included:a) Policy Review The facility's policy titled, Abuse Prohibition, with effective date 07/01/13 and revision date 11/14/25, stated allegations involving abuse with no serious bodily injury would be reported immediately but no later than 24 hours after forming the suspicion of abuse. b) Resident #7 On 03/16/26, an allegation of potential verbal abuse was reported to the Office of Health Facility Licensure and Certification. The incident occurred on 02/13/26 at 7:45 PM. The initial reporting of allegations stated, Resident thought she heard the CNA [certified nursing assistant] calling her a mumbled word that sounded like bitch. Resident told her father and he asked the CNA if it was true .The resident's father asked the CNA not to report it, so no immediate steps were taken. According to the initial reporting of allegations, the incident was discovered during the investigation of an unrelated concern on 03/16/26 and was reported to all required entities at that time. Following this, an investigation was conducted. The five (5) day follow-up, which unsubstantiated the allegation, was submitted on 03/20/26. According to a typed statement on 03/16/26 by Nurse Aide (NA) #1, who was involved in the allegation, the incident had been reported to former Director of Nursing (DON) #88 and former Administrator #89 at the time of the incident. The former DON and Administrator stated the incident did not need reported because it was a muttered word. On 04/01/26 at 1:00 PM, Administrator #47 confirmed the incident involving an allegation of potential verbal abuse that occurred on 02/13/26 was not reported until 03/16/26. No further information was reported through the completion of the survey. c) NA #57 and NA #1 On 04/01/26, the surveyor asked to review the investigation for the allegation of potential verbal abuse described above. In the file was a typed statement. The statement indicated it was from google.com mail and was sent from an iPhone. However, there was no information regarding the writer of the statement. The statement read as follows: I have worked with [Nurse Aide (NA) #53] in this facility for almost three years. She does come in and do her job, and does not call off ever. Our job is far more than just showing up though. I have seen residents trying to talk to her, and her just walk off. Many residents have told me they know she's mad at them. I have heard her call a certain resident pissy pants, and told him he needed to start using a urinal. That was reported by a nurse at one time also. She has also made the comment about it stinking in there while she was changing him. I know that resident was afraid to use his call light at one point because he didn't want her coming in to change him. Multiple residents have told me she's mean and calls them names. I know she has a nickname for everyone she doesn't like. Working with her got so tense, and hostile You never know what kind of mood she's going to be in, and she doesn't just take it out on her coworkers it is with the residents also. I would work with a resident on one side of the curtain, and [NA #53] on the other side with the other resident. There was multiple times residents would yell out and tell her to be easy, and she would say well roll. I would finish up and go help her so I know what was going on. I never witnessed her physically hurting anyone, but she is mean, and always in a horrible mood. She's shut call lights off without answering them multiple times. I also know that she has reported us to state before. She's the one that went online and reported sexual activitu on red hall. She has told many people about doing it. [NA #1] has told so many lies to so many there. She is as mean as [NA #53]. She's always complaining about having to do her job. Complaining about her coworkers, and how no one ever does their jobs. I've heard her calling the residents nicknames also. She does it at the nurses station talking to other coworkers. I don't hang around and listen to her much. I don't have too much interaction with her. I have had a few residents call her the mean one. I know they are talking about her because they say it's the pregnant one. On 04/01/26 at 1:00 PM, Administrator #47 was asked if the allegations of abuse contained in this statement had been reported and investigated. She was unaware of the source of this statement. On 04/01/26 at 1:27 PM, Administrator #47 stated the allegations of abuse contained in this statement had not been previously reported and investigated. However, the matter had just been reported to the required entities. Additionally, the NAs involved had just been suspended pending investigation. No further information was provided through the completion of the survey process.

Based on record review and staff interview, the facility failed to complete a yearly performance appraisal for direct care staff. This is true for one of five nurse aide performance appraisal's reviewed during this survey. Nurse Aide #52. Facility Census: 60Findings included: a) On 04/01/26 at approximately 4:00 PM, Administrator #47 was asked for Nurse Aide (NA) #52's Performance Appraisal for this year and she reported it is not in the chart. The surveyor asked if they could have the most recent one completed. The performance review delivered to the surveyor was dated 09/16/24. On 4/01/26 at 4:02 PM, a reviewed of Employee Performance Appraisal Form for NA #52 who was hired on 12/14/15 revealed her last performance review was completed on 09/16/24. Review of facility title, HR616 Performance Appraisal states: Managers will meet with their regular full-time, regular part-time, and casual employees at least annually to conduct a performance appraisal or have a performance based conversation. In-service education will be provided based on the outcome of these reviews.

Based on record review and staff interview, the facility failed to ensure complete and accurate medical records. This deficient practice had the potential to affect two (2) of three (3) residents reviewed for the care area of advance directives. Resident Identifiers: #2 and #13. Facility Census: 60.Findings included:a) Resident #2 Review of Resident #2's medical records showed a Physician's Determination of Capacity form dated [DATE] that indicated the resident had capacity to make her own medical decisions. The medical records also showed a Physician Orders for Scope of Treatment (POST) form dated [DATE]. A POST form is a form a resident or their representative completes to specify end-of-life wishes. Resident #2's POST form indicated the resident wanted to receive cardio-pulmonary resuscitation (CPR) and full treatments. Resident #2's POST form had not been signed by the resident. The section stating Patient/Patient MPOA [Medical Power of Attorney representative]/surrogate signature (required) was marked with a small x. Review of Resident #2's admission documents revealed the resident was able to sign her name. According to the document titled, Using the POST form, Guidance for Health Care Professionals, available on-line, this section of the form must be signed to be legally valid. On [DATE] at 12:16 PM, Administrator #47 confirmed Resident #2's POST form had not been signed by the resident.No further information was provided through the completion of the survey process. b) Resident #13 Review of Resident #13's physician's orders showed an order written on [DATE] for No CPR [cardio-pulmonary resuscitation]- Do not attempt Resuscitation. Comfort focused treatment. Maximize comfort through symptom management, allowing natural death. Use oxygen suction and manual treatment of airway obstruction as needed for comfort. Avoid treatments listed in full or selective treatment unless consistent with comfort goals. Transfer to hospital only if comfort cannot be achieved in the current setting.Review of Resident #13's medical records showed the resident was determined to have the capacity to make her own medical decisions upon admission to the facility. The resident completed a POST form indicating she did not want CPR. She also wanted comfort-focused treatments. According to the form, Goal: Maximize comfort through symptom management; allow natural death. Use oxygen suction and manual treatment of airway obstruction as needed for comfort. Avoid treatments listed in full or selective treatment unless consistent with comfort goals. Transfer to hospital only if comfort cannot be achieved in the current setting. On the POST form, the resident authorized permission for her MPOA to make changes to the POST form if lost her decision-making capacity. On [DATE], the physician determined Resident #13 no longer had the capacity to make her own medical decisions. On [DATE], Resident #13's resident representative completed a new POST form, indicating the resident was to receive selective treatments instead of comfort-focused treatments. According to the form, Goal: Attempt to restore function while avoiding intensive care and resuscitation efforts (ventilator, defibrillation, and cardioversion.) May use non-invasive positive airway pressure, antibiotics and IV [intravenous] fluids as indicated. Avoid intensive care. Transfer to hospital if treatment needs cannot be met in current location. Another POST form was completed by Resident #13's resident representative on [DATE] to indicate the resident was to receive medically assisted nutrition if needed. This updated POST form continued to indicate no CPR and selective treatments. Resident #13's comprehensive care plan had a focus related to her end-of-life wishes. The focus had been updated [DATE] and stated, [Resident #13] has an established advanced directive: No CPR- Do not attempt Resuscitation. Selective Treatments. Attempt to restore function while avoiding intensive care if possible (e.g., ventilator, defibrillation).May use non-invasive positive airway pressure, antibiotics, and iv fluids as indicated. Transfer to hospital if treatment needs cannot be met in current location.On [DATE] at 10:24 AM, Senior Administrator #21 confirmed Resident #13's physician's orders for end-of-life treatment did not match the end-of-life treatment wishes indicated on her most recent POST form. No further information was provided through the completion of the survey process.

The facility failed to honor resident choices regarding the things that are important in her life in regards to getting out of bed before lunch. This is true for two (2) of two (2) residents reviewed for choices. Resident identifier: #54. Facility census: 60. Findings Included: a) Resident #54 During an interview with Resident #4 on 03/30/26 at 11:32 AM, the resident expressed frustration regarding a delay in assistance with getting out of bed. She stated that she had been waiting for approximately one (1) hour and noted that her aide had previously mentioned they would return with help but had not yet done so. She stated she must get them early or she don't get up in time. During an interview on 03/30/26 at 11:45 AM with Registered Nurse #30 she stated she would get Resident #54's aide to get her out of bed for lunch. An observation at 12:10 PM found Resident #54 still in bed. A second observation at 12:50 PM found Resident #54 still in bed eating lunch. On 03/30/26 at 12:55 PM during an interview, Clinical Lead #62 stated that she would investigate the situation and follow up. On 03/30/26 at 1:05 PM during an interview Clinical Lead #62 subsequently stated that Resident #54 would be assisted out of bed after she finished eating.

Based on staff interview and surveyor intervention, the facility failed to ensure pre meal hand hygiene was performed on one (1) of two (2) residents reviewed for the care area of infection prevention and control. Resident Identifier #55. Facility Census: 60. Findings included: a) During a dining room observation on 03/31/26 at 12:30 PM, it was noted that Resident #55 was not provided with pre-meal hand cleansing by staff. This was verified at 12:53 PM with Registered Nurse Clinical Lead staff #45, who confirmed that the hand wash was not performed. Upon review of the Infection Control Policies and Procedures for Patient Hand Hygiene provided by the Nursing Home Administrator, the policy states: Staff should assist patients/residents (hereafter 'patient') with hand hygiene after toileting and before meals as needed.

Based on record review and staff interview, the facility failed to ensure required members of the Quality Assurance and Performance Improvement (QAPI) team were present to hold the required quarterly meeting. Facility Census: 65. a) QAPI members On 04/03/25 at 1:10 PM, a review of the sign in sheets for QAPI was completed. The review found the Director of Nursing (DON) position was empty during the dates of 02/19/24 through 04/08/24. There was no one filling in the DON position. Therefore, for the dates of 02/19/24 through 04/08/24, the required members did not attend. On 04/03/25 at 2:30 PM, this time frame was confirmed by the Administrator and the current DON. b) QAPI meetings On 04/03/25 at 2:40 PM, a review of the sign in sheets for QAPI was completed. The review found there were no meetings held in the months of 01/2025, 02/2025 or 03/2025. On 04/03/25 at 3:00 PM, the Administrator confirmed there were no meetings held in 01/2025, 02/2025 or 03/2025.

Based on staff interview and observation, the facility to ensure garbage was disposed of properly. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 65. Findings included: a) Dumpsters On 04/01/25 at 9:55 AM, two dumpsters located behind a wooden fence were observed by a state surveyor. Gloves and food as well as cup lids, straws, plastic forks, and boxes laying around both dumpsters. were found. On garbage dumpster #1 both lids were open with lids laid back. Garbage dumpster #2 was open with the lid broken off. On 04/01/25 at 10:00 AM, the Administrator was notified and the state of the dumpsters were confirmed. The Facility Administrator stated, I see what you are saying. Usually the dumpsters are replaced yearly. We will have to call the company and get a new dumpster. Let me call (Name of the Director of Nursing) and let her know. She is my go to person.

Based on observation, record review, and staff interview, the facility failed to implement or develop comprehensive, person-centered care plans for four (4) of 22 residents. Resident #22's care plan was not implemented regarding a dietary restriction, documenting meal intakes, and for the risk of limited engagement. Resident #31's care plan was not implemented for monitoring of medication side effects and behaviors, pain assessments,and anticoagulation monitoring. The facility failed to develop a care plan for Resident #57 and #59 to include all diagnoses. Resident Identifiers: #22, #31, #57, #59, #25. and #51. Facility Census: 65. Findings included: a) Resident #22 On 03/31/25 at 12:38 PM, the lunch trays arrived at the dining room on A hall. Resident #22 was sitting with another resident. Nurse Aide (NA) #66 sat Resident #22's food in front of her. The resident was sitting in a geri-chair with a clothing protector on, which was covering up her hands. The resident was tearful throughout the entire dining experience. On 03/31/25 at 12:49 PM, Licensed Practical Nurse (LPN) # 78 began feeding the Resident #22. The resident waited 11 minutes before a staff member started assisting her with lunch. LPN #78 was standing while assisting Resident #22 and feed the resident pork, which was listed as a dietary restriction. On 03/31/25 at approximately 1:05 PM, LPN #78 was interviewed regarding the dietary restriction. LPN #78 stated, I didn't know. NA #66 stated, I think its a religious thing NA #66 then stated, I served her the food .I didn't realize it was pork .I laid the lunch ticket over here (on counter behind the resident) . After reviewing the lunch ticket, No Pork is typed on the lunch ticket twice. On 04/01/25 at 9:05 AM, the Director of Nursing (DON) was notified of the issue regarding the dietary restriction for the resident. The DON stated, it is not a religious restriction .I think she just didn't eat pork .I agree the care plan under the focus area of nutritional risk was not implemented due to the intervention listed no pork diet as ordered. On 04/01/25 at 11:10 AM, a telephone interview was held with the Medical Power of Attorney (MPOA). The MPOA was asked, is the dietary restriction for pork due to a religious reason? The MPOA stated, no .she was raised to not eat pork .my grandmother never ate pork On 04/01/25 at 11:30 AM, the care plan intervention under the focus area of nutrition risk was not implemented regarding monitor intake at all meals, offer alternate choices if needed, alert dietician and physician to any decline in intake. On 04/02/25 at 11:00 AM, a further review of the meal intake for the last 30 days from 03/04/25 through 04/01/25 was completed. The review found missing documentation for meal intake for the follwing days: --03/09/25 missing documentation for one (1) meal --03/14/25 missing documentation for one (1) meal --03/19/25 missing documentation for one (1) meal --03/23/25 missing documentation for one (1) meal --03/30/25 missing documentation for one (1) meal On 04/02/25 at 12:19 PM, the DON confirmed the meal intakes were not documented; and, the care plan was not implemented. On 03/31/25 at 12:38 PM, the resident was observed in the dining room. The resident was sitting in a geri-chair with a clothes protector on, covering her hands. The resident was tearful throughout the entire dining experience. On 03/31/25 at 3:15 PM, the resident was observed sitting in a geri-chair. The resident was sitting in a corner, tearful for approximately 20 minutes before a staff member approached her. A review of the care plan on 04/01/25 at 11:30 AM, under the focus area of risk for limited engagement found two (2) interventions in regards to the resident being tearful. The first intervention states, observe for signs and symptoms for tearfulness .offer her Hug'able doll to her and if necessary gently guide her to a calm private location. The second intervention listed is as follows: (Resident name) enjoys watching the (name of program) channel in her room. If you notice signs of tearfulness, .offer to put on the (name of program) channel for her. Quiet time in her room while watching her favorite channel helps to calm her down and comfort her. On 04/02/25 at 12:30 PM, the Director of the Memory Unit (DOMU), confirmed the care plan interventions were not implemented. The DOMU then stated, Sometimes other residents don't want the channel changed .I agree there was no huggable doll around and she could be taken to her room to turn on (name of program). On 04/02/25 at 12:49 PM, the DON confirmed the care plan had not been implemented when the resident became tearful. b) Resident #31 On 04/01/25 at 9:14 PM, a record review for unnecessary medications was completed for Resident #31. The review found the care plan interventions were not being implemented regarding the monitoring of medication side effects and behaviors, pain assessments, and anticoagulation monitoring for 01/2025 and 02/2025. The care plan intervention under the focus area of exhibits or has the potential for .behaviors is monitor medications especially new/changed/discontinued, for side effects and resident's/patient's response to contributing to verbal behaviors. The following dates on the Medication Administration Record (MAR) with no documentation are as follows: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/25 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift The care plan intervention under the focus area of resistive to care is observe for pain. Atttempt non-pharmacologic interventions to alleviate pain. The following dates on the MAR with no documentation are as follows: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/25 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift The care plan intervention under the focus area of risk for injury or complications related to the use of antiplatelet and anticoagulant therapy, observe for active bleeding, (i.e. hematuria, bruising, guaiac + stool, nose bleeds, bleeding gums, etc. The following dates on the MAR with no documentation are as follows: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/25 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift On 04/02/25 at 11:15 AM, the DON confirmed the care plan had not been implemented in these care areas. c) Resident #57 On 04/01/25 at 10:31 AM, a record review was completed for Resident #57. The review found the care plan had not been developed to include all diagnoses. The following diagnoses were not included: --unspecified protein-calorie malnutrition --dysphagia, unspecifed On 04/02/25 at 11:15 AM, the DON confirmed the diagnoses were not developed in the care plan. d) Resident #59 On 04/01/25 at 3:00 PM, a record review was completed for Resident #59. The review found the care plan had not been developed to include all diagnoses. The following diagnoses were not included: --hypertension --hyperlipidemia --osteoporosis --anemia --muscle weakness --muscle spasms On 04/02/25 at 11:15 AM, the DON confirmed the diagnoses were not developed in the care plan. e) Resident # 25 On 04/03/25 at 9:52 AM a review of the medical record for Resident #25 who was admitted on [DATE] with diagnoses of schizoaffective disorder, depressive type, anxiety disorder, major depressive disorder, vascular dementia with agitation, psychotic disorder, seizures and mood disturbance. A review of the care plan found the following: Focus is at risk for complications related to the use of antipsychotic, and antidepessant medications dated created 08/17/23 with revision on 11/23/24. Goal will have the smallest most effective dose without side effects through to next review. Date initiated 08//28/23 and revision date of 04/02/25. Interventions administer medications as ordered, be alert for side effects of antidepressants including: sedation, dry mouth . Initiated 08/14/24 revised on 08/15/24. -Be alert for side effects of antipsychotic medication including: blurred vision, sedation, dry mouth . Initiated 08/14/24 revised 08/15/24. A review of the Medication Administration Record (MAR) found a physicians order on 01/13/25 to Monitor for behaviors: 1. pacing, 2. emotional outbursts. 3. verbal agression every day and night shift. Document number (#) of behaviors if none then 0. A review of the Medication Administration Record (MAR) found a physicians order on 01/13/25 to Monitor for behaviors: 1. refusal of care, 2. physical agression toward staff. 3. delusions every day and night shift. Document number (#) of behaviors if none then 0. The January 2025 MAR had no evidence of monitoring behaviors on the following shifts: 01/14-16/25 day shift and night shift. 01/17/25 for night shift 01/28/28 for nght shift The February 2025 MAR had no evidence of monitoring behaviors on day shift on 02/11-12/25/21/25. The March 2025 MAR found no evidence of behavior monitoring on the following: 03/08/25 for night shift 03/12/25 for day shift 03/15/25 for night shift 03/17/25 for day shift In an interview on 04/03/25 at 8:40 AM with the Administrator, he concurred there were issues with documentation and care plans. f) Resident #51 On 04/03/25 at 9:52 AM a review of the medical record for Resident #51 who was admitted on [DATE] with diagnoses of depression, Alzheimer's, dementia with behavioral disorder and wandering. f) Resident #51 On 04/03/25 at 9:52 AM a review of the medical record for Resident #51 who was admitted on [DATE] with diagnoses of depression, Alzheimer's, dementia with behavioral disorder and wandering. A review of the care plan found the following: Focus is at risk for complications related to the use of antipsychotic, and antidepessant medications dated created 08/17/23 with revision on 11/23/24. Goal will have the smallest most effective dose without side effects through to next review. Date initiated 08//28/23 and revision date of 04/02/25. Interventions administer medications as ordered, be alert for side effects of antidepressants including: sedation, dry mouth . Initiated 08/14/24 revised on 08/15/24. -Be alert for side effects of antipsychotic medication including: blurred vision, sedation, dry mouth . Initiated 08/14/24 revised 08/15/24. A review of the Medication Administration Record (MAR) found a physicians order on 01/13/25 to Monitor for behaviors: 1. pacing, 2. emotional outbursts. 3. verbal agression every day and night shift. Document number (#) of behaviors if none then 0. A review of the Medication Administration Record (MAR) found a physicians order on 01/13/25 to Monitor for behaviors: 1. refusal of care, 2. physical agression toward staff. 3. delusions every day and night shift. Document number (#) of behaviors if none then 0. The January 2025 MAR had no evidence of monitoring behaviors on the following shifts: 01/14-16/25 day shift and night shift. 01/17/25 for night shift 01/28/28 for nght shift The February 2025 MAR had no evidence of monitoring behaviors on day shift on 02/11-12/25. The March 2025 MAR found no evidence of behavior monitoring on the following: 03/09/25 for night shift 03/12/25 for day shift 03/15/25 for night shift 03/17/25 for day shift In an interview on 04/03/25 at 8:40 AM with the Administrator, he concurred there were issues with documentation and care plans.

Based on record review, staff interview, resident interview and observation, the facility failed to prepare and serve food at a safe and appetizing temperature. This failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 65. Findings included: a) The facility's policy and procedure stated, All foods will be held at appropriate temperatures, greater than 135 (degrees) F (or as state regulation requires) for hot holding, and less than 41(degrees) F for cold food holding. b) On 04/01/25 at 12:00 PM, the food holding temperature were taken by the Corporate Dietary Manager #83. The following temperatures were obtained: -Holding Temperatures for lunch meal: Lettuce 51.8 - put in freezer Shredded Lettuce 50 - put in freezer Fish - 164.2 Potato Wedges - 183.7 Ground Fish - 181.5 Advanced Mechanical Soft potato wedges - 191.1 (skin off) Meatballs - 195.2 Pureed peaches - 40.3 Rice - 184.2 Pureed rice - 182.1 Pureed fish - 194.7 Peaches - 40.9 Cottage cheese - 39.4 Pureed rice - 172.4 Pureed bread - 170 Fortified pudding - 39.4 The regular leaf lettuce, shredded lettuce and tomatoes were placed in the refrigerator to cool. Final temperatures at 12:16 PM were: Lettuce - 49.4 Shredded lettuce - 45.2 Tomatoes - 52.9 The Corporate Dietary Manager #83 asked the state surveyor, Do you want us to serve? referring to the lettuce and tomato. The state surveyor responded by saying they couldn't tell him to serve or not to serve. Lettuce and tomatoes were not served. No substitution was given for vegetable. c) On 04/01/25 at 12:55 PM, a temperature test tray was taken to B/Blue Wing to check the temperature. Temperatures were taken and confirmed by Corporate Dietary Manager #83. Temperatures were as follows: Fish sandwich - 127.7 Potato wedges - 113.1 Peaches - 96.6

Based on record review and staff interview, the facility failed to ensure care plans were revised for Residents #42 fall, #22 dependent for meals, #57 independent for mobility, #4 full code, #23 give fluids when NPO, and #28 hospice when not ordered. These failed practices affected more than a limited number of residents. Resident identifiers: #42, #22, #57, #4, #23, and #28. Facility census: 65. Findings included: a) Resident #42 On [DATE] at approximately 11:00 AM, a record review was completed for Resident #42. The review found the resident had a fall on [DATE]. An x-ray was completed with no abnormalities found. However, the resident continued to complain with pain upon movement. A computed tomography scan (CT ) was ordered by the facility physician on [DATE]. The CT results were received on [DATE], with the following finding:There are fractures of the left superior and inferior rami, there is also a fracture through the left side of the sacrum. The care plan was reviewed on [DATE] at 11:15 AM. The care plan had not been revised indicating the resident had a fall with injury. The care plan focus area states, Resident is at risk for falls . On [DATE] at 12:19 PM, the Director of Nursing (DON) confirmed the care plan had not revised to indicate the resident had an actual fall with major injury. b) Resident #22 On [DATE] at 11:30 AM, a record review was completed for Resident #22. The care plan under the focus area of Resident requires assistance with activities of daily living (ADL) states the resident is set up assist with eating. However, on [DATE] at 12:38 PM, an observation of the resident being feed per staff was made. On [DATE] at 12:19 PM, the DON confirmed the care plan had not been revised to indicate the resident is dependent at times for meals. c) Resident #57 On [DATE] at 10:31 AM, a record review was completed for Resident #57. The care plan was reviewed and found an intervention of provide resident/patient with supervision ambulating using a walker. However, throughout the survey, from [DATE] through [DATE], no observations of the resident using a walker were made. The resident does walk with a bended at waist gait. This type of gait is due to the resident's diagnosis of Parkinson's disease. On [DATE] at 1:11 PM, the DON was interviewed regarding Resident #57's ability to ambulate. The DON stated, when he first came here he used a walker, but now with the dementia he doesn't know what to do with a walker. The DON confirmed the resident ambulated independently and the care plan had not been revised. d) Resident #4 The facility failed to revise Resident #4's care plan for a change in Code status. On [DATE] at 8:52 AM, the resident's order stated, No CPR- Do not attempt Resuscitation. Comfort focused treatment. Maximize comfort through symptom management, allowing natural death. Use oxygen suction and manual treatment of airway obstruction as needed for comfort. Avoid treatments listed in full or selective treatment unless consistent with comfort goals. Transfer to hospital only if comfort cannot be achieved in the current setting. No artificial means of nutrition. No directions specified for order. The Resident #4's care plan stated, the resident has an established advanced directive of FULL CODE Full Code- Attempt to sustain life by all medically effective means. Provide appropriate medical and surgical treatment as indicated to attempt to prolong life, including intensive care. On [DATE] at 04:12 PM, the resident's updated POST form, dated and signed [DATE], was obtained. The POST form was marked, No CPR: Do Not Attempt Resuscitation and Comfort -focused Treatments. The DON confirmed the resident's care plan stated the resident's advanced directive was for a full code. e) Resident #23 The facility failed to revise Resident #23's care plan to reflect a change in advance directives for an alternate means of nutrition and encourage fluids with meals for an NPO (nothing by mouth) resident. On [DATE] at 2:22 PM, the resident's physician order stated, Full Code- Attempt to sustain life by all medically effective means. Provide appropriate medical and surgical treatment as indicated to attempt to prolong life including intensive care. No artificial means of nutrition desired. No directions specified for order. The resident's current care plan stated, Resident #23 has a HCS and Full Code- Attempt to sustain life by all medically effective means. Provide appropriate medical and surgical treatment as indicated to attempt to prolong life including intensive care. No artificial means of nutrition desired. The resident's orders stated NPO with Enternal Feed. On [DATE] at 04:10 PM, the Director of Nursing confirmed the resident's care plan stated, No artificial means of nutrition desired. On [DATE] at 8:45 AM, the DON confirmed, Resident #23's care plan stated Encourage resident to consume all fluids of choice during meals. Resident's current diet order stated, NPO (nothing by mouth) diet. f) Resident #38 The facility failed to revise Resident #38's care plan who is not receiving hospice services. No order was found on the resident's medical chart for hospice services. The resident's care plan stated, Notify Hospice of yet another fall with minor injury to gain (name of hospice) input for plan of care (POC) intervention., (Name of hospice) to provide resident with a wheelchair with cushion to help enhance independence. and Resident will achieve acceptable level of pain control, as defined by the patient through his hospice care. On [DATE] at 10:15 AM, the DON confirmed, the resident's care plan stated the resident was receiving Hospice Services. No resident in the facility was receiving hospice services at this time per report. 45173 51553

Based on record review and staff interview, the facility failed to complete a change in condition (CIC) for Resident #22's development of a pressure ulcer on the right heel. This was a random opportunity for discovery. Resident Identifier: #22. Facility Census: 65. Findings Include: a) Resident #22 On 03/31/25 at 2:30 PM, a progress note was reviewed. The progress note dated 03/31/25 at 1:16 PM stated, Resident has a blister to her right heel. NP (Nurse Practitioner) in facility this morning and visited resident. New order for Sure Prep to right heel BID (twice daily). POA (Power of Attorney) notified and in agreement with order. (Typed as written.) Upon further review, no change in condition was found for Resident #22. On 04/01/25 at 2:00 PM, an interview was held with the Director of Nursing (DON). The DON confirmed the resident did have a blister to the right heel and no change in condition had been completed.

Based on observation, record review and staff interview, the facility failed to provide care in a manner and environment that promoted a dignified dining experience for the residents. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #61, #50, #22, #57, #1, #2, #29. Facility Census: 65. Findings included: a) On 03/31/25 at 12:55 PM, during the dining observation, resident's were not seated at the same time at tables, the lunch meal did not arrive at the same time for resident's at the same table, six (6) residents were left seated in the center of the dining room while the other resident's were at their tables and served beverages and lunch meals and clothing protectors were placed on residents without asking their preference. At 1:05 PM, Resident #61 tried multiple times to feed Resident #50 from their tray. The state surveyor intervened for staff to re-direct the resident. Resident #50 received the lunch tray at 1:13 PM. Resident #1 was fed at 01:32 PM after the tablemate's lunch had been fed beginning at 1:12 PM. Staff began feeding Resident #2 at 1:16 PM at the same table as Resident #29. Resident #29 was continuously reaching for her tray on table which was moved out of reach by staff. Resident #29 was fed her lunch tray in the dining room after 1:45 PM. Resident's #29's food was on the table the whole time. The facility's policy and procedure stated, Meals are served table by table. 45173 b) Resident #22 On 03/31/25 at 12:38 PM, the lunch trays arrived at the dining room on A hall. Resident #22 was sitting with another resident. Nurse Aide (NA) #66 sat Resident #22's food in front of her. The resident was sitting in a geri-chair with a clothing protector on, which was covering up her hands. The resident was tearful throughout the entire experience. On 03/31/25 at 12:49 PM, Licensed Practical Nurse (LPN) # 78 began feeding the Resident #22. The resident waited 11 minutes before a staff member started assisting the resident with lunch. LPN #78 was standing while assisting Resident #22. On 03/31/25 at approximately 1:05 PM, LPN #78 was interviewed regarding standing while feeding the resident and the resident's wait time for meal assistance. LPN #78 stated, I didn't know. On 04/01/25 at 9:05 AM, the Director of Nursing (DON) was notified of the issue regarding the dignity of the resident during meal time. The DON stated, I will give the nurse education. c) Resident #57 On 03/31/25 at 12:38 PM, the lunch trays arrived at the dining room on A hall. Resident #57 was seated with two (2) other residents at the table. The resident did not receive his food until 12:43 PM, which was five (5) minutes, while the other residents were eating their meals. On 04/01/25 at 9:05 AM, the DON was notified. The DON stated, We are working on meals .Dietary does not put the trays in the cart by rooms. They are loading them on the cart randomly.

Based on observation, staff interview and record review, the facility failed to ensure food was stored properly and food preparation equipment was clean. This failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 65. Findings included: a) The facility's policy and procedure stated, All foods are labeled and dated with the name of the product and the date received and use by date once opened. Manufacturer use by dates are used unit opened. Prepared foods are labeled and dated with the name of product, date opened, and use by date. b) On 03/31/25 at 11:25 PM, the Kitchen Investigation was initiated with the Corporate Dietary Manager #83. The following items were observed and confirmed: Frozen chicken breast in an opened ziploc with no dates on the package. Imperial Beef Base was opened and not dated. Celery and Lettuce were opened, uncovered in a box and not dated. Sandwich bread was opened and not dated. The Corporate Dietary Manager #83 asked, Do we need a use by date? c) On 04/01/25 at 10:40 AM, the pantry on the Memory Unit contained an opened can of Dr. Pepper with tape over opening. An open date only was written on the can and no use by date. The finding was confirmed by Memory Support Director #52. She stated, I will get rid of that ASAP. d) On 04/01/25 at 04/01/25 11:55 AM, the pantry on C hall contained a resident's sherbet opened and not dated, Hormel Thick and Easy - Honey Thick water opened with no date range/use by date, and resident's snacks (fortified pudding and applesauce) with no date range/use by date. These findings were confirmed by Licensed Practical Nurse(LPN) #11. e) The sink behind the dining room serving center for handwashing had a brown substance in the sink bowl and no trash can to dispose of paper towels/garbage. The Corporate Dietary Manager #83 stated, We don't serve here. Dried food on the outside of the refrigerator in the kitchen was confirmed by the manager.

Based on observation, staff interview and record review, the facility failed to ensure daily menus were followed. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 65. Findings included: a) The facility's menu for 03/31/25 was BBQ Pork on Roll, Gelatin Cubes with Whipped Topping and Potato Chips. The BBQ was served on white sandwich bread in the Dining Room and on the hallways per states surveyors' observations. Resident #10, #56 and #26 were on regular diets and all three residents received light bread in place of a roll. Resident #26 demonstrated difficulty picking up and eating the BBQ on light bread. On 04/01/25 at 12:00 PM, the Corporate Dietary Manager #83 confirmed there were no buns/rolls served for the BBQ yesterday. The Corporate Dietary Manager #83 stated, No, we did not. and that the bread truck ran this date. b) The facility's menu for 04/01/25 was Breaded Fish Filet on Roll, Tartar Sauce, Lettuce and Tomato Garnish, Sliced Peaches and Seasoned Potato Wedges. Lettuce and tomato garnish was not served due to serving temperatures.

Based on record review and staff interview, the facility failed to have sufficient staffing for the B hall on 03/29/25 and 03/30/25. This failure has the potential to affect more than a limited number of residents. Facility Census: 65. Findings Include: a) B hall residents On 04/03/25 at 11:30 AM, the daily staff postings were reviewed for 03/29/25 and 03/30/25. The review found only two (2) nurses scheduled for both dates; one (1) on the red hall and one (1) on the blue hall. The red hall has 26 beds and the blue hall had a census of 42 residents. No other nurse was scheduled on the blue hall during day shift. The nurse schedule provided had noted a need for day shift on 03/29/25 and 03/30/25. The daily nursing hours per patient day were above the minimum; but, multiple medications were late and multiple treatment orders were incomplete. The acuity of the residents was higher on these days with only one (1) nurse on the blue hall. The following list of late medications for each resident is as follows: --Resident #28 -03/29/25 Neurontin 300mg (milligram) by mouth three times daily--ordered for 2:00 PM; given at 3:42 PM. This was one hour and 42 minutes late. -03/29/25 Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3ml (milliters) inhale orally three times daily--ordered for 2:00 PM; given at 3:42 PM. This was one hour and 42 minutes late. --Resident #62 -03/30/25 Midodrine 10mg by mouth three times daily--ordered for 9:00 AM; given at 11:32 AM. This is two hours and 32 minutes late. -03/30/25 Zinc 50mg by mouth daily--ordered for 9:00 AM; given at 11:32 AM. This is two hours and 32 minutes late. -03/30/25 Glimepiride 1mg by mouth daily--ordered for 9:00 AM; given at 11:32 AM. This is two hours and 32 minutes late. -03/30/25 Diltiazem 90mg give 2 capsules by mouth daily--ordered for 9:00 AM; given at 11:32 AM. This is two hours and 32 minutes late. --Resident #49 -03/30/25 Losartan Potassium 100mg by mouth daily--ordered for 10:00 AM; given at 11:40 AM. This is one hour and 40 minutes late. -03/30/25 Metoprolol Succinate 100mg by mouth daily--ordered for 10:00 AM; given at 11:40 AM. This is one hour and 40 minutes late. l --03/30/25 Farxiga 10mg by mouth daily--ordered for 10:00 AM; given at 11:39 AM. This is one hour and 39 minutes late. -03/30/25 Spironolactone 25mg by mouth daily--ordered for 10:00 AM; given at 11:39 AM. This is one hour and 39 minutes late. -03/30/25 Apixaban 5mg by mouth two times daily--ordered for 10:00 AM; given at 11:39 AM. This is one hour and 39 minutes late. -03/30/25 Divalproex 500mg by mouth two times daily--ordered for 10:00 AM; given at 11:39 AM. This is one hour and 39 minutes late. --Resident #37 -03/30/25 Duloxetine 20mg by mouth daily--ordered for 8:00 AM; given at 9:54 AM. This is one hour and 54 minutes late. --03/30/25 Farxiga 10mg by mouth daily--ordered for 8:00 AM; given at 9:54 AM. This is one hour and 54 minutes late. -03/30/25 Amlodipine Besylate 10mg by mouth daily--ordered for 8:00 AM; given at 9:54 AM. This is one hour and 54 minutes late. -03/30/25 Folic Acid 1mg by mouth daily--ordered for 8:00 AM; given at 9:54 AM. This is one hour and 54 minutes late. -03/30/25 Quetiapine Furmarate 25mg 1/2 tablet by mouth daily--ordered for 8:00 AM; given at 9:55 AM. This is one hour and 55 minutes late. -03/30/25 Magnesium Oxide 400mg by mouth daily--ordered for 8:00 AM; given at 9:54 AM. This is one hour and 54 minutes late. -03/30/25 Potassium Chloride 10meq (milliequivilant) by mouth daily--ordered for 8:00 AM; given at 9:55 AM. This is one hour and 55 minutes late. -03/30/25 Lisinopril 10mg by mouth daily--ordered for 8:00 AM; given at 9:54 AM. This is one hour and 54 minutes late. -03/30/25 Senna 8.6mg by mouth twice daily--ordered for 8:00 AM; given at 9:55 AM. This is one hour and 55 minutes late. -03/30/25 Thiamine 100mg by mouth daily--ordered for 8:00 AM; given at 9:55 AM. This is one hour and 55 minutes late. -03/30/25 Metoprolol Tartrate 50mg by mouth twice daily--ordered for 8:00 AM; given at 9:55 AM. This is one hour and 55 minutes late. -03/30/25 Basaglar 75 units subcutaneous daily--ordered for 8:00 AM; given at 9:56 AM. This is one hour and 56 minutes late. --Resident #23 -03/29/25 Enteral feed Jevity 1.5 calories 474 ml three times daily--ordered for 5:00 PM; given at 7:10 PM. This is 2 hours and 10 minutes late. --Resident #36 -Tylenol Extra Strength 500mg give 2 tablets by mouth twice daily--ordered for 10:00 AM; given at 11:47 AM. This is one hour and 47 minutes late. -Glycolax Powder give 17 grams by mouth daily--ordered for 10:00 AM; given at 11:47 AM. This is one hour and 47 minutes late. --Resident #8 -Protonix 40mg by mouth twice daily--ordered for 9:00 AM; given at 10:52 AM. This is one hour and 52 minutes late. -Escitalopram 5mg by mouth daily--ordered for 9:00 AM; given at 10:52 AM. This is one hour and 52 minutes late. -Tylenol Extra Strength 500mg by mouth three times a day--ordered for 9:00 AM; given at 10:52 AM. This is one hour and 52 minutes late. --Resident #7 -03/29/25 Sertraline 25mg by mouth daily--ordered for 9:00 AM; given at 10:57 AM. This is one hour and 57 minutes late. --Resident #41 -03/30/25 Cymbalta 20mg by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Zinc 220mg by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Colace 100mg by mouth twice daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Metformin 1000mg by mouth twice daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Protonix 40mg by mouth twice daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Synthroid 100mcg (microgram) by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Farxiga 10mg by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Eliquis 5mg by mouth twice daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Sitagliptin 25mg by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Furosemide 40mg by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Digoxin 125mcg by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. --Resident #50 -03/29/25 Tylenol Extra Strength 500mg give 2 tablets twice daily--ordered for 9:00 AM; given at 11:09 AM. This is two hours and 9 minutes late. -03/29/25 Protonix 40mg daily--ordered for 9:00 AM; given at 11:09 AM. This is two hours and 9 minutes late. -03/29/25 Aspirin 81mg daily--ordered for 9:00 AM; given at 11:09 AM. This is two hours and 9 minutes late. -03/29/25 Omeprazole 20mg twice daily--ordered for 9:00 AM; given at 11:09 AM. This is two hours and 9 minutes late. -03/29/25 Buspar 10mg daily--ordered for 9:00 AM; given at 11:09 AM. This is two hours and 9 minutes late. The following physician's orders for resident treatments were not followed: --Resident #9 -03/29/25 apply antifungal to bilateral groin areas twice daily--no documentation for day shift -03/30/25 apply antifungal to bilateral groin areas twice daily--no documentation for day shift --03/29/25 cleanse MASD to left buttock with no-rinse foaming wash and pat dry. Apply calazime cream to open areas only. Apply hydroguard to surrounding skin every day and night shift --no documentation for day shift --03/30/25 cleanse MASD to left buttock with no-rinse foaming wash and pat dry. Apply calazime cream to open areas only. Apply hydroguard to surrounding skin every day and night shift --no documentation for day shift --Resident #41 -03/29/25 Eye scrubs: mix baby shampoo with warm water, gently wipe each eye separately, rinse with warm water and pat dry, using clean technique every day and night shift--no documentation for day shift. -03/30/25 Eye scrubs: mix baby shampoo with warm water, gently wipe each eye separately, rinse with warm water and pat dry, using clean technique every day and night shift--no documentation for day shift. -03/29/25 Cleanse ulcer to right lower extremity with normal saline, pat dry, apply collagen particles, cover with hydrogel impregnated gauze, wrap with kerlix, and secure with ace wrap every Tuesday, Thursday and Saturday--no documentation for day shift. --Resident #50 -03/29/25 Cleanse bilateral buttocks and scrotum with warm water and mild soap, rinse and dry completely. Apply barrier cream after episodes of incontinence--no documentation for day shift. -03/30/25 Cleanse bilateral buttocks and scrotum with warm water and mild soap, rinse and dry completely. Apply barrier cream after episodes of incontinence--no documentation for day shift. -03/29/25 Hydrocortisone External Cream 2.5% Apply to face, back and thighs every day and night shift--no documentation for day shift. -03/30/25 Hydrocortisone External Cream 2.5% Apply to face, back and thighs every day and night shift--no documentation for day shift. --Resident #20 -03/29/25 Apply Ammonium Lactate External cream to bilateral lower legs every day and night shift--no documentation for day shift. -03/30/25 Apply Ammonium Lactate External cream to bilateral lower legs every day and night shift--no documentation for day shift. -03/29/25 Silver Sulfadiazine cream 1% apply to bilateral groin and buttocks every day and night shift--no documentation for day shift. -03/30/25 Silver Sulfadiazine cream 1% apply to bilateral groin and buttocks every day and night shift--no documentation for day shift. --Resident #63 -03/29/25 Apply barrier cream to MASD to sacrum every day and night shift--no documentation for day shift. -03/30/25 Apply barrier cream to MASD to sacrum every day and night shift--no documentation for day shift. -03/29/25 Cleanse surgical incision to right shoulder with wound cleanser, pat dry, cover with dry dressing every day and night shift--no documentation for day shift. -03/30/25 Cleanse surgical incision to right shoulder with wound cleanser, pat dry, cover with dry dressing every day and night shift--no documentation for day shift. --Resident #42 -03/29/25 Cleanse right heel DTI with normal saline, pat dry, apply betadine to area and cover with foam dressing. Secure with kerlix and tape every Tuesday, Thursday and Saturday--no documentation for day shift. --Resident #58 -03/29/25 Apply kerlix and coban starting behind the toes up to below the knee on bilateral lower extremities every 3 days per Vascular Surgery--no documentation for day shift. --Resident #61 -03/29/25 Enteral Feed: Cleanse site daily with soap and water every day shift--no documentation for day shift. -03/30/25 Enteral Feed: Cleanse site daily with soap and water every day shift--no documentation for day shift. -03/29/25 Monitor surgical incision to right rear head for possible signs/symptoms of infection every day and night shift-no documentation for day shift. -03/30/25 Monitor surgical incision to right rear head for possible signs/symptoms of infection every day and night shift-no documentation for day shift. --Resident #23 -03/29/25 Cleanse PEG site with normal saline moistened gauze and pat dry, apply bacitracin and a split gauze and secure with tape every day shift--no documentation for day shift. -03/30/25 Cleanse PEG site with normal saline moistened gauze and pat dry, apply bacitracin and a split gauze and secure with tape every day shift--no documentation for day shift. --Resident #10 -03/29/25 Acetic Acid Irrigation Solution 0.25% use 30 cc (cubic centimeters) via irrigation every day and night shift for occlusion--no documentation for day shift. -03/30/25 Acetic Acid Irrigation Solution 0.25% use 30 cc (cubic centimeters) via irrigation every day and night shift for occlusion--no documentation for day shift. -03/29/25 Apply z-guard to buttocks every day and night shift for MASD--no documentation for day shift. -03/30/25 Apply z-guard to buttocks every day and night shift for MASD--no documentation for day shift. --Resident #15 -03/29/25 Apply skin prep daily to arterial ulcers to 1st, 2nd and 3rd digits. Notify provider if any signs/symptoms of infection every day shift--no documentation for day shift. -03/30/25 Apply skin prep daily to arterial ulcers to 1st, 2nd and 3rd digits. Notify provider if any signs/symptoms of infection every day shift--no documentation for day shift. --Resident #17 -03/29/25 Monitor left foot for any skin changes related to incident where foot was ran over with a wheel chair x one week. Notify physician if any changes occur every day shift--no documentation for day shift. -03/30/25 Monitor left foot for any skin changes related to incident where foot was ran over with a wheel chair x one week. Notify physician if any changes occur every day shift--no documentation for day shift. --Resident #267 -03/29/25 Apply skin prep outer great left toe every day shift DTI--no documentation for day shift. -03/30/25 Apply skin prep outer great left toe every day shift DTI--no documentation for day shift. --Resident #268 -03/29/25 Monitor surgical incision to left hip, Report any signs/symptoms of infection to provider. Cleanse area with wound cleanser, Pat dry. May leave open to air if no drainage every day and night shift--no documentation for day shift. -03/30/25 Monitor surgical incision to left hip, Report any signs/symptoms of infection to provider. Cleanse area with wound cleanser, Pat dry. May leave open to air if no drainage every day and night shift--no documentation for day shift. On 04/03/25 at 3:30 PM, the DON confirmed the physician's orders were not followed for medication administration or treatments were completed. The DON stated, I don't know what happened those days .I was out-of-town. failed to provide sufficient staffing for the B hall. ASC PS & all findings FACILITY Sufficient and Competent Nurse Staffing 04/03/25 09:18 AM The daily staff posting is hanging at the nurses station. Review of NHPPD 05/27/24 2.89 07/06/24 2.71 08/19/24 2.80 09/03/24 3.31 11/01/24 2.84 11/29/24 2.91 12/26/24 2.65 RN punches 12/14/24 [NAME] Young 12.78 06/09/24 [NAME] 12.35 06/09/24 [NAME] 12.28 07/06/24 [NAME] Young 13.30 08/18/24 [NAME] Young 13.12 09/02/24 [NAME] 12.00 10/31/24 [NAME] 8.00 11/29/24 [NAME] 13.00 Annual evaluation/Staff Education & Competencies Brooke [NAME] 12/14/24---04/24/24 [NAME] 07/28/24---04/24/24 Reydhen Maylig 12/14/24---04/24/24 [NAME] 01/11/25---04/22/24 [NAME] 09/05/24---04/22/24 Interviews with staff 04/03/25 9:50 AM RN #26 we are mandated if needed---I haven't been mandated for a couple of months .no I don't feel like I have enough time .I do my treatments and charting in the evening (12 hour shifts). I'm supposed to get a new nurse who will take another med cart .she starts next week yes we have agency. Last weekend we didn't get coverage for a call in .I had 42 residents. 04/03/25 10:05 AM NA #41 we have mandation days .we take turns too .in the last month I've gotten mandated 2 times .no I feel I have to rush with care so the little things have to wait like straightening up their rooms and nail care .I work 12 hour shifts 3xs a week. Interview with DON 04/03/25 10: for staffing if there are shifts that need covered we use team reach (mass texting system) then we use mandation--per union rules it starts with the people with less seniority then they go to the bottom of the list and we just go down the list. If we still can't get it covered then we have on-call unit managers and ADONs who can cover .we all walk the halls to answer call lights. CNA ratio is 1:10 residents. Daily staffing postings were reviewed for 03/29/25 and 03/20/25. There were two (2) nurses scheduled; one on the red hall and one on the blue hall. The red hall has 26 beds and the blue hall has 42 residents who reside on the blue hall. One nurse had 42 residents. No other nurse was scheduled on the blue hall during day shift. Both of the days, 03/29/25 and 03/30/25, had multiple late medications administered. The treatments were reviewed for both days and

Based on record review and staff interview, the facility failed to ensure physician orders were followed. medications were administered timely, behaviors, and pain were monitored. This had the potential to affect more than a limited number of residents. Resident identifiers: #31, #22, #59, #57, #25, #51 and facility late mdications, #28, #49, #37, #23, #36, #8, #7, $41, #50, #9, #41, #50, #20, #63, #42, #58, #61, #23, #10, #15, #17, #267, and #268. Facility census: 65. Findings included: a) Resident #31 On 04/01/25 at 9:30 AM, a record review was completed for Resident #31. The review found the physician's orders were not being followed on the 01/2025 and 02/2025 medication administration records (MARs). The following physician's orders and dates are as follows: --Anticoagulant Medication Monitoring: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --Monitor for Behaviors: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --Ask resident if they are having pain: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --Monitor swallowing during med pass: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --Antiembolism monitoring: --02/11/25 --02/12/25 On 04/01/25 at 12:19 PM, the Director of Nursing (DON) confirmed the physician's orders were not followed. b) Resident #22 On 03/31/25 at 12:38 PM, an observation was made of the resident being fed pork at lunch time. On 03/31/25 at 2:00 PM, the physician's orders were reviewed for Resident #22. The review found a physician's order for regular, dysphagia advanced texture, standard thin liquids consistency, no pork or pork products. Send finger foods when possible. On 04/01/25 at 11:30 AM, the DON confirmed the physician's order was not followed regarding the dietary restriction of no pork. c) Resident #59 On 04/01/25 at 10:00 AM, a record review was completed for Resident #59. The review found the physician's orders were not being followed on the MARs for 01/2025, 02/2025 and 03/2025. The following physician's orders and dates are as follows: --Ask resident if they are having pain: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --03/08/25 night shift --03/12/25 day shift --03/15/25 night shift --03/17/25 day shift --Is resident free from adverse/side effects of antidepressant medication: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --03/08/25 night shift --03/12/25 day shift --03/15/25 night shift --03/17/25 day shift --Is resident free from adverse/side effects of antipsychotic: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --03/08/25 night shift --03/12/25 day shift --03/15/25 night shift --03/17/25 day shift --Monitor for behaviors: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --03/08/25 night shift --03/12/25 day shift --03/15/25 night shift --03/17/25 day shift --Monitor swallowing during med pass: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --03/08/25 night shift --03/12/25 day shift --03/15/25 night shift --03/17/25 day shift --Is resident free from adverse/side effects of antimanic/antiseizure medication: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --03/08/25 night shift --03/12/25 day shift --03/15/25 night shift --03/17/25 day shift On 04/01/25 at 12:19 PM, the Director of Nursing (DON) confirmed the physician's orders were not followed. d) Resident #57 On 04/01/25 at 10:00 AM, a record review was completed for Resident #57. The review found the physician's orders were not being followed on the MARs for 01/2025, 02/2025 and 03/2025. The following physician's orders and dates are as follows: --Ask resident if they are having pain: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --03/08/25 night shift --03/12/25 day shift --03/15/25 night shift --03/17/25 day shift --Monitor for behaviors: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --03/08/25 night shift --03/12/25 day shift --03/15/25 night shift --03/17/25 day shift --Monitor swallowing during med pass: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --03/08/25 night shift --03/12/25 day shift --03/15/25 night shift --03/17/25 day shift --Ketoconazole Shampoo 2% apply to scalp topically every day shift Monday, Wednesday, Saturday for tinea versicolor --01/23/25 --03/12/25 On 04/01/25 at 12:19 PM, the Director of Nursing (DON) confirmed the physician's orders were not followed. e) Resident # 25 On 04/03/25 at 9:52 AM a review of the medical record for Resident #25 who was admitted on [DATE] with diagnoses of schizoaffective disorder, depressive type, anxiety disorder, major depressive disorder, vascular dementia with agitation, psychotic disorder, seizures and mood disturbance. A review of the care plan found the following: Focus is at risk for complications related to the use of antipsychotic, and antidepessant medications dated created 08/17/23 with revision on 11/23/24. Goal will have the smallest most effective dose without side effects through to next review. Date initiated 08//28/23 and revision date of 04/02/25. Interventions administer medications as ordered, be alert for side effects of antidepressants including: sedation, dry mouth . Initiated 08/14/24 revised on 08/15/24. -Be alert for side effects of antipsychotic medication including: blurred vision, sedation, dry mouth . Initiated 08/14/24 revised 08/15/24. A review of the Medication Administration Record (MAR) found a physicians order on 01/13/25 to Monitor for behaviors: 1. pacing, 2. emotional outbursts. 3. verbal agression every day and night shift. Document number (#) of behaviors if none then 0. A review of the Medication Administration Record (MAR) found a physicians order on 01/13/25 to Monitor for behaviors: 1. refusal of care, 2. physical agression toward staff. 3. delusions every day and night shift. Document number (#) of behaviors if none then 0. The January 2025 MAR had no evidence of monitoring behaviors on the following shifts: 01/14-16/25 day shift and night shift. 01/17/25 for night shift 01/28/28 for nght shift The February 2025 MAR had no evidence of monitoring behaviors on day shift on 02/11-12/25/21/25. The March 2025 MAR found no evidence of behavior monitoring on the following: 03/08/25 for night shift 03/12/25 for day shift 03/15/25 for night shift 03/17/25 for day shift f) Resident #51 On 04/03/25 at 9:58 AM a review of the medical record for Resident #51 who was admitted on [DATE] with diagnoses of depression, Alzheimer's, dementia with behavioral disorder and wandering. A review of the care plan found the following: Focus is at risk for complications related to the use of antipsychotic, and antidepessant medications dated created 08/17/23 with revision on 11/23/24. Goal will have the smallest most effective dose without side effects through to next review. Date initiated 08//28/23 and revision date of 04/02/25. Interventions administer medications as ordered, be alert for side effects of antidepressants including: sedation, dry mouth . Initiated 08/14/24 revised on 08/15/24. -Be alert for side effects of antipsychotic medication including: blurred vision, sedation, dry mouth . Initiated 08/14/24 revised 08/15/24. A review of the Medication Administration Record (MAR) found a physicians order on 01/13/25 to Monitor for behaviors: 1. pacing, 2. emotional outbursts. 3. verbal agression every day and night shift. Document number (#) of behaviors if none then 0. A review of the Medication Administration Record (MAR) found a physicians order on 01/13/25 to Monitor for behaviors: 1. refusal of care, 2. physical agression toward staff. 3. delusions every day and night shift. Document number (#) of behaviors if none then 0. The January 2025 MAR had no evidence of monitoring behaviors on the following shifts: 01/14-16/25 day shift and night shift. 01/17/25 for night shift 01/28/28 for nght shift The February 2025 MAR had no evidence of monitoring behaviors on day shift on 02/11-12/25. The March 2025 MAR found no evidence of behavior monitoring on the following: 03/09/25 for night shift 03/12/25 for day shift 03/15/25 for night shift 03/17/25 for day shift g) Facility On 04/03/25 at 11:30 AM, the daily staff postings were reviewed for 03/29/25 and 03/30/25. The review found only two (2) nurses scheduled for both dates; one (1) on the red hall and one (1) on the blue hall. The red hall has 26 beds and the blue hall had a census of 42 residents who reside on the blue hall. No other nurse was scheduled on the blue hall during day shift. The nurse schedule provided had noted a need for day shift on 03/29/25 and 03/30/25. The daily nursing hours per patient day was above the minimum; but, multiple medications were late and multiple treatment orders were incomplete. The acuity of the residents was higher on these day with only one (1) nurse on the blue hall. The following list of late medications for each resident is as follows: Resident #28 -03/29/25 Neurontin 300mg (milligram) by mouth three times daily--ordered for 2:00 PM; given at 3:42 PM. This was one hour and 42 minutes late. -03/29/25 Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3ml (milliters) inhale orally three times daily--ordered for 2:00 PM; given at 3:42 PM. This was one hour and 42 minutes late. Resident #62 -03/30/25 Midodrine 10mg by mouth three times daily--ordered for 9:00 AM; given at 11:32 AM. This is two hours and 32 minutes late. -03/30/25 Zinc 50mg by mouth daily--ordered for 9:00 AM; given at 11:32 AM. This is two hours and 32 minutes late. -03/30/25 Glimepiride 1mg by mouth daily--ordered for 9:00 AM; given at 11:32 AM. This is two hours and 32 minutes late. -03/30/25 Diltiazem 90mg give 2 capsules by mouth daily--ordered for 9:00 AM; given at 11:32 AM. This is two hours and 32 minutes late. Resident #49 -03/30/25 Losartan Potassium 100mg by mouth daily--ordered for 10:00 AM; given at 11:40 AM. This is one hour and 40 minutes late. -03/30/25 Metoprolol Succinate 100mg by mouth daily--ordered for 10:00 AM; given at 11:40 AM. This is one hour and 40 minutes late. l --03/30/25 Farxiga 10mg by mouth daily--ordered for 10:00 AM; given at 11:39 AM. This is one hour and 39 minutes late. -03/30/25 Spironolactone 25mg by mouth daily--ordered for 10:00 AM; given at 11:39 AM. This is one hour and 39 minutes late. -03/30/25 Apixaban 5mg by mouth two times daily--ordered for 10:00 AM; given at 11:39 AM. This is one hour and 39 minutes late. -03/30/25 Divalproex 500mg by mouth two times daily--ordered for 10:00 AM; given at 11:39 AM. This is one hour and 39 minutes late. Resident #37 -03/30/25 Duloxetine 20mg by mouth daily--ordered for 8:00 AM; given at 9:54 AM. This is one hour and 54 minutes late. --03/30/25 Farxiga 10mg by mouth daily--ordered for 8:00 AM; given at 9:54 AM. This is one hour and 54 minutes late. -03/30/25 Amlodipine Besylate 10mg by mouth daily--ordered for 8:00 AM; given at 9:54 AM. This is one hour and 54 minutes late. -03/30/25 Folic Acid 1mg by mouth daily--ordered for 8:00 AM; given at 9:54 AM. This is one hour and 54 minutes late. -03/30/25 Quetiapine Furmarate 25mg 1/2 tablet by mouth daily--ordered for 8:00 AM; given at 9:55 AM. This is one hour and 55 minutes late. -03/30/25 Magnesium Oxide 400mg by mouth daily--ordered for 8:00 AM; given at 9:54 AM. This is one hour and 54 minutes late. -03/30/25 Potassium Chloride 10meq (milliequivilant) by mouth daily--ordered for 8:00 AM; given at 9:55 AM. This is one hour and 55 minutes late. -03/30/25 Lisinopril 10mg by mouth daily--ordered for 8:00 AM; given at 9:54 AM. This is one hour and 54 minutes late. -03/30/25 Senna 8.6mg by mouth twice daily--ordered for 8:00 AM; given at 9:55 AM. This is one hour and 55 minutes late. -03/30/25 Thiamine 100mg by mouth daily--ordered for 8:00 AM; given at 9:55 AM. This is one hour and 55 minutes late. -03/30/25 Metoprolol Tartrate 50mg by mouth twice daily--ordered for 8:00 AM; given at 9:55 AM. This is one hour and 55 minutes late. -03/30/25 Basaglar 75 units subcutaneous daily--ordered for 8:00 AM; given at 9:56 AM. This is one hour and 56 minutes late. Resident #23 -03/29/25 Enteral feed Jevity 1.5 calories 474 ml three times daily--ordered for 5:00 PM; given at 7:10 PM. This is 2 hours and 10 minutes late. Resident #36 -Tylenol Extra Strength 500mg give 2 tablets by mouth twice daily--ordered for 10:00 AM; given at 11:47 AM. This is one hour and 47 minutes late. -Glycolax Powder give 17 grams by mouth daily--ordered for 10:00 AM; given at 11:47 AM. This is one hour and 47 minutes late. Resident #8 -Protonix 40mg by mouth twice daily--ordered for 9:00 AM; given at 10:52 AM. This is one hour and 52 minutes late. -Escitalopram 5mg by mouth daily--ordered for 9:00 AM; given at 10:52 AM. This is one hour and 52 minutes late. -Tylenol Extra Strength 500mg by mouth three times a day--ordered for 9:00 AM; given at 10:52 AM. This is one hour and 52 minutes late. Resident #7 -03/29/25 Sertraline 25mg by mouth daily--ordered for 9:00 AM; given at 10:57 AM. This is one hour and 57 minutes late. Resident #41 -03/30/25 Cymbalta 20mg by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Zinc 220mg by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Colace 100mg by mouth twice daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Metformin 1000mg by mouth twice daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Protonix 40mg by mouth twice daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Synthroid 100mcg (microgram) by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Farxiga 10mg by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Eliquis 5mg by mouth twice daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Sitagliptin 25mg by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Furosemide 40mg by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Digoxin 125mcg by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. Resident #50 -03/29/25 Tylenol Extra Strength 500mg give 2 tablets twice daily--ordered for 9:00 AM; given at 11:09 AM. This is two hours and 9 minutes late. -03/29/25 Protonix 40mg daily--ordered for 9:00 AM; given at 11:09 AM. This is two hours and 9 minutes late. -03/29/25 Aspirin 81mg daily--ordered for 9:00 AM; given at 11:09 AM. This is two hours and 9 minutes late. -03/29/25 Omeprazole 20mg twice daily--ordered for 9:00 AM; given at 11:09 AM. This is two hours and 9 minutes late. -03/29/25 Buspar 10mg daily--ordered for 9:00 AM; given at 11:09 AM. This is two hours and 9 minutes late. The following physician's orders for resident treatments were not followed: Resident #9 -03/29/25 apply antifungal to bilateral groin areas twice daily--no documentation for day shift -03/30/25 apply antifungal to bilateral groin areas twice daily--no documentation for day shift --03/29/25 cleanse MASD to left buttock with no-rinse foaming wash and pat dry. Apply calazime cream to open areas only. Apply hydroguard to surrounding skin every day and night shift --no documentation for day shift --03/30/25 cleanse MASD to left buttock with no-rinse foaming wash and pat dry. Apply calazime cream to open areas only. Apply hydroguard to surrounding skin every day and night shift --no documentation for day shift Resident #41 -03/29/25 Eye scrubs: mix baby shampoo with warm water, gently wipe each eye separately, rinse with warm water and pat dry, using clean technique every day and night shift--no documentation for day shift. -03/30/25 Eye scrubs: mix baby shampoo with warm water, gently wipe each eye separately, rinse with warm water and pat dry, using clean technique every day and night shift--no documentation for day shift. -03/29/25 Cleanse ulcer to right lower extremity with normal saline, pat dry, apply collagen particles, cover with hydrogel impregnated gauze, wrap with kerlix, and secure with ace wrap every Tuesday, Thursday and Saturday--no documentation for day shift. Resident #50 -03/29/25 Cleanse bilateral buttocks and scrotum with warm water and mild soap, rinse and dry completely. Apply barrier cream after episodes of incontinence--no documentation for day shift. -03/30/25 Cleanse bilateral buttocks and scrotum with warm water and mild soap, rinse and dry completely. Apply barrier cream after episodes of incontinence--no documentation for day shift. -03/29/25 Hydrocortisone External Cream 2.5% Apply to face, back and thighs every day and night shift--no documentation for day shift. -03/30/25 Hydrocortisone External Cream 2.5% Apply to face, back and thighs every day and night shift--no documentation for day shift. Resident #20 -03/29/25 Apply Ammonium Lactate External cream to bilateral lower legs every day and night shift--no documentation for day shift. -03/30/25 Apply Ammonium Lactate External cream to bilateral lower legs every day and night shift--no documentation for day shift. -03/29/25 Silver Sulfadiazine cream 1% apply to bilateral groin and buttocks every day and night shift--no documentation for day shift. -03/30/25 Silver Sulfadiazine cream 1% apply to bilateral groin and buttocks every day and night shift--no documentation for day shift. Resident #63 -03/29/25 Apply barrier cream to MASD to sacrum every day and night shift--no documentation for day shift. -03/30/25 Apply barrier cream to MASD to sacrum every day and night shift--no documentation for day shift. -03/29/25 Cleanse surgical incision to right shoulder with wound cleanser, pat dry, cover with dry dressing every day and night shift--no documentation for day shift. -03/30/25 Cleanse surgical incision to right shoulder with wound cleanser, pat dry, cover with dry dressing every day and night shift--no documentation for day shift. Resident #42 -03/29/25 Cleanse right heel DTI with normal saline, pat dry, apply betadine to area and cover with foam dressing. Secure with kerlix and tape every Tuesday, Thursday and Saturday--no documentation for day shift. Resident #58 -03/29/25 Apply kerlix and coban starting behind the toes up to below the knee on bilateral lower extremities every 3 days per Vascular Surgery--no documentation for day shift. Resident #61 -03/29/25 Enteral Feed: Cleanse site daily with soap and water every day shift--no documentation for day shift. -03/30/25 Enteral Feed: Cleanse site daily with soap and water every day shift--no documentation for day shift. -03/29/25 Monitor surgical incision to right rear head for possible signs/symptoms of infection every day and night shift-no documentation for day shift. -03/30/25 Monitor surgical incision to right rear head for possible signs/symptoms of infection every day and night shift-no documentation for day shift. Resident #23 -03/29/25 Cleanse PEG site with normal saline moistened gauze and pat dry, apply bacitracin and a split gauze and secure with tape every day shift--no documentation for day shift. -03/30/25 Cleanse PEG site with normal saline moistened gauze and pat dry, apply bacitracin and a split gauze and secure with tape every day shift--no documentation for day shift. Resident #10 -03/29/25 Acetic Acid Irrigation Solution 0.25% use 30 cc (cubic centimeters) via irrigation every day and night shift for occlusion--no documentation for day shift. -03/30/25 Acetic Acid Irrigation Solution 0.25% use 30 cc (cubic centimeters) via irrigation every day and night shift for occlusion--no documentation for day shift. -03/29/25 Apply z-guard to buttocks every day and night shift for MASD--no documentation for day shift. -03/30/25 Apply z-guard to buttocks every day and night shift for MASD--no documentation for day shift. Resident #15 -03/29/25 Apply skin prep daily to arterial ulcers to 1st, 2nd and 3rd digits. Notify provider if any signs/symptoms of infection every day shift--no documentation for day shift. -03/30/25 Apply skin prep daily to arterial ulcers to 1st, 2nd and 3rd digits. Notify provider if any signs/symptoms of infection every day shift--no documentation for day shift. Resident #17 -03/29/25 Monitor left foot for any skin changes related to incident where foot was ran over with a wheel chair x one week. Notify physician if any changes occur every day shift--no documentation for day shift. -03/30/25 Monitor left foot for any skin changes related to incident where foot was ran over with a wheel chair x one week. Notify physician if any changes occur every day shift--no documentation for day shift. --Resident #267 -03/29/25 Apply skin prep outer great left toe every day shift DTI--no documentation for day shift. -03/30/25 Apply skin prep outer great left toe every day shift DTI--no documentation for day shift. Resident #268 -03/29/25 Monitor surgical incision to left hip, Report any signs/symptoms of infection to provider. Cleanse area with wound cleanser, Pat dry. May leave open to air if no drainage every day and night shift--no documentation for day shift. -03/30/25 Monitor surgical incision to left hip, Report any signs/symptoms of infection to provider. Cleanse area with wound cleanser, Pat dry. May leave open to air if no drainage every day and night shift--no documentation for day shift. 30153

Based on record review and staff interview, the facility failed to have evidence of thorough investigations and prevention of further abuse while investigations were in progress. The facility was aware of sexual abuse by a male resident toward female residents. They did not conduct investigations when the abuse occurred. They did work to protect female residents from further sexual abuse after multiple occurrences of sexual abuse were observed. For the one (1) unusual occurrence that was reported there was no five (5) day follow up that contained an appropriate corrective actions. Resident #64 was touching female residents in the breast and vaginal area. The staff felt it was not a big deal if the female residents were not in distress. All sixteen (16) female residents on the dementia unit had the potential to be affected. The facilities lack of action to investigate the sexual abuse allegations placed eleven (11) female residents at continued risk of sexual abuse for over six (6) months prior to Surveyor intervention. Resident identifiers: #64, #57, #56, #61, #62, #42, #43, #44, #45, #48, #49, #50, #51, #52, #58, #66. Facility census: 64. The facility was notified of the Immediate Jeopardy (I) at 5:52 PM on 02/13/24. The I began on 07/31/23. This was the date of the first incident between Resident #64 and a female resident. The facility submitted their initial abatement plan of correction (PC) at 9:00 PM on 02/13/24. The State Agency (AS) approved the facility's PC at 9:10 PM on 02/13/24. The IJ was abated on 02/14/24 at 1:00 PM. The facility's approved abatement POC consisted of the following: All residents of the facility have the potential to be affected. Re-education was provided by the Director of Nursing (DON)/Designee to all employees on 02/13/24 from 6:00 PM to 800 PM to ensure that allegations of sexual abuse were identified, thoroughly investigated, and reported to the appropriate state agencies. A post-test to validate understanding was included. Any employees not available during this time frame will be provided re-education, including post-test upon the beginning of next shift to work. New employees will be provided with education, including post-test during orientation by the DON/designee. The Director of Nursing (DON)/designee will monitor progress notes and behavior monitoring tasks starting on 02/13/24 at 8:00 PM to ensure that allegations of sexual abuse are identified, thoroughly investigated, and reported the appropriate state agencies daily across all shifts for 2 weeks including weekends and holidays, then 3 times a week for 2 weeks and then randomly thereafter. Results of monitors will be reported by the Director of Nursing (DON)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and/or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee. Once the IJ was abated on 02/13/23 at 9:00 PM the deficient practice remained, and the scope and severity (S/S) was decreased from an I to a H. Once the IJ was removed harm remained for the following residents using the reasonable person concept. Resident #57, #56, #61, and #62 suffered psychosocial harm as a result of the he facility's failure to protect the residents from sexual abuse from Resident #64. Facility census: 64. The facility was notified of the Immediate Jeopardy (IJ) at 5:52 PM on 02/13/24. The facility submitted their initial abatement plan of correction (POC) at 9:00 PM on 02/13/24. The State Office approved the facility's POC at 9:10 PM on 02/13/24. After observation, staff interview, review of facility documentation, and record review determining the implementation of the POC, the IJ was abated at 1:00 PM on 02/14/24. The IJ started on 02/13/24 at 5:52 PM and ended on 02/14/24 at 1:00 PM. The facility's approved abatement POC consisted of the following: Resident #64 no longer resides in the facility at this time. In the event of his return, he will not reside on the memory support unit and will be admitted to the Blue Unit. Resident #64's mobility status will be assessed by the therapy department upon return to the facility. Based on mobility status, the facility will establish monitoring parameters and document every shift. The Nursing Home Administrator (NHA)/designee will monitor documentation every shift for appropriate levels of monitoring for 8 weeks. The Interdisciplinary Team (IDT) will meet weekly regarding Resident #64 to determine the appropriate level of monitoring for 8 weeks. The Nursing Home Administrator (NHA) reported the allegations of sexual abuse for Resident #57, #56, #61, and #62 on 02/13/24 at 11:25 PM to appropriate state agencies. All residents have the potential to be affected. The Director of Nursing/designee conducted an audit of the reportables on 02/13/24 at 11:45 PM from 01/15/24 to current on 02/13/24 to ensure the 5-day follow-up was completed and sent to the appropriate agencies with any corrective action immediately upon discovery. Re-education was provided by the Director of Nursing (DON)/Designee to all employees on 02/13/24 at 6:00-8:00 PM to ensure that allegations of sexual abuse are identified, thoroughly investigated and reported to appropriate state agencies as required. A post-test to validate understanding was given. Any employees not available during this time frame will be provided re-education, including pot-test, upon the beginning of the next shift to work. New employees will be provided education, including post-test during orientation by the DON/designee. The Nursing Home Administrator (NHA)/designee will monitor on 02/13/24 at 10:00 PM to ensure thorough investigations of resident allegations of sexual abuse and maintain documentation that alleged violations were thoroughly investigated, and report the results to appropriate state agencies within 5 working days of the incidents daily for 2 weeks, then 5 times a week for 2 weeks, then 3 times a week for 4 weeks, then randomly thereafter. Results of monitors will be reported by the Director of Nursing (DON)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and/or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee. Findings included: a) Abuse Prohibition Policy Review of the facility's Abuse Prohibition Policy revealed the following details: - Sexual Abuse was defined as, a non-consensual sexual contact of any time with a patient. It includes but is not limited to sexual harassment, sexual coercion, or sexual assault. -Neglect was defined as, the failure, indifference, or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This includes the failure to implement an effective communication system across all shifts for communicating necessary care and information between Center, patient, practitioners, and patient representatives. -The section of the Abuse Prohibition policy titled PURPOSE indicated the reason for the policy was to ensure that Center staff are doing all that is within their control to prevent occurrences of abuse for all patients. -Additionally, the section titled PROCESS also indicated anyone who witnessed an incident of suspected abuse was to report the incident to his/her supervisor immediately. It then directed the notified supervisor would report the suspected abuse immediately to the Administrator or designee and other officials in accordance with state law. Lastly, it directed that all reports of suspected abuse must also be reported to the patient's family and attending physician. -The policy indicated that if the suspected abuse was patient-to-patient, the patient who had in any way threatened or attacked another would be removed from the setting or situation and an investigation would be completed. Additionally, it noted that the Center would provide adequate supervision when the risk of patient-to-patient altercation is suspected. -Number seven (7) of the section titled PROCESS directed that immediately upon receiving information concerning a report of suspected or alleged abuse, the Administrator would report allegation not later than 2 hours after the allegation is made. -Number eight (8) of the section titled PROCESS indicated, The Center will protect patients from further harm during an investigation. b) Staff Interview with CNA #28 It's bad. Especially when we only have two (2) nurse aides on the hall. [Resident #64's nickname) targets certain females: [Resident #57's First and Last Name], [Resident #56's First and Last Name], [Resident #61's First and Last Name], and [Resident #62's First and Last Name]. By the time we get to him, he's usually successful with touching the female (either her breast or vagina) and we resort to redirecting him. We are always told by the nurses that it not that big of an issue since the female residents aren't in distress. That doesn't seem right. c) Staff Interview with CNA #49 -Nurse Aide interventions/redirections are needed almost daily. I've lost track of how many times it's happened. It seems to be getting worse. Now it is not just in resident rooms but in the tv room and the dining room. He's (Resident #64) usually successful in touching the females before we get to him. He's easy to redirect out of their rooms, but then he's back at it again in five minutes. I wish administration would teach us the correct interventions that would help prevent it from actually happening to the ladies. We're always told by our superiors if there is no distress, just keep redirecting him. The females aren't being protected. d) Staff Interview with CNA #53 It's worse in the mornings while breakfast is being served and staff are feeding other residents. It depends on how busy we are but there are times we don't get to him before he has been successful in entering a female resident's room and putting his hand up her shirt or down her pants. Nurses say it's not reportable if the female residents don't show signs of distress. I've been told by nurses to NOT document the sexual behaviors because he's already been identified as someone who exhibits inappropriate behaviors. We have talked amongst ourselves as aides, and we are starting to document under the public sexual acts option when we've told the nurses about his behaviors when he is touching other females without their consent because it's simply not right what is happening, and they are not reporting it. They (the female residents) have the right to be protected. e) Staff Interview with Anonymous Therapy Staff Member #84 I have witnessed him (Resident #64) touching female residents in their private areas several times. The direct care staff really struggle with keeping up with him. The best they can usually do is redirect him AFTER a touching incident has occurred. Staff say it's not a reportable unless the ladies show signs of distress. f) Staff Interview with Anonymous Therapy Staff Member #78 -The Nurse Aides were talking about the weekend of 02/03/24 - 02/04/24 and stated Resident #64 had entered Resident #62's room and when a nurse aide entered the room, Resident #64 had his penis on Resident #62's face. The nurse aide intervened and removed Resident #64 from the room and reported to the nurse on duty. It was being discussed among the nurse aides that the reporting nurse aide who had witnessed the event was told it was not reportable because Resident #62 showed no signs of distress, had previously been a prostitute and who knows if she was even bothered by it or not? The therapy staff member stated they had heard a nurse making the same exact statement when it was being discussed after the fact. Review of the facility reportable's log did not show a report had been made to the appropriate state agencies. Review of resident records did not reveal documentation of this incident. -On 02/08/24 a nurse aide had told Anonymous Therapy Staff Member #78 that Resident #64 had touched Resident #65's crotch. The therapy staff member reported this in writing to the Director of Nursing and never received a response. Review of the facility reportable's log did not show a report had been made to the appropriate state agencies. Review of resident records did not reveal documentation of this incident. g) Record review of Electronic Medical Records Nursing Notes from Resident #64's electronic medical record displayed the following times incidents were NOT reported to the appropriate state agencies as possible abuse: -General Note on 01/28/2024 at 08:20 AM, Resident continuing to be grossly sexual with female resident(s). Resident witnessed attempting to grab at said female resident(s) breasts. Resident removed from room multiple times. Resident brought to nursing station for closer monitoring this day. -General Note on 2/8/2024 at 7:05 PM, Resident is constantly entering female resident's rooms while they are sleeping to touch them inappropriately. He has to be watched closely to prevent this. ST [Speech Therapist] wheeled resident out of a female's room twice. Resident will also sit in his wheelchair in the hallway and wait for a female resident to walk by and attempt to grab their breasts/vaginas as they walk by. Review of the Behavior Monitoring and Interventions task revealed the following dates where Nurse Aides document Public Sexual Acts for Resident #64. -01/17/24 -01/26/24 -02/01/24 -02/04/24 -02/07/24 There was no further documentation related to what these sexual acts were nor was there any reporting of possible abuse on those dates. h) Review of the Facility's Abuse/Neglect Reportables Log Review of the facility's abuse/neglect reportables log, completed on 02/13/24 at 10:00 AM, revealed the following reportables related to Resident #64: An Unusual Event (Unusual Occurrence) Reportable was completed and sent to state agencies on 09/01/23. The details of the Unusual Event Reportable were, Residents [Resident #57's First and Last Name] and [Resident #64's First and Last Name] were observed by staff touching each other. [Resident 64's Last Name] touched [Resident #57's First Name]'s breast. [Resident #57's First Name] was touching his body (arms, legs, hand). Redirected and separated. By definition Unusual Occurrences are events that do not meet the definitions of abuse, neglect, and/or misappropriation of resident property. Reporting of unusual occurrences is voluntary. i) Interview with Director of Nursing (DON) During an interview on 02/13/24 at approximately 2:22 PM, the DON reported, His (Resident #64's) behaviors have been a high-focus area for me since I started this position in late September. When asked how the decision is ultimately made about what is and what is not a reportable event, the DON reported the facility social worker drives a lot of the reporting and it has a lot to do with whether the alleged event was detrimental or caused harm to a resident. The DON could not answer why the 09/01/23 incident where Resident #64 touched Resident #57 was reported as an Unusual Occurrence noting that the reporting had been done by the facility social worker who was off on medical leave. The DON acknowledged that the Unusual Occurrence report did not have a five-day follow-up associated with it. The DON indicated that the facility has more reportables here than any other place I've worked. When asked about why CNAs would be reporting that they've been told by nurses that Resident #64's resident to resident sexual aggression was not a reportable event since he was care planned to have inappropriate sexual behaviors and the women he was touching were not reportedly in visible distress, the DON remained silent for a long while. While discussing the reasonable person concept and explaining one could conclude that as a female having a male enter your room and place his hand up your shirt to fondle your breast or place his hand down your pants to touch your vagina, it would result in serious psychosocial harm/mental anguish, the DON then stated the nurses are trained to call her with any allegations of abuse. When asked if she felt Resident #57's documented aggression towards Resident #64 where she punched him three (3) or four (4) times in his thigh could have been a direct result of Resident #64 repeatedly touching her breasts, the DON remained silent. When asked if she might know why there have been many instances documented in Resident #64's record where he had been exhibiting sexually aggressive behaviors but there was no documentation that she had been contacted, the DON shrugged and indicated she did not have an answer to that question.

Based on policy review, record review and staff interview, the facility failed to ensure that alleged violations involving resident sexual abuse were reported, not later than 2 hours of the events / allegations being brought to the facility's attention, to appropriate state agencies as required. Resident #64 was touching female residents in the breast and vaginal area. The staff felt it was not a big deal if the female residents were not in distress. All sixteen (16) female residents on the dementia unit had the potential to be affected. The facilities lack of action to investigate and report the sexual abuse allegations placed the residents on the dementia unit at risk for serious injury or death. The abuse continued over six (6) months prior to surveyor intervention. These were random opportunities for discovery during a complaint survey. Resident identifiers: #57, #56, #61, #62, #64, #42, #43, #44, #45, #48, #49, #50, #51, #52, #58, #66. Facility census: 64. The facility was notified of the Immediate Jeopardy (IJ) at 5:52 PM on 02/13/24. The facility submitted their initial abatement plan of correction (POC) at 9:00 PM on 02/13/24. The State Office approved the facility's POC at 9:10 PM on 02/13/24. After observation, staff interview, review of facility documentation, and record review determining the implementation of the POC, the IJ was abated at 1:00 PM on 02/14/24. The facility's approved abatement POC consisted of the following: The Nursing Home Administrator (NHA) reported the allegations of sexual abuse for Resident #57, #56, #61, and #62 on 02/13/24 at 11:59 PM to appropriate state agencies. The Nursing Home Administrator (NHA) reported the allegations of sexual abuse on 01/28/24, 02/08/24, 01/17/24, 01/26/24, 02/01/24, 02/04/24, and 02/07/24 regarding Resident #64 the perpetrator with unknown victim to the appropriate state agencies on 02/13/24 at 11:00 PM. All residents have the potential to be affected. The Director of Nursing (DON)/designee interviewed residents residing on the Memory Support Unit with a BIMS of 8 or of above for potential sexual abuse on 02/13/24 and completed on 02/13/24 at 7:00 PM with any corrective action taken immediately upon discovery. The Director of Nursing (DON)/designee conducted skin checks on residents residing on the Memory Support Unit with a BIMS of 7 or below if resident permitted for potential sexual abuse on 02/13/24 and completed 02/13/24 at 7:38 PM with any corrective action immediately upon discovery. Re-education was provided by the Director of Nursing (DON)/Designee to all employees on 02/13/24 at 6:00-8:00 PM to ensure that allegations of sexual abuse are identified, thoroughly investigated and reported to appropriate state agencies as required. A post-test to validate understanding was given. Any employees not available during this time frame will be provided re-education, including pot-test, upon the beginning of the next shift to work. New employees will be provided education, including post-test during orientation by the DON/designee. The Director of Nursing (DON)/Designee will monitor progress notes and behavior monitoring tasks starting on 02/13/24 at 8:08 PM to ensure that allegations of sexual abuse are identified, thoroughly investigated and reported to the appropriate state agencies daily across all shifts for 2 weeks including weekends and holidays, then 3 times a week for 2 weeks then randomly thereafter. Results of monitors will be reported by the Director of Nursing (DON)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and/or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee. The IJ was abated on 02/14/23 at 1:00 PM. Using the reasonable person concept, the facility's failure to protect the residents right to be free from sexual abuse/resident-to-resident sexual aggression more than likely resulted in mental anguish and psychosocial harm for Residents #57, #56, #61, and #62. Findings included: a) Abuse Prohibition Policy Review of the facility's Abuse Prohibition Policy revealed the following details: - Sexual Abuse was defined as, a non-consensual sexual contact of any time with a patient. It includes but is not limited to sexual harassment, sexual coercion, or sexual assault. -Neglect was defined as, the failure, indifference, or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This includes the failure to implement an effective communication system across all shifts for communicating necessary care and information between Center, patient, practitioners, and patient representatives. -The section of the Abuse Prohibition policy titled PURPOSE indicated the reason for the policy was to ensure that Center staff are doing all that is within their control to prevent occurrences of abuse for all patients. -Additionally, the section titled PROCESS also indicated anyone who witnessed an incident of suspected abuse was to report the incident to his/her supervisor immediately. It then directed the notified supervisor would report the suspected abuse immediately to the Administrator or designee and other officials in accordance with state law. Lastly, it directed that all reports of suspected abuse must also be reported to the patient's family and attending physician. -The policy indicated that if the suspected abuse was patient-to-patient, the patient who had in any way threatened or attacked another would be removed from the setting or situation and an investigation would be completed. Additionally, it noted that the Center would provide adequate supervision when the risk of patient-to-patient altercation is suspected. -Number seven (7) of the section titled PROCESS directed that immediately upon receiving information concerning a report of suspected or alleged abuse, the Administrator would report allegation not later than 2 hours after the allegation is made. -Number eight (8) of the section titled PROCESS indicated, The Center will protect patients from further harm during an investigation. b) Staff Interview with CNA #28 It's bad. Especially when we only have two (2) nurse aides on the hall. [Resident #64's nickname) targets certain females: [Resident #57's First and Last Name], [Resident #56's First and Last Name], [Resident #61's First and Last Name], and [Resident #62's First and Last Name]. By the time we get to him, he's usually successful with touching the female (either her breast or vagina) and we resort to redirecting him. We are always told by the nurses that it not that big of an issue since the female residents aren't in distress. That doesn't seem right. c) Staff Interview with CNA #49 -Nurse Aide interventions/redirections are needed almost daily. I've lost track of how many times it's happened. It seems to be getting worse. Now it is not just in resident rooms but in the tv room and the dining room. He's (Resident #64) usually successful in touching the females before we get to him. He's easy to redirect out of their rooms, but then he's back at it again in five minutes. I wish administration would teach us the correct interventions that would help prevent it from actually happening to the ladies. We're always told by our superiors if there is no distress, just keep redirecting him. The females aren't being protected. d) Staff Interview with CNA #53 It's worse in the mornings while breakfast is being served and staff are feeding other residents. It depends on how busy we are but there are times we don't get to him before he has been successful in entering a female resident's room and putting his hand up her shirt or down her pants. Nurses say it's not reportable if the female residents don't show signs of distress. I've been told by nurses to NOT document the sexual behaviors because he's already been identified as someone who exhibits inappropriate behaviors. We have talked amongst ourselves as aides, and we are starting to document under the public sexual acts option when we've told the nurses about his behaviors when he is touching other females without their consent because it's simply not right what is happening, and they are not reporting it. They (the female residents) have the right to be protected. e) Staff Interview with Anonymous Therapy Staff Member #84 I have witnessed him (Resident #64) touching female residents in their private areas several times. The direct care staff really struggle with keeping up with him. The best they can usually do is redirect him AFTER a touching incident has occurred. Staff say it's not a reportable unless the ladies show signs of distress. f) Staff Interview with Anonymous Therapy Staff Member #78 -The Nurse Aides were talking about the weekend of 02/03/24 - 02/04/24 and stated Resident #64 had entered Resident #62's room and when a nurse aide entered the room, Resident #64 had his penis on Resident #62's face. The nurse aide intervened and removed Resident #64 from the room and reported to the nurse on duty. It was being discussed among the nurse aides that the reporting nurse aide who had witnessed the event was told it was not reportable because Resident #62 showed no signs of distress, had previously been a prostitute and who knows if she was even bothered by it or not? The therapy staff member stated they had heard a nurse making the same exact statement when it was being discussed after the fact. Review of the facility reportable's log did not show a report had been made to the appropriate state agencies. Review of resident records did not reveal documentation of this incident. -On 02/08/24 a nurse aide had told Anonymous Therapy Staff Member #78 that Resident #64 had touched Resident #65's crotch. The therapy staff member reported this in writing to the Director of Nursing and never received a response. Review of the facility reportable's log did not show a report had been made to the appropriate state agencies. Review of resident records did not reveal documentation of this incident. g) Record review of Electronic Medical Records Nursing Notes from Resident #64's electronic medical record displayed the following times incidents were NOT reported to the appropriate state agencies as possible abuse: -General Note on 01/28/2024 at 08:20 AM, Resident continuing to be grossly sexual with female resident(s). Resident witnessed attempting to grab at said female resident(s) breasts. Resident removed from room multiple times. Resident brought to nursing station for closer monitoring this day. -General Note on 2/8/2024 at 7:05 PM, Resident is constantly entering female resident's rooms while they are sleeping to touch them inappropriately. He has to be watched closely to prevent this. ST [Speech Therapist] wheeled resident out of a female's room twice. Resident will also sit in his wheelchair in the hallway and wait for a female resident to walk by and attempt to grab their breasts/vaginas as they walk by. Review of the Behavior Monitoring and Interventions task revealed the following dates where Nurse Aides document Public Sexual Acts for Resident #64. -01/17/24 -01/26/24 -02/01/24 -02/04/24 -02/07/24 There was no further documentation related to what these sexual acts were nor was there any reporting of possible abuse on those dates. h) Review of the Facility's Abuse/Neglect Reportables Log Review of the facility's abuse/neglect reportables log, completed on 02/13/24 at 10:00 AM, revealed the following reportables related to Resident #64: 1. An eINTERACT SBAR Summary for Providers, dated 09/01/23 at 11:05 AM, indicated the following: Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Other change in condition Relevant medical history is: Dementia Nursing observations, evaluation, and recommendations are: Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: monitor An Unusual Event (Unusual Occurrence) Reportable was completed and sent to state agencies on 09/01/23. The details of the Unusual Event Reportable were, Residents [Resident #57's First and Last Name] and [Resident #64's First and Last Name] were observed by staff touching each other. [Resident 64's Last Name] touched [Resident #57's First Name]'s breast. [Resident #57's First Name] was touching his body (arms, legs, hand). Redirected and separated. By definition Unusual Occurrences are events that do not meet the definitions of abuse, neglect, and/or misappropriation of resident property. Reporting of unusual occurrences is voluntary. i) Interview with Director of Nursing (DON) During an interview on 02/13/24 at approximately 2:22 PM, the DON reported, His (Resident #64's) behaviors have been a high-focus area for me since I started this position in late September. When asked how the decision is ultimately made about what is and what is not a reportable event, the DON reported the facility social worker drives a lot of the reporting and it has a lot to do with whether the alleged event was detrimental or caused harm to a resident. The DON could not answer why the 09/01/23 incident where Resident #64 touched Resident #57 was reported as an Unusual Occurrence noting that the reporting had been done by the facility social worker who was off on medical leave. The DON indicated that the facility has more reportables here than any other place I've worked. When asked about why CNAs would be reporting that they've been told by nurses that Resident #64's resident to resident sexual aggression was not a reportable event since he was care planned to have inappropriate sexual behaviors and the women he was touching were not reportedly in visible distress, the DON remained silent for a long while. While discussing the reasonable person concept and explaining one could conclude that as a female having a male enter your room and place his hand up your shirt to fondle your breast or place his hand down your pants to touch your vagina, it would result in serious psychosocial harm/mental anguish, the DON then stated the nurses are trained to call her with any allegations of abuse. When asked if she felt Resident #57's documented aggression towards Resident #64 where she punched him three (3) or four (4) times in his thigh could have been a direct result of Resident #64 repeatedly touching her breasts, the DON remained silent. When asked if she might know why there have been many instances documented in Resident #64's record where he had been exhibiting sexually aggressive behaviors but there was no documentation that she had been contacted, the DON shrugged and indicated she did not have an answer to that question. Before the interview ended, the DON stated, He (Resident #64) is like a child acting out to get attention. I don't believe it is an intimacy issue. I think he wants to move to the other hall so he can play cards with his old friends.

Based on policy review, staff interview, and record review, the facility failed to protect the residents right to be free from abuse that resulted in mental anguish for Resident #57, #56, #61, and #62. Resident #64 was touching female residents in the breast and vaginal area. The staff felt it was not a big deal if the female residents were not in distress. All sixteen (16) female residents on the dementia unit had the potential to be affected. The facilities lack of action to investigate the sexual abuse allegations placed Residents #57, #56, #61, and #62 at continued risk of sexual abuse for over six (6) months prior to Surveyor intervention. Resident identifiers: #64, #57, #56, #61, #62, #42, #43, #44, #45, #48, #49, #50, #51, #52, #58, #66. Facility census: 64. The facility was notified of the Immediate Jeopardy (IJ) at 5:26 PM on 02/13/24. The facility submitted their plan of correction (POC) at 9:00 PM on 02/13/24. The State Agency (SA) approved the facility's POC at 9:10 PM on 02/13/24. The IJ began on 07/31/23 the date of the first incident between Resident #64 and a female resident. The IJ was abated at 1:00 PM on 02/14/24. The facility's approved abatement POC consisted of the following: Resident #64 no longer resides in the facility at this time. In the event of his return, he will not reside on the memory support unit and will be admitted to the Blue Unit. Resident #64's mobility status will be assessed by the therapy department upon return to the facility. Based on mobility status, the facility will establish monitoring parameters and document every shift. The Nursing Home Administrator (NHA)/designee will monitor documentation every shift for appropriate levels of monitoring for 8 weeks. The Interdisciplinary Team (IDT) will meet weekly regarding Resident #64 to determine the appropriate level of monitoring for 8 weeks. Resident #57 no longer resides in the facility at this time. The licensed nurse conducted skin checks on Residents #56, #61, and #62 on 02/13/24 and completed on 02/13/24 at 7:38 PM. The licensed nurse evaluated Residents #56, #61, and #62 for emotional and psychological harm on 02/13/24 at 7:10 PM with no concerns identified. All residents of the facility have the potential to be affected. The Director of Nursing (DON)/designee interviewed residents residing on the Memory Support Unit with a BIMS of 7 or below if resident presented for potential sexual abuse on 02/13/24 and completed on 02/13/24 at 7:38 PM with any corrective action immediately upon discovery. Re-education was provided by the Director of Nursing (DON)/Designee to all employees on 02/13/24 from 6:00 PM to 800 PM to ensure that allegations of sexual abuse were identified, thoroughly investigated, and reported to the appropriate state agencies. A post-test to validate understanding was included. Any employees not available during this time frame will be provided re-education, including post-test upon the beginning of next shift to work. New employees will be provided with education, including post-test during orientation by the DON/designee. The Director of Nursing (DON)/designee will monitor progress notes and behavior monitoring tasks starting on 02/13/24 at 8:00 PM to ensure that allegations of sexual abuse are identified, thoroughly investigated, and reported the appropriate state agencies daily across all shifts for 2 weeks including weekends and holidays, then 3 times a week for 2 weeks and then randomly thereafter. Results of monitors will be reported by the Director of Nursing (DON)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and/or in-servicing until the issue is resolved, them randomly thereafter as determined by the QIC committee. Once the IJ was abated on 02/13/23 at 9:00 PM the deficient practice remained, and the scope and severity (S/S) was decreased from an I to a H. Using the reasonable person concept, the facility's failure to protect the residents right to be free from sexual abuse/resident-to-resident sexual aggression more than likely resulted in mental anguish and psychosocial harm for Residents #57, #56, #61, and #62. Findings included: a) Abuse Prohibition Policy Review of the facility's Abuse Prohibition Policy revealed the following details: - Sexual Abuse was defined as, a non-consensual sexual contact of any time with a patient. It includes but is not limited to sexual harassment, sexual coercion, or sexual assault. -Neglect was defined as, the failure, indifference, or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This includes the failure to implement an effective communication system across all shifts for communicating necessary care and information between Center, patient, practitioners, and patient representatives. -The section of the Abuse Prohibition policy titled PURPOSE indicated the reason for the policy was to ensure that Center staff are doing all that is within their control to prevent occurrences of abuse for all patients. -The section of the Abuse Prohibition policy titled PROCESS indicated: 1. The Center must ensure that all staff are aware of reporting requirements and must support an environment in which covered individuals report a reasonable suspicion of a crime. 2. The Center will post conspicuously in an appropriate location a sign specifying the rights of employes under the Elder Justice Act (EJA). The sign shall include: 2.1 The reporting requirements of each employee. 2.2 A statement that an employee may file a complaint with the state survey agency against any long-term care Center that retaliates against an employee for reporting or causing a report to be made, and information about how to file such a complaint to the state survey agency. 2.3 The sign will be posted in the same area that the Center posts other required employee signs. -Additionally, the section titled PROCESS also indicated anyone who witnessed an incident of suspected abuse was to report the incident to his/her supervisor immediately. It then directed the notified supervisor would report the suspected abuse immediately to the Administrator or designee and other officials in accordance with state law. Lastly, it directed that all reports of suspected abuse must also be reported to the patient's family and attending physician. -The policy indicated that if the suspected abuse was patient-to-patient, the patient who had in any way threatened or attacked another would be removed from the setting or situation and an investigation would be completed. Additionally, it noted that the Center would provide adequate supervision when the risk of patient-to patient altercation is suspected. -Number seven (7) of the section titled PROCESS directed that immediately upon receiving information concerning a report of suspected or alleged abuse, the Administrator would report the allegation not later than 2 hours after the allegation is made. -Number eight (8) of the section titled PROCESS indicated, The Center will protect patients from further harm during an investigation. -Number nine (9) of the section titled PROCESS stated the facility would take steps to revise patients' care plans where indicated if there was a change in the patients' medical, nursing, physical, mental or psychosocial needs or preferences as a result of an incident of abuse. -Number ten (10) of the section titled PROCESS indicated the Administrator would at monthly Quality Assurance and Performance Improvement (QAPI) meetings, review all allegations of abuse to analyze occurrences to determine what changes are needed, if any, to prevent further occurrences. b) Staff Interview with CNA #28 During a staff interview with CNA #28 on 02/14/24 at 12:23 PM the CNA said, It's bad. Especially when we only have two (2) nurse aides on the hall. [Resident #64's nickname) targets certain females: [Resident #57's First and Last Name], [Resident #56's First and Last Name], [Resident #61's First and Last Name], and [Resident #62's First and Last Name]. By the time we get to him, he's usually successful with touching the female (either her breast or vagina) and we resort to redirecting him. We are always told by the nurses that it is not that big of an issue since the female residents aren't in distress. That doesn't seem right. c) Staff Interview with CNA #49 During a staff interview on 02/14/24 at 12:31 PM with Nurse Aide #49 the nurse aide said, Nurse Aide interventions/redirections are needed almost daily. I've lost track of how many times it's happened. It seems to be getting worse. Now it is not just in resident rooms but in the tv room and the dining room. He's (Resident #64) usually successful in touching the females before we get to him. He's easy to redirect out of their rooms, but then he's back at it again in five minutes. I wish administration would teach us the correct interventions that would help prevent it from actually happening to the ladies. We're always told by our superiors if there is no distress, just keep redirecting him. The females aren't being protected. d) Staff Interview with CNA #53 An interview with CNA #53 on 02/13/24 at 1:35 PM revealed, It's worse in the mornings while breakfast is being served and staff are feeding other residents. It depends on how busy we are but there are times we don't get to him before he has been successful in entering a female resident's room and putting his hand up her shirt or down her pants. Nurses say it's not reportable if the female residents don't show signs of distress. I've been told by nurses to NOT document the sexual behaviors because he's already been identified as someone who exhibits inappropriate behaviors. We have talked amongst ourselves as aides, and we are starting to document under the public sexual acts option when we've told the nurses about his behaviors when he is touching other females without their consent because it's simply not right what is happening, and they are not reporting it. They (the female residents) have the right to be protected. e) Staff Interview with Anonymous Therapy Staff Member #84 I have witnessed him (Resident #64) touching female residents in their private areas several times. The direct care staff really struggle with keeping up with him. The best they can usually do is redirect him AFTER a touching incident has occurred. Staff say it's not a reportable unless the ladies show signs of distress. f) Staff Interview with Anonymous Therapy Staff Member #78 -The Nurse Aides were talking about the weekend of 02/03/24 - 02/04/24 and stated Resident #64 had entered Resident #62's room and when a nurse aide entered the room, Resident #64 had his penis on Resident #62's face. The nurse aide intervened and removed Resident #64 from the room and reported to the nurse on duty. It was being discussed among the nurse aides that the reporting nurse aide who had witnessed the event was told it was not reportable because Resident #62 showed no signs of distress, had previously been a prostitute and who knows if she was even bothered by it or not? The therapy staff member stated they had heard a nurse making the same exact statement when it was being discussed after the fact. Review of the facility reportable log did not show a report had been made to the appropriate state agencies. Review of resident records did not reveal documentation of this incident. -On 02/08/24 a nurse aide had told Anonymous Therapy Staff Member #78 that Resident #64 had touched Resident #65's crotch. The therapy staff member reported this in writing to the Director of Nursing and never received a response. g) Record review of Electronic Medical Records Nursing Notes from Resident #64's electronic medical record displayed the following times incidents were not reported to the appropriate state agencies as possible abuse: -General Note on 01/28/2024 at 08:20 AM, Resident continuing to be grossly sexual with female resident(s). Resident witnessed attempting to grab at said female resident(s) breasts. Resident removed from room multiple times. Resident brought to nursing station for closer monitoring this day. -General Note on 2/8/2024 at 7:05 PM, Resident is constantly entering female resident's rooms while they are sleeping to touch them inappropriately. He has to be watched closely to prevent this. ST [Speech Therapist] wheeled resident out of a female's room twice. Resident will also sit in his wheelchair in the hallway and wait for a female resident to walk by and attempt to grab their breasts/vaginas as they walk by. Review of the Behavior Monitoring and Interventions task revealed the following dates where Nurse Aides document Public Sexual Acts for Resident #64. -01/17/24 -01/26/24 -02/01/24 -02/04/24 -02/07/24 There was no further documentation related to what these sexual acts were nor was there any reporting of possible abuse on those dates. h) Review of the Facility's Abuse/Neglect Reportables Log Review of the facility's abuse/neglect reportables log, completed on 02/13/24 at 10:00 AM, revealed the following reportables related to Resident #64: 1. SBAR (Situation, Background, Assessment, and Recommendation) Summary for Providers, dated 07/31/23 at 10:00 PM, indicated, CNA witnessed resident [Resident #64] and female resident [Resident #57] having contact intercourse in his room. Called for nurse. When nurse arrived, resident [Resident #64] had already dressed and was sitting in his chair by his bed and female resident had her shirt on and had one leg in her attends covering her peri area. She finished dressing and CNA walked her to TV room. This resident stayed in his room. Residents assessed. No injuries noted. No distress noted. 15-minute checks applied to both. A General Note, dated 8/1/2023 at 2:19 AM, noted, 07/31/23 at 2200 cna found resident having contact intercourse in his room during room checks. Separated. Assessed. No injuries or distress noted. 15-minute checks on residents no less than 72 hours. CEO and Social Services Director, Doctor notified immediately. Social Services Director notified the MPOAs. Left message with this residents MPOA. Further record review revealed: -Resident #57 had a Brief Interview for Mental Status (BIMS) score of five (05) according to her 05/12/23 admission Minimum Data Set (MDS). A score of five (05) indicates severe cognitive impairment. -Resident #64 had a BIMS score of 11 according to his 06/13/23 admission MDS. A score of 11 indicates moderate cognitive impairment. 2. Medical record review dated 09/01/23 at 11:05 AM, indicated the following: Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Other change in condition Relevant medical history is: Dementia Nursing observations, evaluation, and recommendations are: Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: monitor An Unusual Event Reportable was completed and sent to state agencies on 09/01/23. The details of the Unusual Event Reportable were, Residents [Resident #57's First and Last Name] and [Resident #64's First and Last Name] were observed by staff touching each other. [Resident 64's Last Name] touched [Resident #57's First Name]'s breast. [Resident #57's First Name] was touching his body (arms, legs, hand). Redirected and separated. 3. SBAR dated 10/22/23 at 4:05 PM, noted, CNA created custom alert regarding said resident (Resident #64) having hands down [Resident #56's First and Last Initial] pants. CNA states she entered room to pick up breakfast trays and said resident was pulling hands out of [Resident #56]'s pants. CNA redirected resident (Resident #64) to resident's own room and advised resident to eat breakfast. CNA continued to check on resident frequently while on floor until resident went to common area. Further record review revealed: -Resident #56 had a BIMS score of two (02) according to her 08/01/23 admission Minimum Data Set (MDS). A score of two (02) indicates severe cognitive impairment. 4. SBAR Summary for Providers, dated 12/04/23 at 5:25 PM, indicated, Another resident [Resident #57] punched this resident [Resident #64] 3 or 4 times in the right upper thigh. No bruising or injuries at this time. -Resident #57 had a BIMS score of zero (00) according to her 11/17/23 Significant Change MDS. A score of zero (00) indicates severe cognitive impairment. i) Review of Resident 64's Care Plan Review of Resident #64's care plan, completed on 02/13/24 at 11:00 AM, revealed resident was first care planned for inappropriate sexual behaviors on 08/01/23. His care plan was not modified again as it related to his inappropriate sexual behaviors until 01/25/24 when it was noted that the physician would complete a medication review due to increased anxiety and sexual behaviors. j) Interview with Director of Nursing (DON) During an interview on 02/13/24 at approximately 3:00 PM, the DON reported, His (Resident #64's) behaviors have been a high-focus area for me since I started this position in late September. When asked how the decision was ultimately made about what was and what was not a reportable event, the DON reported the facility social worker drives a lot of the reporting and it has a lot to do with whether the alleged event was detrimental or caused harm to a resident. The DON indicated that the facility has more reportables here than any other place I've worked. When asked about why CNAs would be reporting that they've been told by nurses that Resident #64's resident to resident sexual aggression was not a reportable event since he was care planned to have inappropriate sexual behaviors and the women he was touching were not reportedly in visible distress, the DON remained silent for a long while. While discussing the reasonable person concept and explaining one could conclude that as a female having a male enter your room and place his hand up your shirt to fondle your breast or place his hand down your pants to touch your vagina, it would result in serious psychosocial harm/mental anguish, the DON then stated the nurses were trained to call her with any allegations of abuse. When asked if she felt Resident #57's documented aggression towards Resident #64 where she punched him three (3) or four (4) times in his thigh could have been a direct result of Resident #64 repeatedly touching her breasts, the DON remained silent. When asked if she might know why there have been many instances documented in Resident #64's record where he had been exhibiting sexually aggressive behaviors but there was no documentation that she had been contacted, the DON shrugged and indicated she did not have an answer to that question but the nursing staff had failed to notify her of all the resident-to-resident concerns. Before the interview ended, the DON stated, He (Resident #64) is like a child acting out to get attention. I don't believe it is an intimacy issue. I think he wants to move to the other hall so he can play cards with his old friends. k) Interview with Payroll and Scheduling Manager During an interview on 02/13/24 at approximately 5:40 PM, the Payroll and Scheduling Manager confirmed the facility had not posted a sign specifying the rights of employes under the Elder Justice ACT which should have included: -The reporting requirements of each employee. -A statement that an employee may file a complaint with the state survey agency against any long-term care Center that retaliates against an employee for reporting or causing a report to be made, and information about how to file such a complaint to the state survey agency. -The sign should have been posted in the same area that the Center posts other required employee signs. The Payroll and Scheduling manager indicated she was somewhat new to the position and indicated she would immediately address the error. l) Interview with Administrator During an interview on 12/14/23 at 1:25 PM, the following issues were addressed with the Administrator: -The Abuse Prohibition policy indicated that the Center would protect residents from further harm. -The Abuse Prohibition policy indicated resident care plans would be updated following incidents of abuse. -The Abuse Prohibition policy indicated the Administrator would at monthly Quality Assurance and Performance Improvement (QAPI) meetings, review all allegations of abuse to analyze occurrences to determine what changes were needed, if any, to prevent further occurrences. When asked if there was any evidence the Abuse Prohibition policy had been followed, the Administrator indicated she had just started on 02/01/24 and stated, I will have to look. I'm not sure how we were handling the issue in QAPI meetings. No further details were provided prior to exit from the facility on 02/14/24 at 2:30 PM.

Based on staff interview and record review, the facility failed to implement their written Abuse Prohibition policy as it related to identifying investigating and reporting allegations of sexual abuse. The facility also failed to follow procedures to investigate any such allegations and prevent future sexual abuse from happening. The facilities lack of action to identify, investigate, and report the sexual abuse allegations placed sixteen (16) female residents residing on the dementia unit at continued risk of sexual abuse for over six (6) months prior to surveyor intervention. Review of facility records found that there were 16 other female residents on the locked memory care unit where Resident #64 resided and were potential victims of his behavior. Resident identifiers: #64, #57, #56, #61, #62, #42, #43, #44, #45, #48, #49, #50, #51, #52, #58, #66. Facility census: 64. The facility was notified of the Immediate Jeopardy (IJ) at 7:13 PM on 02/13/24. The facility submitted their initial abatement plan of correction (POC) at 9:00 PM on 02/13/24. The State Office approved the facility's POC at 9:10 PM on 02/13/24. The IJ began on 07/31/23 when Resident #64 was found having sexual intercourse with Resident #57. The IJ was abated on 02/14/24 at 1:00 PM. The facility's approved abatement POC consisted of the following: The Clinical Lead provided re-education to the Nursing Home Administrator on 02/13/24 at 8:02 PM regarding implementation of the abuse and neglect policy related to reporting allegations of sexual abuse and failed to follow procedures to investigate with a post-test to validate understanding. All residents of the facility have the potential to be affected. The Nursing Home Administrator/designee posted the Elder Justice Act (EJA) with the reporting requirements for each employee in the employee service hall on 02/13/24 at 6:00 PM. Re-education was provided by the Director of Nursing (DON)/Designee to all employees on 02/13/24 at 6:00-8:00 PM to ensure that allegations of sexual abuse are identified, thoroughly investigated and reported to appropriate state agencies as required. A post-test to validate understanding was given. Any employees not available during this time frame will be provided re-education, including pot-test, upon the beginning of the next shift to work. New employees will be provided education, including post-test during orientation by the DON/designee. The Nursing Home Administrator (NHA)/designee will monitor starting on 02/13/24 at 10:00 PM to ensure the abuse and neglect policy is implemented daily for 2 weeks, then 5 times a week for 2 weeks, then 3 times a week for 4 weeks, then randomly thereafter. Results of monitors will be reported by the Director of Nursing (DON)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and/or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee. Using the reasonable person concept, the facility's failure to protect the residents right to be free from sexual abuse/resident-to-resident sexual aggression more than likely resulted in mental anguish and psychosocial harm for Residents #57, #56, #61, and #62. Findings included: a) Abuse Prohibition Policy Review of the facility's Abuse Prohibition Policy revealed the following details: - Sexual Abuse was defined as, a non-consensual sexual contact of any time with a patient. It includes but is not limited to sexual harassment, sexual coercion, or sexual assault. -Neglect was defined as, the failure, indifference, or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This includes the failure to implement an effective communication system across all shifts for communicating necessary care and information between Center, patient, practitioners, and patient representatives. -The section of the Abuse Prohibition policy titled PURPOSE indicated the reason for the policy was to ensure that Center staff are doing all that is within their control to prevent occurrences of abuse for all patients. -The section of the Abuse Prohibition policy titled PROCESS indicated: 1. The Center must ensure that all staff are aware of reporting requirements and must support an environment in which covered individuals report a reasonable suspicion of a crime. 2. The Center will post conspicuously in an appropriate location a sign specifying the rights of employes under the EJA. The sign shall include: 2.1 The reporting requirements of each employee. 2.2 A statement that an employee may file a complaint with the state survey agency against any long-term care Center that retaliates against an employee for reporting or causing a report to be made, and information about how to file such a complaint to the state survey agency. 2.3 The sign will be posted in the same area that the Center posts other required employee signs. -Additionally, the section titled PROCESS also indicated anyone who witnessed an incident of suspected abuse was to report the incident to his/her supervisor immediately. It then directed the notified supervisor would report the suspected abuse immediately to the Administrator or designee and other officials in accordance with state law. Lastly, it directed that all reports of suspected abuse must also be reported to the patient's family and attending physician. -The policy indicated that if the suspected abuse was patient-to-patient, the patient who had in any way threatened or attacked another would be removed from the setting or situation and an investigation would be completed. Additionally, it noted that the Center would provide adequate supervision when the risk of patient-to-patient altercation is suspected. -Number seven (7) of the section titled PROCESS directed that immediately upon receiving information concerning a report of suspected or alleged abuse, the Administrator would report allegation not later than 2 hours after the allegation is made. -Number eight (8) of the section titled PROCESS indicated, The Center will protect patients from further harm during an investigation. -Number nine (9) of the section titled PROCESS stated the facility would take steps to revise patients' care plans where indicated if there was a change in the patients' medical, nursing, physical, mental or psychosocial needs or preferences as a result of an incident of abuse. -Number ten (10) of the section titled PROCESS indicated the Administrator would at monthly Quality Assurance and Performance Improvement (QAPI) meetings, review all allegations of abuse to analyze occurrences to determine what changes are needed, if any, to prevent further occurrences. b) Staff Interview with CNA #28 It's bad. Especially when we only have two (2) nurse aides on the hall. [Resident #64's nickname) targets certain females: [Resident #57's First and Last Name], [Resident #56's First and Last Name], [Resident #61's First and Last Name], and [Resident #62's First and Last Name]. By the time we get to him, he's usually successful with touching the female (either her breast or vagina) and we resort to redirecting him. We are always told by the nurses that it not that big of an issue since the female residents aren't in distress. That doesn't seem right. c) Staff Interview with CNA #49 -Nurse Aide interventions/redirections are needed almost daily. I've lost track of how many times it's happened. It seems to be getting worse. Now it is not just in resident rooms but in the tv room and the dining room. He's (Resident #64) usually successful in touching the females before we get to him. He's easy to redirect out of their rooms, but then he's back at it again in five minutes. I wish administration would teach us the correct interventions that would help prevent it from actually happening to the ladies. We're always told by our superiors if there is no distress, just keep redirecting him. The females aren't being protected. d) Staff Interview with CNA #53 It's worse in the mornings while breakfast is being served and staff are feeding other residents. It depends on how busy we are but there are times we don't get to him before he has been successful in entering a female resident's room and putting his hand up her shirt or down her pants. Nurses say it's not reportable if the female residents don't show signs of distress. I've been told by nurses to NOT document the sexual behaviors because he's already been identified as someone who exhibits inappropriate behaviors. We have talked amongst ourselves as aides, and we are starting to document under the public sexual acts option when we've told the nurses about his behaviors when he is touching other females without their consent because it's simply not right what is happening, and they are not reporting it. They (the female residents) have the right to be protected. e) Staff Interview with Anonymous Therapy Staff Member #84 I have witnessed him (Resident #64) touching female residents in their private areas several times. The direct care staff really struggle with keeping up with him. The best they can usually do is redirect him AFTER a touching incident has occurred. Staff say it's not a reportable unless the ladies show signs of distress. f) Staff Interview with Anonymous Therapy Staff Member #78 -The Nurse Aides were talking about the weekend of 02/03/24 - 02/04/24 and stated Resident #64 had entered Resident #62's room and when a nurse aide entered the room, Resident #64 had his penis on Resident #62's face. The nurse aide intervened and removed Resident #64 from the room and reported to the nurse on duty. It was being discussed among the nurse aides that the reporting nurse aide who had witnessed the event was told it was not reportable because Resident #62 showed no signs of distress, had previously been a prostitute and who knows if she was even bothered by it or not? The therapy staff member stated they had heard a nurse making the same exact statement when it was being discussed after the fact. Review of the facility reportable's log did not show a report had been made to the appropriate state agencies. Review of resident records did not reveal documentation of this incident. -On 02/08/24 a nurse aide had told Anonymous Therapy Staff Member #78 that Resident #64 had touched Resident #65's crotch. The therapy staff member reported this in writing to the Director of Nursing and never received a response. Review of the facility reportable's log did not show a report had been made to the appropriate state agencies. Review of resident records did not reveal documentation of this incident. g) Record review of Electronic Medical Records Nursing Notes from Resident #64's electronic medical record displayed the following times incidents were NOT reported to the appropriate state agencies as possible abuse: -General Note on 01/28/2024 at 08:20 AM, Resident continuing to be grossly sexual with female resident(s). Resident witnessed attempting to grab at said female resident(s) breasts. Resident removed from room multiple times. Resident brought to nursing station for closer monitoring this day. -General Note on 2/8/2024 at 7:05 PM, Resident is constantly entering female resident's rooms while they are sleeping to touch them inappropriately. He has to be watched closely to prevent this. ST [Speech Therapist] wheeled resident out of a female's room twice. Resident will also sit in his wheelchair in the hallway and wait for a female resident to walk by and attempt to grab their breasts/vaginas as they walk by. Review of the Behavior Monitoring and Interventions task revealed the following dates where Nurse Aides document Public Sexual Acts for Resident #64. -01/17/24 -01/26/24 -02/01/24 -02/04/24 -02/07/24 There was no further documentation related to what these sexual acts were nor was there any reporting of possible abuse on those dates. h) Review of the Facility's Abuse/Neglect Reportables Log Review of the facility's abuse/neglect reportables log, completed on 02/13/24 at 10:00 AM, revealed the following reportables related to Resident #64: 1. An eINTERACT SBAR (Situation, Background, Assessment, and Recommendation) Summary for Providers, dated 07/31/23 at 10:00 PM, indicated, CNA witnessed resident [Resident #64] and female resident [Resident #57] having contact intercourse in his room. Called for nurse. When nurse arrived, resident [Resident #64] had already dressed and was sitting in his chair by his bed and female resident had her shirt on and had one leg in her attends covering her peri area. She finished dressing and CNA walked her to TV room. This resident stayed in his room. Residents assessed. No injuries noted. No distress noted. 15-minute checks applied to both. A General Note, dated 8/1/2023 at 2:19 AM, noted, 07/31/23 at 2200 cna found resident having contact intercourse in his room during room checks. Separated. Assessed. No injuries or distress noted. 15-minute checks on residents no less than 72 hours. CEO and Social Services Director, Doctor notified immediately. Social Services Director notified the MPOAs. Left message with this residents MPOA. Further record review revealed: -Resident #57 had a Brief Interview for Mental Status (BIMS) score of five (05) according to her 05/12/23 admission Minimum Data Set (MDS). A score of five (05) indicates severe cognitive impairment. -Resident #64 had a BIMS score of 11 according to his 06/13/23 admission MDS. A score of 11 indicates moderate cognitive impairment. 2. An eINTERACT SBAR Summary for Providers, dated 09/01/23 at 11:05 AM, indicated the following: Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Other change in condition Relevant medical history is: Dementia Nursing observations, evaluation, and recommendations are: Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: monitor An Unusual Event Reportable was completed and sent to state agencies on 09/01/23. The details of the Unusual Event Reportable were, Residents [Resident #57's First and Last Name] and [Resident #64's First and Last Name] were observed by staff touching each other. [Resident 64's Last Name] touched [Resident #57's First Name]'s breast. [Resident #57's First Name] was touching his body (arms, legs, hand). Redirected and separated. 3. A General Note, dated 10/22/23 at 4:05 PM, noted, CNA created custom alert regarding said resident (Resident #64) having hands down [Resident #56's First and Last Initial] pants. CNA states she entered room to pick up breakfast trays and said resident was pulling hands out of [Resident #56]'s pants. CNA redirected resident (Resident #64) to resident's own room and advised resident to eat breakfast. CNA continued to check on resident frequently while on floor until resident went to common area. Further record review revealed: -Resident #56 had a BIMS score of two (02) according to her 08/01/23 admission Minimum Data Set (MDS). A score of two (02) indicates severe cognitive impairment. 4. An eINTERACT SBAR Summary for Providers, dated 12/04/23 at 5:25 PM, indicated, Another resident [Resident #57] punched this resident [Resident #64] 3 or 4 times in the right upper thigh. No bruising or injuries at this time. -Resident #57 had a BIMS score of zero (00) according to her 11/17/23 Significant Change MDS. A score of zero (00) indicates severe cognitive impairment. i) Review of Resident 64's Care Plan Review of Resident #64's care plan, completed on 02/13/24 at 11:00 AM, revealed resident was first care planned for inappropriate sexual behaviors on 08/01/23. His care plan was not modified again as it related to his inappropriate sexual behaviors until 01/25/24 when it was noted that the physician would complete a medication review due to increased anxiety and sexual behaviors. j) Interview with Director of Nursing (DON) During an interview on 02/13/24 at approximately 3:00 PM, the DON reported, His (Resident #64's) behaviors have been a high-focus area for me since I started this position in late September. When asked how the decision is ultimately made about what is and what is not a reportable event, the DON reported the facility social worker drives a lot of the reporting and it has a lot to do with whether the alleged event was detrimental or caused harm to a resident. The DON indicated that the facility has more reportables here than any other place I've worked. When asked about why CNAs would be reporting that they've been told by nurses that Resident #64's resident to resident sexual aggression was not a reportable event since he was care planned to have inappropriate sexual behaviors and the women he was touching were not reportedly in visible distress, the DON remained silent for a long while. While discussing the reasonable person concept and explaining one could conclude that as a female having a male enter your room and place his hand up your shirt to fondle your breast or place his hand down your pants to touch your vagina, it would result in serious psychosocial harm/mental anguish, the DON then stated the nurses are trained to call her with any allegations of abuse. When asked if she felt Resident #57's documented aggression towards Resident #64 where she punched him three (3) or four (4) times in his thigh could have been a direct result of Resident #64 repeatedly touching her breasts, the DON remained silent. When asked if she might know why there have been many instances documented in Resident #64's record where he had been exhibiting sexually aggressive behaviors but there was no documentation that she had been contacted, the DON shrugged and indicated she did not have an answer to that question but the nursing staff had failed to notify her of all the resident-to-resident concerns. Before the interview ended, the DON stated, He (Resident #64) is like a child acting out to get attention. I don't believe it is an intimacy issue. I think he wants to move to the other hall so he can play cards with his old friends. k) Interview with Payroll and Scheduling Manager During an interview on 02/13/24 at approximately 6:00 PM, the Payroll and Scheduling Manager confirmed the facility had not posted a sign specifying the rights of employes under the EJA which should have included: -The reporting requirements of each employee. -A statement that an employee may file a complaint with the state survey agency against any long-term care Center that retaliates against an employee for reporting or causing a report to be made, and information about how to file such a complaint to the state survey agency. -The sign should have been posted in the same area that the Center posts other required employee signs. The Payroll and Scheduling manager indicated she was somewhat new to the position and indicated she would immediately address the error. l) Interview with Administrator During an interview on 12/14/23 at 1:25 PM, the following issues were addressed with the Administrator: -The Abuse Prohibition policy indicated that the Center would protect residents from further harm. -The Abuse Prohibition policy indicated resident care plans would be updated following incidents of abuse. -The Abuse Prohibition policy indicated the Administrator would at monthly Quality Assurance and Performance Improvement (QAPI) meetings, review all allegations of abuse to analyze occurrences to determine what changes were needed, if any, to prevent further occurrences. When asked if there was any evidence the Abuse Prohibition policy had been followed, the Administrator indicated she had just started on 02/01/24 and stated, I will have to look. I'm not sure how we were handling the issue in QAPI meetings. No further details were provided prior to exiting the facility on 02/14/24 at 2:30 PM.

Based on staff interview and record review, the facility administration failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Administration including the facility administrator and director of nursing (DON) was aware of resident to resident sexual abuse going on in the facility and failed to take appropriate action(s) to protect vulnerable residents. This was a random opportunity for discovery throughout the complaint survey process. The lack of action on the part of the administration created a problem for all seventeen (17) female residents living on the dementia unit. Resident identifiers: 64, #57, #56, #61, #62, #42, #43, #44, #45, #48, #49, #50, #51, #52, #58, #66. Facility census: 64. Findings included: a) Abuse Prohibition Policy Review of the facility's Abuse Prohibition Policy revealed the following details: - Sexual Abuse was defined as, a non-consensual sexual contact of any time with a patient. It includes but is not limited to sexual harassment, sexual coercion, or sexual assault. -Neglect was defined as, the failure, indifference, or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This includes the failure to implement an effective communication system across all shifts for communicating necessary care and information between Center, patient, practitioners, and patient representatives. -The section of the Abuse Prohibition policy titled PURPOSE indicated the reason for the policy was to ensure that Center staff are doing all that is within their control to prevent occurrences of abuse for all patients. -The section of the Abuse Prohibition policy titled PROCESS indicated: 1. The Center must ensure that all staff are aware of reporting requirements and must support an environment in which covered individuals report a reasonable suspicion of a crime. 2. The Center will post conspicuously in an appropriate location a sign specifying the rights of employes under the EJA. The sign shall include: 2.1 The reporting requirements of each employee. 2.2 A statement that an employee may file a complaint with the state survey agency against any long-term care Center that retaliates against an employee for reporting or causing a report to be made, and information about how to file such a complaint to the state survey agency. 2.3 The sign will be posted in the same area that the Center posts other required employee signs. -Additionally, the section titled PROCESS also indicated anyone who witnessed an incident of suspected abuse was to report the incident to his/her supervisor immediately. It then directed the notified supervisor would report the suspected abuse immediately to the Administrator or designee and other officials in accordance with state law. Lastly, it directed that all reports of suspected abuse must also be reported to the patient's family and attending physician. -The policy indicated that if the suspected abuse was patient-to-patient, the patient who had in any way threatened or attacked another would be removed from the setting or situation and an investigation would be completed. Additionally, it noted that the Center would provide adequate supervision when the risk of patient-to patient altercation is suspected. -Number seven (7) of the section titled PROCESS directed that immediately upon receiving information concerning a report of suspected or alleged abuse, the Administrator would report allegation not later than 2 hours after the allegation is made. -Number eight (8) of the section titled PROCESS indicated, The Center will protect patients from further harm during an investigation. -Number nine (9) of the section titled PROCESS stated the facility would take steps to revise patients' care plans where indicated if there was a change in the patients' medical, nursing, physical, mental or psychosocial needs or preferences as a result of an incident of abuse. -Number ten (10) of the section titled PROCESS indicated the Administrator would at monthly Quality Assurance and Performance Improvement (QAPI) meetings, review all allegations of abuse to analyze occurrences to determine what changes are needed, if any, to prevent further occurrences. b) Staff Interview with CNA #28 It's bad. Especially when we only have two (2) nurse aides on the hall. [Resident #64's nickname) targets certain females: [Resident #57's First and Last Name], [Resident #56's First and Last Name], [Resident #61's First and Last Name], and [Resident #62's First and Last Name]. By the time we get to him, he's usually successful with touching the female (either her breast or vagina) and we resort to redirecting him. We are always told by the nurses that it not that big of an issue since the female residents aren't in distress. That doesn't seem right. c) Staff Interview with CNA #49 -Nurse Aide interventions/redirections are needed almost daily. I've lost track of how many times it's happened. It seems to be getting worse. Now it is not just in resident rooms but in the tv room and the dining room. He's (Resident #64) usually successful in touching the females before we get to him. He's easy to redirect out of their rooms, but then he's back at it again in five minutes. I wish administration would teach us the correct interventions that would help prevent it from actually happening to the ladies. We're always told by our superiors if there is no distress, just keep redirecting him. The females aren't being protected. d) Staff Interview with CNA #53 It's worse in the mornings while breakfast is being served and staff are feeding other residents. It depends on how busy we are but there are times we don't get to him before he has been successful in entering a female resident's room and putting his hand up her shirt or down her pants. Nurses say it's not reportable if the female residents don't show signs of distress. I've been told by nurses to NOT document the sexual behaviors because he's already been identified as someone who exhibits inappropriate behaviors. We have talked amongst ourselves as aides, and we are starting to document under the public sexual acts option when we've told the nurses about his behaviors when he is touching other females without their consent because it's simply not right what is happening, and they are not reporting it. They (the female residents) have the right to be protected. e) Staff Interview with Anonymous Therapy Staff Member #84 I have witnessed him (Resident #64) touching female residents in their private areas several times. The direct care staff really struggle with keeping up with him. The best they can usually do is redirect him AFTER a touching incident has occurred. Staff say it's not a reportable unless the ladies show signs of distress. f) Staff Interview with Anonymous Therapy Staff Member #78 -The Nurse Aides were talking about the weekend of 02/03/24 - 02/04/24 and stated Resident #64 had entered Resident #62's room and when a nurse aide entered the room, Resident #64 had his penis on Resident #62's face. The nurse aide intervened and removed Resident #64 from the room and reported to the nurse on duty. It was being discussed among the nurse aides that the reporting nurse aide who had witnessed the event was told it was not reportable because Resident #62 showed no signs of distress, had previously been a prostitute and who knows if she was even bothered by it or not? The therapy staff member stated they had heard a nurse making the same exact statement when it was being discussed after the fact. Review of the facility reportable's log did not show a report had been made to the appropriate state agencies. Review of resident records did not reveal documentation of this incident. -On 02/08/24 a nurse aide had told Anonymous Therapy Staff Member #78 that Resident #64 had touched Resident #65's crotch. The therapy staff member reported this in writing to the Director of Nursing and never received a response. Review of the facility reportable's log did not show a report had been made to the appropriate state agencies. Review of resident records did not reveal documentation of this incident. g) Record review of Electronic Medical Records Nursing Notes from Resident #64's electronic medical record displayed the following times incidents were NOT reported to the appropriate state agencies as possible abuse: -General Note on 01/28/2024 at 08:20 AM, Resident continuing to be grossly sexual with female resident(s). Resident witnessed attempting to grab at said female resident(s) breasts. Resident removed from room multiple times. Resident brought to nursing station for closer monitoring this day. -General Note on 2/8/2024 at 7:05 PM, Resident is constantly entering female resident's rooms while they are sleeping to touch them inappropriately. He has to be watched closely to prevent this. ST [Speech Therapist] wheeled resident out of a female's room twice. Resident will also sit in his wheelchair in the hallway and wait for a female resident to walk by and attempt to grab their breasts/vaginas as they walk by. Review of the Behavior Monitoring and Interventions task revealed the following dates where Nurse Aides document Public Sexual Acts for Resident #64. -01/17/24 -01/26/24 -02/01/24 -02/04/24 -02/07/24 There was no further documentation related to what these sexual acts were nor was there any reporting of possible abuse on those dates. h) Review of the Facility's Abuse/Neglect Reportables Log Review of the facility's abuse/neglect reportables log, completed on 02/13/24 at 10:00 AM, revealed the following reportables related to Resident #64: 1. An eINTERACT SBAR (Situation, Background, Assessment, and Recommendation) Summary for Providers, dated 07/31/23 at 10:00 PM, indicated, CNA witnessed resident [Resident #64] and female resident [Resident #57] having contact intercourse in his room. Called for nurse. When nurse arrived, resident [Resident #64] had already dressed and was sitting in his chair by his bed and female resident had her shirt on and had one leg in her attends covering her peri area. She finished dressing and CNA walked her to TV room. This resident stayed in his room. Residents assessed. No injuries noted. No distress noted. 15-minute checks applied to both. A General Note, dated 8/1/2023 at 2:19 AM, noted, 07/31/23 at 2200 cna found resident having contact intercourse in his room during room checks. Separated. Assessed. No injuries or distress noted. 15-minute checks on residents no less than 72 hours. CEO and Social Services Director, Doctor notified immediately. Social Services Director notified the MPOAs. Left message with this residents MPOA. Further record review revealed: -Resident #57 had a Brief Interview for Mental Status (BIMS) score of five (05) according to her 05/12/23 admission Minimum Data Set (MDS). A score of five (05) indicates severe cognitive impairment. -Resident #64 had a BIMS score of 11 according to his 06/13/23 admission MDS. A score of 11 indicates moderate cognitive impairment. 2. An eINTERACT SBAR Summary for Providers, dated 09/01/23 at 11:05 AM, indicated the following: Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Other change in condition Relevant medical history is: Dementia Nursing observations, evaluation, and recommendations are: Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: monitor An Unusual Event Reportable was completed and sent to state agencies on 09/01/23. The details of the Unusual Event Reportable were, Residents [Resident #57's First and Last Name] and [Resident #64's First and Last Name] were observed by staff touching each other. [Resident 64's Last Name] touched [Resident #57's First Name]'s breast. [Resident #57's First Name] was touching his body (arms, legs, hand). Redirected and separated. 3. A General Note, dated 10/22/23 at 4:05 PM, noted, CNA created custom alert regarding said resident (Resident #64) having hands down [Resident #56's First and Last Initial] pants. CNA states she entered room to pick up breakfast trays and said resident was pulling hands out of [Resident #56]'s pants. CNA redirected resident (Resident #64) to resident's own room and advised resident to eat breakfast. CNA continued to check on resident frequently while on floor until resident went to common area. Further record review revealed: -Resident #56 had a BIMS score of two (02) according to her 08/01/23 admission Minimum Data Set (MDS). A score of two (02) indicates severe cognitive impairment. 4. An eINTERACT SBAR Summary for Providers, dated 12/04/23 at 5:25 PM, indicated, Another resident [Resident #57] punched this resident [Resident #64] 3 or 4 times in the right upper thigh. No bruising or injuries at this time. -Resident #57 had a BIMS score of zero (00) according to her 11/17/23 Significant Change MDS. A score of zero (00) indicates severe cognitive impairment. i) Review of Resident 64's Care Plan Review of Resident #64's care plan, completed on 02/13/24 at 11:00 AM, revealed resident was first care planned for inappropriate sexual behaviors on 08/01/23. His care plan was not modified again as it related to his inappropriate sexual behaviors until 01/25/24 when it was noted that the physician would complete a medication review due to increased anxiety and sexual behaviors. j) Interview with Director of Nursing (DON) During an interview on 02/13/24 at approximately 3:00 PM, the DON reported, His (Resident #64's) behaviors have been a high-focus area for me since I started this position in late September. When asked how the decision is ultimately made about what is and what is not a reportable event, the DON reported the facility social worker drives a lot of the reporting and it has a lot to do with whether the alleged event was detrimental or caused harm to a resident. The DON could not answer why the 09/01/23 incident where Resident #64 touched Resident #57 was reported as an Unusual Occurrence noting that the reporting had been done by the facility social worker who was off on medical leave. The DON acknowledged that the Unusual Occurrence report did not have a five-day follow-up associated with it. The DON indicated that the facility has more reportables here than any other place I've worked. When asked about why CNAs would be reporting that they've been told by nurses that Resident #64's resident to resident sexual aggression was not a reportable event since he was care planned to have inappropriate sexual behaviors and the women he was touching were not reportedly in visible distress, the DON remained silent for a long while. While discussing the reasonable person concept and explaining one could conclude that as a female having a male enter your room and place his hand up your shirt to fondle your breast or place his hand down your pants to touch your vagina, it would result in serious psychosocial harm/mental anguish, the DON then stated the nurses are trained to call her with any allegations of abuse. When asked if she felt Resident #57's documented aggression towards Resident #64 where she punched him three (3) or four (4) times in his thigh could have been a direct result of Resident #64 repeatedly touching her breasts, the DON remained silent. When asked if she might know why there have been many instances documented in Resident #64's record where he had been exhibiting sexually aggressive behaviors but there was no documentation that she had been contacted, the DON shrugged and indicated she did not have an answer to that question, but the nursing staff had failed to notify her of all the resident-to-resident concerns. Before the interview ended, the DON stated, He (Resident #64) is like a child acting out to get attention. I don't believe it is an intimacy issue. I think he wants to move to the other hall so he can play cards with his old friends. k) Interview with Payroll and Scheduling Manager During an interview on 02/13/24 at approximately 5:40 PM, the Payroll and Scheduling Manager confirmed the facility had not posted a sign specifying the rights of employes under the EJA which should have included: -The reporting requirements of each employee. -A statement that an employee may file a complaint with the state survey agency against any long-term care Center that retaliates against an employee for reporting or causing a report to be made, and information about how to file such a complaint to the state survey agency. -The sign should have been posted in the same area that the Center posts other required employee signs. The Payroll and Scheduling manager indicated she was somewhat new to the position and indicated she would immediately address the error. l) Interview with Administrator During an interview on 12/14/23 at 1:25 PM, the following issues were addressed with the Administrator: -The Abuse Prohibition policy indicated that the Center would protect residents from further harm. -The Abuse Prohibition policy indicated resident care plans would be updated following incidents of abuse. -The Abuse Prohibition policy indicated the Administrator would at monthly Quality Assurance and Performance Improvement (QAPI) meetings, review all allegations of abuse to analyze occurrences to determine what changes were needed, if any, to prevent further occurrences. When asked if there was any evidence the Abuse Prohibition policy had been followed, the Administrator indicated she had just started on 02/01/24 and stated, I will have to look. I'm not sure how we were handling the issue in QAPI meetings. No further details were provided prior to exit from the facility on 02/14/24 at 2:30 PM.

Based on resident interview, medical record review, staff interview, and policy review, the facility failed to ensure two (2) of three (3) residents reviewed for abuse, were free from physical, emotional, mental and/or sexual abuse. Resident #40 expressed fear of Resident #75 who had grabbed her and kissed her on the cheek. Resident #75 allegedly struck Resident #51 in the face with his fist and on another occasion struck the resident multiple times with a metal object. Resident identifiers: #40, #51, and #75. Facility census: 53. Findings include: a) Resident #40 During a Stage 1 interview on 08/22/16 at 3:42 p.m., Resident #40 expressed fear of Resident #75. She said the mean man was dangerous and they (the facility) knew it, and kept him knowing. The resident said the facility should have done something sooner. She added that he had struck (name of Resident #51) several times with a metal object. The Director of Nursing (DON) identified Resident #40 was referring to Resident #75. Resident #40's medical record, reviewed on 08/24/16 at 9:17 a.m., found the resident's [DIAGNOSES REDACTED]. Her minimum data set (MDS) assessment with an assessment reference date of 08/03/16, identified the resident scored 14 on The Brief Interview for Mental Status (BIMS) indicating Resident #40 was cognitively intact. A progress note, dated 06/12/16, indicated Resident 40 had expressed a concern regarding Resident #75 and she was told by the nurse to stay away from him. During an interview on 08/24/16 at 4:07 p.m., with the DON and current administrator, the administrator related the facility had additional information they would like to share. The DON stated that Resident #75 thought Resident #40 was his daughter and would pet down her back and kiss her on the head. The DON said she did not know it was actually sexual behavior because the resident (#75) had dementia. During another interview, on 08/30/16 at 10:47 a.m., in the presence of another surveyor, Resident #40, when asked again to describe the incident between herself and Resident #75, said she was in the hallway and Resident #75 grabbed her and kissed her on the cheek. She repeated that she did not know why Resident #75 kissed her, but it scared her and she told the nurse, who told her to stay away from him. Resident 40 stated she felt fearful and voiced she would not have been able to get away from Resident #75 if he approached her and stated, He was crazy. The resident stated she had always been afraid of Resident 75, and again voiced he had hit (Resident #51's name) with a metal object. Observations of transfers on 08/23/16, 08/24/16 and 08/25/16, revealed Resident #40 transferred with the use of a mechanical lift and was totally dependent on staff. Once in the wheelchair, the resident was able to propel herself, but moved very, very slowly. Review of Resident #75's medical record, on 08/24/16 at 9:17 a.m., found he was able to walk without assistance. The administrator, interviewed on 08/30/16 at 1:22 p.m. acknowledged no evidence was present to indicate the facility actively sought a resolution to Resident #40's concern and that telling Resident #40 to stay away from Resident #75 was not an adequate intervention as she required the use of a wheelchair and Resident #75 was ambulatory. The administrator agreed the facility should have addressed Resident #40's fears. b) Resident #51 During a Stage 1 interview on 08/22/16 at 3:42 p.m., Resident #40 voiced that Resident #75 had exhibited violent behaviors and had been physically abusive prior to his discharge. The resident said The mean man hit (Resident #51) on the head - he was dangerous and they knew it and kept him knowing. The resident further added, He had already hit her (Resident #51) in the head with his fist. Resident #40 reported she saw Resident #75 pushing a table down the hallway, and he hit Resident #51 four (4) for five (5) times with the metal leg from off the table. She added, We all was panicking, scared to death. I couldn't (could not) sleep. They took him out and brought him back the same night. Reportable allegations, reviewed on 08/23/16 at 4:09 p.m., noted an allegation of resident to resident abuse with Resident #75 as the alleged perpetrator. The report, dated 06/20/16, indicated the incident occurred on 06/19/16 at about 8:50 p.m. The nurse noted that while administering medications she heard the alleged victim screaming for help, and when nursing staff arrived, Resident #75 was using a metal object to strike the victim in the head and upper back. Both residents were transferred to the hospital for evaluation and treatment. The five (5) day follow-up report indicated Resident #75 had obtained a bedside table from the therapy room with a piece of equipment on it, picked up the piece of equipment, slammed it to the floor, breaking a leg off the equipment, which he picked up and used to hit Resident #51 repeatedly. Resident #51's statement indicated Resident #75 came down the hallway pushing the bedside table with the exercise equipment on it. The resident said she told him she did not think he was allowed to do that. She said as he got closer to her he picked up the equipment and threw it in the floor, and after it broke he picked up a piece of it and hit her repeatedly in the head. She related she screamed, and staff came to help her. Resident #51 said she thought he was going to kill her, and only felt safe after he was put on one on one (1:1) supervision with a staff member. Resident #40's witness statement in the reportable allegation indicated she saw Resident #75 standing up in the hall. He was staring and pointing at Resident #40 and she told another resident He is going to do something, he is up to something .I seen him coming with the table, he started walking slow then he started walking faster and ran into (Resident #51's name). He was hitting her back with the table repeatedly hard. He took the metal leg, I don't know where he got it from, but he hit (Resident #51) on the head four to five (4-5) times really hard. I still can't (can not) get it out of my head. We were all really afraid. We couldn't do anything to help her. We were all yelling for help. Witness statements provided by staff indicated the LPN on red hall heard someone screaming and ran toward the sound. When the nurse approached the area, she observed Resident #75 striking Resident #51 repeatedly with an object. She indicated the object used to strike Resident #51 was broken off of a bicycle exercise equipment. Another LPN said she heard screams in the hall and ran toward the screams. She indicated Resident #51 had her hands over her head to protect herself. One nurse aide (NA) reported she was outside on break and did not witness any of the event and one resident related he/she was in a room providing direct care and did not see what actually happened, but assisted the LPN to keep Resident #75 away from Resident #51 with one-on-one monitoring. Another NA related using the restroom, and when finished, saw Resident #75 lowering his hands with the therapy equipment, and staff had intervened. The hospital discharge summary, dated 06/19/16 indicated Resident #51 had a mild closed head injury, and contusions to the vertex/occipital scalp due to an alleged assault. Another emergency department note indicated the Registered Nurse from the facility indicated the chief complaint was that Resident #51 was struck to the back of the head multiple times and another note in the section indicated Resident #51 was struck to the left side of the jaw the previous day. The hospital preliminary report from the ambulance service indicated Resident #51 informed them the same resident had struck her in the left side of the jaw the previous day. Follow-up interviews with the DON and ADON on 08/30/16 between 8:30 a.m. and 10:30 a.m., indicated they were not aware of the alleged incident voiced by Resident #51 indicating Resident #75 had hit her in the jaw. They confirmed no reports were available to indicate the facility had identified and/or intervened on behalf of Resident #51. c) Resident #75 Progress notes, reviewed at 9:43 a.m. indicated Resident #75 arrived by private car with family on 06/10/16. The reason for admission was noted as exacerbation of chronic illness long-term care. The admission information indicated Resident #75 had a [DIAGNOSES REDACTED]. Progress notes, dated 06/10/16 to 06/20/16 revealed the following chain of events: -- 06/10/16 at 12:45 p.m., Resident #75 was admitted from another facility -- 06/11/16 at 6:57 p.m., and 06/12/16 and at 7:49 a.m. indicated the resident was continuously having exit seeking behaviors, stating he needed to go home, staff educated he lived at the facility, the resident verbalized understanding, turned around and pushed on the bar of the door. Staff intervention was to monitor closely. -- 06/12/16 at 7:49 a.m., the note indicated Resident #75 attempted to exit the building at the beginning of the shift (7:00 p.m.) and had said he was leaving and did not care what happened to him. -- 06/12/16 at 7:58 a.m., noted Resident #75 was observed making sexual obviators (sic) to female residents, redirected to other activities and closely monitoring for further behaviors. -- 06/13/16 at 1:34 p.m., indicated the resident wandered in the hallways and into several other residents' rooms, was exit seeking and was redirected with moderate redirection. -- 06/14/16 at 2:25 p.m., a note by Administrator #82 indicated the family was notified of a room transfer from a semi-private to private room, but did not indicate why. -- 06/14/16 at 6:46 p.m. a social history and assessment noted a Brief Interview for Mental Status with a score of 5.0, which indicated the resident was severely cognitively impaired. -- 06/15/16 .Resident roaming hallways stopping in front of females doorways standing there looking in at them resident difficult with redirecting away from doorways -- 06/17/16 at 11:21 a.m., an interdisciplinary note by the assistant director of nursing (ADON), indicated Resident #75 .ambulates independently in center .does exit seek at times, but is easily redirected .pleasant and appears to be adjusting easily to new environment. -- 06/17/16 at 7:43 p.m., a note indicated Resident #75 continued to wander into other residents' rooms, was agitated several times today. -- 06/18/16 at 4:44 a.m. indicated the resident wanders all over the facility and into other rooms Resident becomes agitated at times and is easily redirected. -- 06/18/16 at 7:00 p.m. indicated Resident #75 exited via the front door with a visitor . gets easily agitated at others when the (they) are accusatory toward him, and noted the resident expressed his desire to leave the facility several times. -- 06/19/16 at 2:02 p.m., .wandering all over the facility going into others rooms .does go to exit doors often requesting he needed out. -- 06/19/16 at 2:02 p.m., a progress note indicated his daughter took him out for breakfast and upon return was crying, upset, and had said, He was so mean to me. He told me I was stupid. He kept saying You just don't (do not) know, you just don't know. The daughter had informed them the resident threatened to just take off and go over the hill and get away from here. The nurse noted Resident #75 was very agitated, activity staff took him outside and sat with him, and he was getting more upset about being there. The nurse voiced he had been moved to a private room, but did not know why. -- 06/19/16 at 9:21 p.m., discussed, Patient with increased agitation noted. Called to hallway by screams in hallway. Found resident actively using a wheelchair leg rest to hit another resident to back of the head and upper back. Hard to redirect at this time. Nurse immediately removed wheelchair rest from resident's hands. He was able to be assisted patient back to his room after several attempts. Patient still displays confusion and anger An order was received for 1:1 supervision and resident transferred to the hospital. -- 06/20/16 at 1:24 p.m., indicated an order was received for medication administration, no entry as to what time the resident returned from the hospital. While out of the facility, resident was determined to have 100 percent coverage of benefits and was transferred via private vehicle with his daughter to another facility at 3:33 p.m. One to one (1:1 ) intervention continued until he left the building. Nurse Aide #16, interviewed on 08/24/16 at 10:04 a.m., voiced she was unaware Resident #75 had exhibited sexual behaviors of any type, or had thought Resident #40 looked like his daughter and did not like her interacting with Resident #51. The NA was not aware staff were to monitor the resident closely. NA #16 stated Resident #75's mood varied - he was sometimes pleasant and sometimes very short. On 08/24/16 at 1:07 p.m., upon inquiry regarding Resident #75's sexual obviators, the administrator reviewed the progress note dated 06/12/16. The administrator voiced he did not know what was meant by the note and would speak with the director of nursing (DON) as to how the incident was handled and what interventions were implemented. Further discussion at 2:54 p.m. with the administrator and director of nursing (DON), the DON said the facility thought Resident #75 petted down Resident #40's back and kissed her because he thought she was his daughter and she looked like his daughter. She further added that Resident #75 did not like Resident #40 talking to the black lady he perceived to be a male (identified by the DON as Resident #51). The care plan, reviewed on 08/24/16 at 9:17 a.m. included a problem statement of cognitive impairment and interventions included: monitor for behaviors, underlying causes, monitor for pain, monitor and evaluate types of changes in cognitive status, evaluate behavioral symptoms for underlying causes, evaluate for the need of a behavioral/psychological consult. The care plan did not address anxiety for which the resident received [MEDICATION NAME], sexual behaviors, elopement attempts, or Resident #75's actual agitated and aggressive behavior. The care plan did not address Resident #75's belief that Resident #40 was his daughter or his dislike of her talking to Resident #51. Licensed Practical Nurse (LPN) #45 interviewed on 08/24/16 at 10:48 a.m., stated Resident #75 did not like people who were black, was always looking for a way to get out of the building, and seemed upset with his daughter for bringing him to the facility. The nurse related the resident could hold a good conversation, was aggressive at times, wandered, would go to the doors, curse sometimes, but was not aware of sexual obviators. LPN #45 said she thought other residents were fearful of him and would say to her, Be careful. Don't (do not) let him hurt you. Upon inquiry as to which residents were fearful, the nurse related she could not remember. The medical record, reviewed with Registered Nurse (RN) #68 at 12:00 p.m. on 08/25/16, confirmed Resident #75 had received the [MEDICAL CONDITION] medication [MEDICATION NAME], an antianxiety medication, from the time of admission on 06/10/16. The RN confirmed the care plan did not address the use of the anxiety, or of sexual behaviors toward female residents. Additionally, the care plan did not address the resident's anxiety for which he received [MEDICATION NAME], or the possible emotional connection to Resident #40 (thought she looked like/or was his daughter) or aversion to Resident #51 (who staff said Resident #75 identified as a black male.) The care plan indicated staff would monitor for behaviors, but did not identify what behaviors. Upon inquiry as to how often or when several occasions occurred, the nurse verified one would not know without asking the nurse. Nurse #68 confirmed the medical record did not provide a clear picture of Resident #75's behaviors, or how frequently the behaviors occurred. When asked which diversion interventions were successful and which interventions were not successful, RN #68 confirmed the medical record did specify how many times the resident was agitated, or which interventions were utilized and were successful or failed. e) The abuse policy indicated the facility staff would do what was within their control to prevent occurrences of abuse and neglect and prevention included identifying, correcting, and intervening in situations in which abuse was more likely to occur and included patient to patient abuse. The policy also noted a representative from social services or designee would monitor the resident's feelings concerning the incident, as well as the resident's involvement in the investigation. f) No evidence was provided to indicate the facility had adequately intervened and monitored Resident #75 to ensure the safety of residents. No evidence was present to indicate which interventions the facility had tried and found ineffective when or how frequently Resident #75 exhibited signs/symptoms of agitation and what those signs and symptoms included, or that a plan was developed related to sexual behaviors, his possible dislike of black individuals, and his perceived need to protect Resident #40 from Resident #51. No evidence was presented to indicate the facility monitored for changes that would trigger abusive behavior or ensured that staff assigned had knowledge of Resident #75's behavioral care needs. Progress notes dated 06/17/16, 06/18/16 and 06/19/16 noted the resident had several episodes of agitated behavior and did not like to be directed. There was no evidence found to indicate the facility had actively sought a resolution prior to the assault on Resident #51. The administrator, interviewed on 08/30/16 at 1:22 p.m., acknowledged no evidence was present to indicate the facility actively sought a resolution to Resident #40's concern and that telling Resident #40 to stay away from Resident #75 was not an adequate intervention as she required the use of a wheelchair and Resident #75 was ambulatory. Additionally, the facility provided no evidence to indicate Resident #40's fear had been address during the perpetrators stay at the facility. There was no evidence the facility identified Resident #75's behaviors were escalating and attempted to identify and address causal factors, and/or sought medical interventions while evaluating the resident. This failure culminated in actual harm to Resident #51 who sustained injuries to her head when Resident #75 hit her with a metal object, and residents, who like Resident #40, were afraid of Resident #75.

Based on resident interview, staff interview, and medical record review, the facility failed to assess and monitor a newly admitted resident and failed to implement interventions when his behaviors began to escalate culminating in actual harm when he hit Resident #51 with a metal object. This was found for one (1) of one (1) resident reviewed for behaviors. Resident identifier: #75, #40, and #51. Facility census: 53. Findings include: a) Resident #75 Resident #75's medical record, reviewed on 08/24/16 at 9:07 a.m., the resident found the discharge transition plan from the nursing home from which he transferred 06/10/16, that identified the resident had dementia without behaviors. The receiving facility's admission summary dated 06/10/16 also reflected the [DIAGNOSES REDACTED]. The resident's admission comprehensive minimum data set assessment, with an assessment reference date of 06/15/16, identified he wandered daily, that his wandering put him at significant risk of getting into potentially dangerous places, and that his wandering significantly intruded upon the privacy or activities of others. The assessment also identified he sometimes understood others and sometimes could be understood. Progress notes, reviewed at 9:43 a.m. on 08/24/16, indicated Resident #75 arrived by private car from another nursing home with his family on 06/10/16. The reason for admission was noted as exacerbation of chronic illness long-term care. The admission information indicated Resident #75 had a [DIAGNOSES REDACTED]. Progress notes, dated 06/10/16 to 06/20/16 revealed the following chain of events: -- 06/10/16 at 12:45 p.m. - Resident #75 was admitted from another facility -- 06/11/16 at 6:57 p.m., and 06/12/16 and at 7:49 a.m. - described the resident was continuously having exit seeking behaviors, stating he needed to go home, staff educated him he lived at the facility, the resident verbalized understanding, turned around and pushed on the bar of the door (exit door). Staff intervention was to monitor closely. -- 06/12/16 at 7:49 a.m., the note indicated Resident #75 attempted to exit the building at the beginning of the shift (7:00 p.m.). Resident up at beginning of shift; several attempts to exit building. When I tried to redirect resident, he said he was leaving and he didn't care what happened to him -- 06/12/16 at 7:58 a.m., noted Resident #75 was observed making sexual obviators (sic) (overtures) to female residents, redirected to other activities and closely monitoring for further behaviors. -- 06/13/16 at 1:34 p.m. - indicated the resident wandered in the hallways and into several other residents' rooms, was exit seeking, and redirected with moderate redirection. -- 06/14/16 at 2:25 p.m. - A note written by Administrator #82 indicated the family was notified of a room transfer from a semi-private to private room, but did not indicate why. -- 06/14/16 at 6:46 p.m. - a social history and assessment noted the resident's score for the Brief Interview for Mental Status was 5.0 which indicated the resident was severely cognitively impaired. -- 06/15/16 at 1:54 a.m. - .resident roaming hallways stopping in front of females doorways standing there looking in at them resident difficult with redirecting away from doorways -- 06/17/16 at 11:21 a.m., an interdisciplinary note by the assistant director of nursing (ADON), indicated Resident #75 .ambulates independently in center .does exit seek at times, but is easily redirected .pleasant and appears to be adjusting easily to new environment. -- 06/17/16 at 7:43 p.m., a note indicated Resident #75 continued to wander into other residents rooms, was agitated several times today. -- 06/18/16 at 4:44 a.m. - the resident wanders all over the facility and into other rooms .Resident becomes agitated at times and is easily redirected. -- 06/18/16 at 7:00 p.m. indicated Resident #75 exited via the front door with a visitor .gets easily agitated at others when the (they) are accusatory toward him, and noted the resident expressed his desire to leave the facility several times. -- 06/19/16 at 2:02 p.m. - wandering all over the facility going into others rooms .does go to exit doors often requesting he needed out. -- 06/19/16 at 2:02 p.m. - a progress note indicated his daughter took him out for breakfast and upon return was crying, upset, and had said, He was so mean to me. He told me I was stupid. He kept saying, You just don't (do not) know, you just don't know. The daughter had informed them the resident threatened to, Just take off and go over the hill and get away from here. The nurse noted Resident #75 was very agitated, activity staff took him outside and sat with him, and he was getting more upset about being there. The nurse voiced he had been moved to a private room, but did not know why. -- 06/19/16 at 9:21 p.m. - discussed, Patient with increased agitation noted. Called to hallway by screams in hallway. Found resident actively using a wheelchair leg rest to hit another resident (Resident #51) to back of the head and upper back. Hard to redirect at this time. Nurse immediately removed wheelchair rest from resident's hands. He was able to be assisted patient back to his room after several attempts. Patient still displays confusion and anger order received for 1:1 supervision and resident transferred to the hospital. -- 06/20/16 at 1:24 p.m. - an order was received for medication administration. There was no entry in the resident's medical record to identify what time the resident returned from the hospital. While out of the facility, resident was determined to have 100 percent coverage of benefits and the resident's daughter transferred him by private vehicle to another facility at 3:33 p.m. One to one (1:1) intervention continued until he left the building. During a Stage 1 interview on 08/22/16 at 3:42 p.m., Resident #40 alleged fear of Resident #75. The resident said the facility should have done something sooner. Resident #40 continued saying that Resident #75 had exhibited violent behaviors and had been physically abusive prior to his discharge. The resident said, The mean man (Resident #75) hit (Resident #51) on the head - he was dangerous and they knew it and kept him knowing. The resident further added, He had already hit her (Resident #51) in the head with his fist. Resident #40 reported she saw Resident #75 pushing a table down the hallway, and he hit Resident #51 four (4) for five (5) times with the metal leg from off the table. She added, We all was panicking, scared to death. I couldn't (could not) sleep. They took him out and brought him back the same night. Reportable allegations, reviewed on 08/23/16 at 4:09 p.m., noted an allegation of resident to resident abuse with Resident #75 as the alleged perpetrator. The report, dated 06/20/16, indicated the incident occurred on 06/19/16 at about 8:50 p.m. The nurse noted that while administering medications she heard the alleged victim screaming for help, and when nursing staff arrived, Resident #75 was using a metal object to strike the victim in the head and upper back. Both residents were transferred to the hospital for evaluation and treatment. The five (5) day follow-up report indicated Resident #75 had obtained a bedside table from the therapy room with a piece of equipment on it, picked up the piece of equipment, slammed it to the floor, breaking a leg off the piece of equipment, which he picked up and used to hit Resident #51 repeatedly. Resident #51's statement indicated Resident #75 came down the hallway pushing the bedside table with the exercise equipment on it. The resident said she told him she did not think he was allowed to do that. She said as he got closer to her he picked up the equipment and threw it in the floor, and after it broke he picked up a piece of it and hit her repeatedly in the head. She related she screamed and staff came to help her. Resident #51 said she thought he was going to kill her, and only felt safe after he was put on one on one (1:1) with a staff member. Resident #40's witness statement in the reportable allegation indicated she saw Resident #75 standing up in the hall. He was staring and pointing at Resident #40 and she told another resident He is going to do something, he is up to something .I seen him coming with the table, he started walking slow then he started walking faster and ran into (Resident #51's name). He was hitting her back with the table repeatedly hard. He took the metal leg, I don't know where he got it from, but he hit (Resident #51) on the head four to five (4-5) times really hard. I still can't (cannot) get it out of my head. We were all really afraid. We couldn't do anything to help her. We were all yelling for help. The hospital discharge summary, dated 06/19/16 indicated Resident #51 had a mild closed head injury, and contusions to the vertex/occipital scalp due to an alleged assault. Another emergency department note indicated the Registered Nurse from the facility indicated the chief complaint was that Resident #51 was struck to the back of the head multiple times and another note in the section indicated Resident #51 was struck to the left side of the jaw the previous day. The hospital preliminary report from the ambulance service indicated Resident #51 informed them a resident had struck her on the left side of the jaw the previous day. Follow-up interviews with the DON and ADON on 08/30/16 between 8:30 a.m. and 10:30 a.m., indicated they were not aware of the alleged incident voiced by Resident #51 indicating Resident #75 had hit her in the jaw. They confirmed no reports were available to indicate the facility had identified and/or intervened on behalf of Resident #51. On 08/25/16 at 9:51 a.m., during a follow-up interview with Resident #40 when asked to describe the incident between herself and Resident #75 on 06/12/16, she said she was in the hallway and Resident #75 grabbed her and kissed her. When asked where he kissed her, she said her cheek and placed her hand on her face. The resident related she did not know why Resident #75 kissed her, but it scared her and she told the nurse. The resident said the nurse told her to stay away from him. With further inquiry, the resident said she felt fearful and voiced she would not have been able to get away from the resident if he approached her. She added, He was a big guy. During another interview, on 08/30/16 at 10:47 a.m., in the presence of another surveyor, Resident #40, when asked again to describe the incident between herself and Resident #75, said she was in the hallway and Resident #75 grabbed her and kissed her on the cheek. She repeated that she did not know why Resident #75 kissed her, but it scared her and she told the nurse, who told her to stay away from him. Resident 40 stated she felt fearful and voiced she would not have been able to get away from Resident #75 if he approached her and stated, He was crazy. The resident stated she had always been afraid of Resident 75, and again voiced he had hit (Resident #51's name) with a metal object. When asked about her interview with the former administrator, Resident #40 denied a conversation between herself and Administrator #82. The resident said no one had followed up with her regarding her concern and she was not sure what had been done about it. Review of Resident #75's care plan on 08/24/16 at 9:17 a.m., found a problem statement regarding his cognitive impairment. The interventions included, monitor for behaviors, underlying causes, monitor for pain, monitor and evaluate types of changes in cognitive status, evaluate behavioral symptoms for underlying causes, evaluate for the need of a behavioral/psychological consult. The care plan did not address anxiety for which the resident received [MEDICATION NAME] (an antianxiety medication), sexual behaviors, elopement attempts, or Resident #75's actual agitated and aggressive behavior. The care plan did not address Resident #75's belief that Resident #40 was his daughter or his dislike of her talking to Resident #51. Nurse Aide #16, interviewed on 08/24/16 at 10:04 a.m., said she was unaware Resident #75 had exhibited sexual behaviors of any type, or had thought Resident #40 looked like his daughter (The Director of Nursing said Resident #75 thought Resident #40 looked like his daughter, or was his daughter) and did not like her interacting with Resident #51. The NA was not aware staff were to monitor the resident closely. NA #16 stated Resident #75's mood varied, and was sometimes pleasant and sometimes very short. During an interview with Licensed Practical Nurse (LPN) #45 on 08/24/16 at 10:48 a.m., the nurse reported Resident #75 seemed upset about being at the facility and exhibited aggressive behaviors at times, and related he did not like black people. The LPN stated she thought residents were fearful of him because they would say, Be careful. Don't (do not) let him hurt you. Upon inquiry as to which residents were fearful, the nurse related she could not remember. On 08/24/16 at 1:07 p.m., upon inquiry regarding Resident #75's sexual behaviors, the administrator reviewed the progress note dated 06/12/16. The administrator voiced he did not know what was meant by the note and would speak with the director of nursing (DON) as to how the incident was handled and what interventions were implemented. During a further discussion at 2:54 p.m., with the administrator and director of nursing (DON), the DON voiced the facility thought Resident #75 petted down Resident #40's back and kissed her because he thought she was his daughter and she looked like his daughter. She further added that Resident #75 did not like Resident #40 talking to the black lady he perceived to be a male (identified by the DON as Resident #51). Licensed Practical Nurse (LPN) #45, interviewed on 08/24/16 at 10:48 a.m., stated that Resident #75 did not like people who were black, was always looking for a way to get out of the building, and seemed upset with his daughter for bringing him to the facility. The nurse related the resident could hold a good conversation, was aggressive at times, wandered, would go to the doors, curse sometimes, but was not aware of sexual behaviors. LPN #45 said she thought other residents were fearful of him and would say to her, Be careful. Don't (do not) let him hurt you. Upon inquiry as to which residents were fearful, the nurse said she could not remember. The medical record, reviewed with Registered Nurse (RN) #68 at 12:00 p.m. on 08/25/16, confirmed Resident #75 had received the [MEDICAL CONDITION] medication [MEDICATION NAME] from the time of admission on 06/10/16. The RN confirmed the care plan did not address the use of [MEDICATION NAME], or of sexual behaviors toward female residents. Additionally, the care plan did not address that, according to the Director of Nursing, the resident thought Resident #40 looked like, or was, his daughter. Additionally, the plan did not address Resident #75's aversion to Resident #51 (a female), who staff said Resident #75 identified as a black male. The care plan indicated staff would monitor for behaviors, but did not identify active behaviors. Upon inquiry as to how often or when several occasions occurred, the nurse verified one would not know without asking the nurse. RN #68 confirmed the medical record did not provide a clear picture of Resident #75's behaviors, how frequently the behaviors occurred, and the specific interventions staff used. When asked what diversion interventions were provided, and whether the interventions were successful or unsuccessful, RN #68 confirmed the medical record did specify how many times the resident was agitated, or which interventions were utilized and successful or failed. No evidence was provided to indicate the facility provided guidance to direct care staff to help them identify what might trigger behaviors, measured to employ in an attempt to avoid an escalation of behaviors, and had not ensured all direct care staff were aware of the need to monitor Resident #75 to ensure the safety of other residents. No evidence was present to indicate which interventions the facility had tried and found ineffective, when or how frequently Resident #75 exhibited signs/symptoms of agitation and what those signs and symptoms included, or that a plan was developed related to sexual behaviors, his possible dislike of black individuals and his perceived need to protect Resident #40 from Resident #51. The facility provided no evidence to support it monitored for changes that would trigger abusive behavior or ensured that staff assigned had knowledge of Resident #75's behavioral care needs. Progress notes dated 06/17/16, 06/18/16, and 06/19/16 noted the resident had several episodes of agitated behavior and resisted redirection. There was no evidence to indicate the facility had actively sought a resolution prior to the assault with a metal object, resulting in actual harm to Resident #51.

Based on resident interview, staff interview, medical record review, policy review, the social services job description, and review of allegations reported to state agencies, resident council minutes, and concern/grievance/complaint forms, the facility failed to ensure the provision of medically related social services were sufficient and appropriate to meet residents' needs. This practice affected four (4) residents, but had the potential to affect more than a limited number. The facility failed to identify and pursue the provision of medically related social services services; for a resident with escalating behaviors, for a resident who expressed another resident had made sexual overtures, for a resident who indicated staff were not answering call lights appropriately and timely, for a resident who complained about being left on a bed pan, and for a resident who voiced missing personal property. Resident identifiers: #75, #40, #2 and #81. Facility census: 53. Findings include: a) Resident #75 Resident #75's medical record, reviewed on 08/24/16 at 9:07 a.m., noted a discharge transition plan and admission summary which indicated the resident had a [DIAGNOSES REDACTED]. A hospital discharge summary, dated 06/20/16 indicated the resident was evaluated for aggressive behaviors. Progress notes, reviewed at 9:43 a.m. indicated Resident #75 arrived by private car with family on 06/10/16. The reason for admission was noted as exacerbation of chronic illness long-term care. Progress notes, dated 06/10/16 to 06/20/16 revealed the following chain of events: -- 06/10/16 at 12:45 p.m., Resident #75 was admitted from another facility. -- 06/11/16 at 6:57 p.m., and 06/12/16 and at 7:49 a.m. indicated the resident was continuously having exit seeking behaviors, stating he needed to go home, staff educated he lived at the facility, the resident verbalized understanding, turned around and pushed on the bar of the door. Staff intervention was to monitor closely. -- 06/12/16 at 7:49 a.m., the note indicated Resident #75 attempted to exit the building at the beginning of the shift (7:00 p.m.) and had said he was leaving and did not care what happened to him. -- 06/12/16 at 7:58 a.m., noted Resident #75 was observed making sexual overtures to female residents, redirected to other activities and closely monitoring for further behaviors. -- 06/13/16 at 1:34 p.m., indicated the resident wandered in the hallways and into several other residents rooms, was exit seeking and redirected with moderate redirection. -- 06/14/16 at 2:25 p.m., A note per Administrator #82 indicated the family was notified of a room transfer from a semi-private to private room, but did not indicate why. -- 06/14/16 at 6:46 p.m. a social history and assessment noted a brief interview for mental status with score of 5.0 which indicated the resident was severely cognitively impaired. -- 06/15/16 .Resident roaming hallways stopping in front of females doorways standing there looking in at them resident difficult with redirecting away from doorways . -- 06/17/16 at 11:21 a.m., an interdisciplinary note per the assistant director of nursing (ADON), indicated Resident #75 .ambulates independently in center .does exit seek at times, but is easily redirected .pleasant and appears to be adjusting easily to new environment. -- 06/17/16 at 7:43 p.m., a note indicated Resident #75 continued to wander into other residents rooms, was agitated several times today. -- 06/18/16 at 4:44 a.m. indicated the resident wanders all over the facility and into other rooms Resident becomes agitated at times and is easily redirected. -- 06/18/16 at 7:00 p.m. indicated Resident #75 exited via the front door with a visitor . gets easily agitated at others when the (they) are accusatory toward him, and noted the resident expressed his desire to leave the facility several times. -- -6/19/16 at 2:02 p.m., wandering all over the facility going into others rooms .does go to exit doors often requesting he needed out. -- 06/19/16 at 2:02 p.m., a progress note indicated his daughter took him out for breakfast and upon return was crying, upset, and had said, He was so mean to me. He told me I was stupid. He kept saying 'you just don't (do not) know, you just don't know.' The daughter had informed them the resident threatened to just take off and go over the hill and get away from here. The nurse noted Resident #75 was very agitated, activity staff took him outside and sat with him, and he was getting more upset about being there. The nurse voiced he had been moved to a private room, but did not know why. -- 06/19/16 at 9:21 p.m., discussed, Patient with increased agitation noted. Called to hallway by screams in hallway. Found resident actively using a wheelchair leg rest to hit another resident (Resident #51) to back of the head and upper back. Hard to redirect at this time. Nurse immediately removed wheelchair rest from resident's hands. He was able to be assisted patient back to his room after several attempts. Patient still displays confusion and anger order received for 1:1 supervision and resident transferred to the hospital. -- 06/20/16 at 1:24 p.m. indicated an order was received for medication administration, no entry as to what time the resident returned from the hospital. While out of the facility, resident was determined to have 100 percent coverage of benefits and was transferred via private vehicle with daughter to another facility at 3:33 p.m. One to one (1:1 ) intervention continued until discharged at about 3:30 p.m. Nurse Aide #16, interviewed on 08/24/16 at 10:04 a.m., voiced she was unaware Resident #75 had exhibited sexual behaviors of any type, or had thought Resident #40 looked like his daughter and did not like her interacting with Resident #51. The NA was not aware staff were to monitor the resident closely. NA #16 stated Resident #75's mood varied, and was sometimes pleasant and sometimes very short. On 08/24/16 at 1:07 p.m., upon inquiry regarding Resident #75's sexual overtures, the administrator reviewed the progress note entry, dated 06/12/16. The administrator voiced he did not know what was meant by the note and would speak with the director of nursing (DON) as to how the incident was handled and what interventions were implemented. With further discussion at 2:54 p.m., with the administrator and director of nursing (DON), voiced the facility thought Resident #75 petted down Resident #40's back and kissed her because he thought she was his daughter and she looked like his daughter. She further added that Resident #75 did not like Resident #40 talking to the black lady he perceived to be a male (identified by the DON as Resident #51). The care plan, reviewed on 08/24/16 at 9:17 a.m. noted a focus of cognitive impairment and indicated interventions included: monitor for behaviors, underlying causes, monitor for pain, monitor and evaluate types of changes in cognitive status, evaluate behavioral symptoms for underlying causes, evaluate for the need of a behavioral/psychological consult. The care plan did not address the use of buspirone, sexual behaviors/overtures, elopement attempts or Resident #75's actual agitated and aggressive behavior. The care plan did not address Resident #75's belief that Resident #40 was his daughter or his dislike of her talking to Resident #51. Licensed Practical Nurse (LPN) #45 interviewed on 08/24/16 at 10:48 a.m., stated that Resident #75 did not like people who were black, was always looking for a way to get out and seemed upset with his daughter for bringing him to the facility. The nurse related the resident could hold a good conversation, was aggressive at times, wandered, would go to the doors, curse sometimes, but was not aware of sexual overtures. LPN #45 said she thought other residents were fearful of him and would say to her, Be careful. Don't (do not) let him hurt you. Upon inquiry as to which residents were fearful, the nurse related she could not remember. The medical record, reviewed with Registered Nurse (RN) #68 at 12:00 p.m. on 08/25/16, confirmed Resident #75 had received psychotropic medication from the time of admission on 06/10/16 and included buspirone, an antianxiety medication. The RN confirmed the care plan did not address the use of buspirone medication, including symptoms exhibited by Resident #75 requiring its use, or of sexual aviators of female residents. Additionally, the care plan did not indicate the resident had developed a false belief regarding Resident #40 (thought she looked like/or was his daughter) or aversion to Resident #51 (whom staff said Resident #75 identified as a black male.) The care plan indicated staff would monitor for behaviors, but did not identify active behaviors. Upon inquiry as to how often or when several occasions occurred, the nurse verified one would not know without asking the nurse. Nurse #68 confirmed the medical record did not provide a clear picture of Resident #75's behaviors, or how frequently the behaviors occurred. When asked which diversion interventions were acted upon and were successful and which interventions were not successful, RN #68 confirmed the medical record did specify how many times the resident was agitated, or which interventions were utilized and successful or failed. f) No evidence was provided to indicate the facility had adequately intervened and provided social services for Resident #75. No evidence was present to indicate which interventions the facility had tried and found ineffective, when or how frequently Resident #75 exhibited signs/symptoms of agitation, and what those signs and symptoms included, or that a plan was developed related to sexual overtures. There was also no evidence that a plan was developed to address his possible dislike of black individuals and his perceived need to protect Resident #40 from Resident #51. No evidence was presented to indicate the facility monitored for changes that would trigger abusive behavior or ensured that staff assigned had knowledge of Resident #75's behavioral care needs. Progress notes dated 06/17/16, 06/18/16 and 06/19/16 noted the resident had several episodes of agitated behavior, did not like to be re-directed, but no evidence was presented to indicate the facility had actively sought a resolution prior to the assault on Resident #51, at which time Resident #75 was transferred to another facility. b) Resident #40 During a stage one interview, on 08/22/16 at 3:42 p.m., Resident #40 alleged fear of Resident #75. Resident #40 voiced the mean man was dangerous and they (the facility) knew it, and kept him knowing. The resident said the facility should have done something sooner. Resident #40 alleged fear of the resident (identified as Resident #75 by the director of nursing (DON) and said he had struck (Resident #51's name) several times with a metal object. Resident #40's medical record, reviewed on 08/24/16 at 9:17 a.m., noted a minimum data set (MDS) with an assessment reference date of 08/03/16. The brief interview for mental status (BIMS) of 14 indicated Resident #40 was cognitively intact, with mild impairment. (the score ranges from 1-15). A progress note, dated 06/12/16 indicated Resident 40 had expressed a concern regarding Resident #75 and she was told by the nurse to stay away from him. Resident #40's [DIAGNOSES REDACTED]. The concerns/grievance/complaint log and forms, allegations reported to state agencies, and incident/accident logs, dated 06/01/16 to 08/23/16, reviewed on 08/24/16 at 1:15 p.m., provided no evidence a concern had been reported by Resident #40 regarding Resident #75's behavior(s) or that an incident/altercation had occurred between Resident #51 and Resident #75 prior to 06/19/16. The DON and current administrator, interviewed on 08/24/16 at 4:07 p.m., confirmed no investigation had been completed regarding Resident #40's allegation/concern reported to the nurse regarding Resident #75. During another discussion, at 2:54 p.m., the administrator related the facility had additional information they would like to share. The DON stated that Resident #75 thought Resident #40 was his daughter and would pet down her back and kiss her on the head. The DON said she thought maybe a concern form had been completed, but was not sure. The director said she did not know it was actually sexual behavior because the resident had dementia. With further inquiry, at approximately 4:30 p.m., on 08/24/16, nurse practice educator (NPE) provided a hand written grievance form (all others had been type written), dated 06/12/16. The investigation and action stated, Administrator interviewed resident, resident (Resident #40) stated resident (initials of Resident #75) Kiss her on the top of the head not lips, Resident voiced no additional concerns. No additional information was provided on the form. Resident #40, was interviewed again on 08/25/16 at 9:51 a.m. Resident #40 denied a conversation between herself and the former administrator (ADM) #82. When Resident #40 was asked about her interview/conversation with ADM #82 she denied anyone had spoken with her regarding the incident. Resident #40 stated three (3) times that no one had followed-up with her regarding her concern after she told the nurse, and she was not sure what had been done about it. Further review of the medical record, on 08/25/16 at 11:40 a.m., provided no evidence the facility had intervened to ensure they had addressed her fear of Resident # 75 or protected her to ensure her psychological well-being. During another interview, on 08/30/16 at 10:47 a.m., in the presence of another surveyor, Resident #40 was asked to describe the incident between herself and Resident #75. She said she was in the hallway, Resident #75 grabbed her and kissed her. When asked where he kissed her, she said her cheek and placed her hand on her face. The resident related she did not know why Resident #75 kissed her, but it scared her and she told the nurse. The resident said the nurse told her to stay away from him. With further inquiry, Resident #40 stated she felt fearful and voiced she would not have been able to get away from Resident #75 if he approached her and stated, He was crazy. The resident stated she had always been afraid of Resident #75, and again voiced he had hit (Resident #51's name) prior to the incident with the metal object and staff knew it. Observations of transfers on 08/23/16, 08/24/16 and 08/25/16, revealed Resident #40 transferred with the use of a mechanical lift and was totally dependent on staff. Once in the wheelchair, the resident was able to propel herself, but moved very, very slowly. Review of Resident #75's medical record, on 08/24/16 at 9:17 a.m., indicated the alleged perpetrator was able to walk without assistance. g) The administrator, interviewed on 08/30/16 at 1:22 p.m., acknowledged no evidence was present to indicate the facility actively sought a resolution to Resident #40's concern and that telling Resident #40 to stay away from Resident #75 was not an adequate intervention as she required the use of a wheelchair and Resident #75 was ambulatory. Additionally, the facility provided no evidence to indicate Resident #40's fear had been address during the perpetrators stay at the facility and stated social services should have intervened on behalf of the resident(s). c) Resident #40 Review of the Resident Council minutes dated 04/08/16, at 10:30 a.m. on 08/29/16, reveled a concern under the section titled Daily Care/Nursing stating: Waiting too long when needing to use the restroom. Activities Director #39 reviewed the Resident Council minutes during an interview on 08/29/16 at 12:00 p.m. and reported there was no department response for the concern noted in the April 2016 minutes, because it was only voiced by Resident #40. The concern was to be followed up by Social Worker #32. The Grievance/Concern forms and logs dated March 2016 through July 2016 were reviewed on 08/29/16 at 11:00 a.m. The records lacked any grievances/concerns related to Resident #40's concern with the delay in receiving assistance with toileting. During an interview at 10:15 a.m. on 08/30/16, the Administrator acknowledged there were no records related to Resident #40's grievance/concern voiced during the Resident Council meeting on 04/08/16 about the delay in receiving assistance when needing to use the restroom. d) Resident #2 Review of the Grievance/Concern forms on 08/29/16 at 11:00 a.m., found Resident #2 had reported a concern to Social Worker (SW) #32 on 06/24/16. The Grievance/Concern form states: Resident stated the the CNAs (nursing assistants) on duty did not put her to bed in a timely manner. The section titled Resolution of Grievance/Concern is incomplete. The record is silent as to whether or not the grievance/concern was resolved and how the resident was notified of any resolution. During an interview. at 9:26 a.m. on 08/30/16, Resident #2 reported Social Worker #32 had not followed up with her concerns voiced in June 2016 related to not being assisted to bed in a timely manner and stated there still is a problem with staff responding timely to her needs. The Administrator was interviewed at 10:15 a.m. on 08/30/16. He acknowledged SW #32 had not completed the Grievance/Concern form dated 06/24/16 for Resident #2. e) Resident #81 On 08/22/16 at 2:47 p.m. a Stage I interview of the Quality Indicator Survey (QIS) was conducted with Resident #81. When asked the question: Have you had any missing personal items? He replied, Yes my wallet with identification, insurance card, food stamp card, bank card and $100.00 in cash. Did you tell staff about the missing items? He replied, Yes, the nurses and the Social worker. Has the staff told you they are looking for your missing items? He replied, Yes they would get back to me last week. On 08/23/16 at 9:30 a.m. the Social Worker (SW) #32 stated during an interview, He (Resident #81) said his wallet was missing and this is the first of I heard of it. She then provided a copy of the Inventory of Personal Effects form for Resident #81. The Inventory of Personal Effects form displayed an inventory list for articles of clothing, a watch, a set of keys and $1.90 in money. The form lacked a Resident signature and date and lacked a date that the inventory was conducted by the Environmental Services Director (ESD). A medical record review on 08/24/16 at 2:44 p.m. revealed this [AGE] year old male was admitted from an acute care community hospital on [DATE], discharged to the hospital on [DATE], re-admitted on [DATE], discharged to the hospital on [DATE], re-admitted on [DATE], discharged to the hospital on [DATE] for surgery and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. He is documented to have capacity to make medical decisions. His Brief Interview for Mental Status (BIMS) is 15 indicating that he is intact cognitively. A social services progress note dated 04/28/16 stated (typed as written): Phoned (name of hospital) in search of residents wallet and belongings. Transferred to several departments and security offered to return my call. The Nursing Home Administrator (NHA) stated in an interview on 08/24/2016 at 3:28 p.m., if it is a missing item such as clothes then it is searched for within 24 hours to see if it is in the laundry or another room, but if it is money then automatically an incident/accident report or a concern/grievance form is completed and reported to the appropriate state agencies. Resident #81 reported in a follow-up interview on 08/25/2016 at 8:58:a.m., They found my keys but not my wallet with the contents. I am not sure if it is at the hospital or somewhere else, but I had it when I left my apartment. This is upsetting because it has my social security card, my insurance card, my food stamp card and my bank card. In this day and age who knows what someone would do stealing my identify. During an interview with the Director of Social Services (DSS) #32 and the Nursing Home Administrator on 08/25/2016 at 9:03 a.m., the SW explained the procedure for completing the Inventory of Personal Effects form for residents upon admission. The the ESD to inventory the residents personal effects and completes the form. The resident or the legal representative sign and date the form and also the ESD signs and dates the form. When inquired if there were other Inventory of Personal Effects forms available for Resident #81 from his multiple admission DSS #32 commented, that was the only one from his initial admission. She further commented this had to be from his initial admission because they only do one even though it is not dated when it was completed. DSS #32 stated, I did not fill out a concern and/or an incident/accident form in April because I didn't think I needed to for his missing wallet and personal identification. She further agreed a concern and or incident/accident form should have been completed, an investigation should have been conducted, a report to the appropriate state agencies completed due to misappropriation of funds and the resident should have been informed of a resolution. She further stated that the resident's bank card and his identification were found by his landlord at his apartment and she had started working on Monday 08/22/16 to have his social security card replaced and his food stamp card. She did not reply when asked if a replacement should have been obtained in April when she was made aware of the missing information. She did acknowledge that it is her responsibility as the DSS to assist residents in obtaining and/or replacement of their personal identification cards such as social security cards and medical cards. DSS #32 confirmed the process was started when this surveyor inquired about his personal identification cards. The NHA reported the facility is in the process of replacing his monies of $100.00. The NHA agreed changes would need to be implemented and education completed for reporting and completion of concern, incident/accident forms and reportable's. He commented he had taken over the facility as NHA on 07/05/16 and was not aware of all of the system failures at present but was working on getting the matters resolved that have brought to his attention during the survey. The NHA further stated the facility policy/procedure was not followed in this matter and provided a copy of the grievance/concern policy/procedure, accident/incident policy/procedure, abuse prohibition and a job description for the DSS. A review of the facility policy/procedure titled GRIEVANCE/CONCERN on 08/25/16 at 10:45 a.m. stated, .Center leadership will investigate, document, and follow up on all formal concerns and grievances registered by any patient or patient representative . On 08/25/16 at 10:55 a.m. a review of the facility policy/procedure titled Abuse Prohibition--State of West Virginia revealed: .6. Upon receiving information concerning a report of .misappropriation of patient property .the CED or designee will: 6.2 Report as follows: 6.2.1 OHFLAC .DHHR Adult Protective services and Ombudsman program. A review of the facility job description titled Director of Social Services on 08/30/16 at 1:40 p.m. included: .Position Summary: The Director of Social Services plans, develops, organizes, evaluates and directs the overall operation of the Social Services department in accordance with the National Association of Social Workers (NASW) Code of Ethics and maintaining compliance with federal, state, and local guidelines and regulations . .The Director of of Social Services is responsible for fostering a climate, policies and routines that enable residents to maximize their individuality, independence and dignity. This climate shall provide patients/residents with the highest practical level of physical, mental and psychosocial well-being and quality of life.

Based on resident interview, medical record review, staff interview, policy review, and facility record review, the facility failed to implement its written policies and procedures to ensure two (2) of four (4) residents reviewed for abuse, were free from abuse by another resident. Resident #40 was afraid of Resident #75, who had kissed her on the cheek and touched her back. Resident #51 was physically assaulted. The facility to develop and implement intervention strategies to prevent occurrences of behaviors, and adequately monitor for changes that would trigger Resident #75's escalating abusive behaviors resulting in actual harm to Residents #40 and #51. Resident identifiers: #40, #51, and #75. Facility census: 53. Findings include: a) Resident #40 During a Stage 1 interview on 08/22/16 at 3:42 p.m., Resident #40 expressed fear of Resident #75. She said the mean man was dangerous and they (the facility) knew it, and kept him knowing. The resident said the facility should have done something sooner. She added that he had struck (name of Resident #51) several times with a metal object. The Director of Nursing (DON) identified Resident #40 was referring to Resident #75. Resident #40's medical record, reviewed on 08/24/16 at 9:17 a.m., found the resident's [DIAGNOSES REDACTED]. Her minimum data set (MDS) assessment with an assessment reference date of 08/03/16, identified the resident scored 14 on The Brief Interview for Mental Status (BIMS) indicating Resident #40 was cognitively intact. A progress note, dated 06/12/16, indicated Resident 40 had expressed a concern regarding Resident #75 and she was told by the nurse to stay away from him. The DON and current administrator, interviewed on 08/24/16 at 2:54 p.m., confirmed no investigation had been completed regarding Resident #40's allegation/concern reported to the nurse regarding Resident #75. During another discussion, at 4:07 p.m., the administrator related the facility had additional information they would like to share. The DON stated that Resident #75 thought Resident #40 was his daughter and would pet down her back and kiss her on the head. The DON said she thought maybe a concern form had been completed, but was not sure. The director said she did not know it was actually sexual behavior because the resident had dementia. Further review of the medical record on 08/25/16 at 11:40 a.m., found no evidence the facility had intervened to ensure Resident #40 was protected or addressed her fear of Resident #75, to ensure her psychological well-being. During another interview on 08/30/16 at 10:47 a.m., in the presence of another surveyor, Resident #40 when asked to describe the incident between herself and Resident #75, she repeated she was in the hallway and Resident #75 grabbed her and kissed her. When asked where he kissed her, she again said her cheek and placed her hand on her face. The resident related she did not know why Resident #75 kissed her, but it scared her and she told the nurse. The resident said the nurse told her to stay away from him. With further inquiry, Resident 40 stated she felt fearful and voiced she would not have been able to get away from Resident #75 if he approached her and stated, He was crazy. The resident stated she had always been afraid of Resident 75, and again voiced he had hit (Resident #51's name) prior to the incident with the metal object and staff knew it. Observations of transfers on 08/23/16, 08/24/16 and 08/25/16, revealed Resident #40 transferred with the use of a mechanical lift and was totally dependent on staff. Once in the wheelchair, the resident was able to propel herself, but moved very, very slowly. Review of Resident #75's medical record, on 08/24/16 at 9:17 a.m., indicated the alleged perpetrator was able to walk without assistance. The administrator, interviewed on 08/30/16 at 1:22 p.m. acknowledged no evidence was present to indicate the facility actively sought a resolution to Resident #40's concern and that telling Resident #40 to stay away from Resident #75 was not an adequate intervention as she required the use of a wheelchair and Resident #75 was ambulatory. The administrator agreed the facility should have addressed Resident #40's fears. These findings were determined to constitute actual harm to Resident #40. b) Resident #51 During a Stage 1 interview on 08/22/16 at 3:42 p.m., Resident #40 voiced that Resident #75 had exhibited violent behaviors and had been physically abusive prior to his discharge. The resident said The mean man hit (Resident #51) on the head - he was dangerous and they knew it and kept him knowing. The resident further added, He had already hit her in the head with his fist. Resident #40 reported she saw Resident #75 pushing a table down the hallway, and he hit Resident #51 four (4) for five (5) times with the metal leg from off the table. She added, We all was panicking, scared to death. I couldn't (could not) sleep. They took him out and brought him back the same night. Reportable allegations, reviewed on 08/23/16 at 4:09 p.m., noted an allegation of resident to resident abuse with Resident #75 as the alleged perpetrator. The report, dated 06/20/16, indicated the incident occurred on 06/19/16 at about 8:50 p.m. The nurse noted that while administering medications, she heard the alleged victim screaming for help, and when nursing staff arrived, Resident #75 was using a metal object to strike the victim in the head and upper back. Both residents were transferred to the hospital for evaluation and treatment. The five (5) day follow-up report indicated Resident #75 had obtained a bedside table from the therapy room with a piece of equipment on it, picked up the piece of equipment, slammed it to the floor, breaking a leg on the piece or equipment, which he picked up and used to hit Resident #51 repeatedly. Resident #51's statement indicated Resident #75 came down the hallway pushing the bedside table with the exercise equipment on it. The resident said she told him she did not think he was allowed to do that. She said as he got closer to her he picked up the equipment and threw it in the floor, and after it broke he picked up a piece of it and hit her repeatedly in the head. She related she screamed and staff came to help her. Resident #51 said she thought he was going to kill her, and only felt safe after he was put on one on one (1:1) monitoring by a staff member. Resident #40's witness statement indicated she saw Resident #75 standing up in the hall. He was staring and pointing at Resident #40 and she told another resident He is going to do something, he is up to something .I seen him coming with the table, he started walking slow then he started walking faster and ran into (Resident #51's name). He was hitting her back with the table repeatedly hard. He took the metal leg, I don't know where he got it from, but he hit (Resident #51) on the head four to five (4-5) times really hard. I still can't (can not) get it out of my head. We were all really afraid. We couldn't do anything to help her. We were all yelling for help. Witness statements provided by staff indicated the LPN on red hall heard someone screaming and ran toward the sound. When the nurse approached the area, she observed Resident #75 striking Resident #51 repeatedly with an object. She indicated the object used to strike Resident #51 was broken off of a bicycle exercise equipment. Another LPN said she heard screams in the hall and ran toward the screams. She indicated Resident #51 had her hands over her head to protect herself. One nurse aide (NA) reported she was outside on break and did not witness any of the event and one resident related he/she was in a room providing direct care and did not see what actually happened, but assisted the LPN to keep Resident #75 away from Resident #51 with one-on-one monitoring. Another NA related using the restroom, and when finished, saw Resident #75 lowering his hands with the therapy equipment, and staff had intervened. The hospital discharge summary, dated 06/19/16 indicated Resident #51 had a mild closed head injury, and contusions to the vertex/occipital scalp due to an alleged assault. Another emergency department note indicated the Registered Nurse from the facility indicated the chief complaint was that Resident #51 was struck to the back of the head multiple times and another note in the section indicated Resident #51 was struck to the left side of the jaw the previous day. The hospital preliminary report from the ambulance service indicated Resident #51 informed them the same resident struck her in the left side of the jaw the previous day. Follow-up interviews with the DON and ADON on 08/30/16 between 8:30 a.m. and 10:30 a.m., indicated they were not aware of the alleged incident voiced by Resident #51 indicating Resident #75 had hit her jaw. They confirmed no reports were available to indicate the facility had identified and/or intervened on behalf of Resident #51. These findings were determined to have constitued actual harm to Resident #51. c) Resident #75 Resident #75's medical record, reviewed on 08/24/16 at 9:07 a.m., noted a discharge transition plan and admission summary which indicated the resident had a [DIAGNOSES REDACTED]. Progress notes, reviewed at 9:43 a.m. indicated Resident #75 arrived by private car with family on 06/10/16. The reason for admission was noted as exacerbation of chronic illness long-term care. The admission information indicated Resident #75 had a [DIAGNOSES REDACTED]. Progress notes, dated 06/10/16 to 06/20/16 revealed the following chain of events: -- 06/10/16 at 12:45 p.m., Resident #75 was admitted from another facility -- 06/11/16 at 6:57 p.m., and 06/12/16 and at 7:49 a.m. indicated the resident was continuously having exit seeking behaviors, stating he needed to go home, staff educated he lived at the facility, the resident verbalized understanding, turned around and pushed on the bar of the door. Staff intervention was to monitor closely. -- 06/12/16 at 7:49 a.m., the note indicated Resident #75 attempted to exit the building at the beginning of the shift (7:00 p.m.) and had said he was leaving and did not what happened to him. -- 06/12/16 at 7:58 a.m., noted Resident #75 was observed making sexual obviators (sic) to female residents, redirected to other activities and closely monitoring for further behaviors. -- 06/13/16 at 1:34 p.m., indicated the resident wandered in the hallways and into several other residents rooms, was exit seeking and redirected with moderate redirection. -- 06/14/16 at 2:25 p.m., A note by Administrator #82 indicated the family was notified of a room transfer from a semi-private to private room, but did not indicate why. -- 06/14/16 at 6:46 p.m. a social history and assessment noted a brief interview for mental status with score of 5.0 which indicated the resident was severely cognitively impaired. -- 06/15/16 .Resident roaming hallways stopping in front of females doorways standing there looking in at them resident difficult with redirecting away from doorways -- 06/17/16 at 11:21 a.m., an interdisciplinary note per the assistant director of nursing (ADON), indicated Resident #75 .ambulates independently in center .does exit seek at times, but is easily redirected .pleasant and appears to be adjusting easily to new environment. -- 06/17/16 at 7:43 p.m., a note indicated Resident #75 continued to wander into other residents rooms, was agitated several times today. -- 06/18/16 at 4:44 a.m. indicated the resident wanders all over the facility and into other rooms .Resident becomes agitated at times and is easily redirected. -- 06/18/16 at 7:00 p.m. indicated Resident #75 exited via the front door with a visitor . gets easily agitated at others when the (they) are accusatory toward him, and noted the resident expressed his desire to leave the facility several times. -- -6/19/16 at 2:02 p.m., wandering all over the facility going into others rooms .does go to exit doors often requesting he needed out. -- 06/19/16 at 2:02 p.m. a progress note indicated his daughter took him out for breakfast and upon return was crying, upset, and had said, He was so mean to me. He told me I was stupid. He kept saying you just don't (do not) know, you just don't know. The daughter had informed them the resident threatened to just take off and go over the hill and get away from here. The nurse noted Resident #75 was very agitated, activity staff took him outside and sat with him, and he was getting more upset about being there. The nurse voiced he had been moved to a private room, but did not know why. -- 06/19/16 at 9:21 p.m., discussed, Patient with increased agitation noted. Called to hallway by screams in hallway. Found resident actively using a wheelchair leg rest to hit another resident to back of the head and upper back. Hard to redirect at this time. Nurse immediately removed wheelchair rest from resident's hands. He was able to be assisted patient back to his room after several attempts. Patient still displays confusion and anger order received for 1:1 supervision and resident transferred to the hospital. -- 06/20/16 at 1:24 p.m. indicated an order was received for medication administration, no entry as to what time the resident returned from the hospital. While out of the facility, resident was determined to have 100 percent coverage of benefits and was transferred via private vehicle with daughter to another facility at 3:33 p.m. One to one (1:1 ) intervention continued until the resident left the building. Nurse Aide #16, interviewed on 08/24/16 at 10:04 a.m., voiced she was unaware Resident #75 had exhibited sexual behaviors of any type, or had thought Resident #40 looked like his daughter and did not like her interacting with Resident #51. The NA was not aware staff were to monitor the resident closely. NA #16 stated Resident #75's mood varied, and was sometimes pleasant and sometimes very short. On 08/24/16 at 1:07 p.m., upon inquiry regarding Resident #75's sexual obviators, the administrator reviewed the progress note dated 06/12/16. The administrator voiced he did not know what was meant by the note and would speak with the director of nursing (DON) as to how the incident was handled and what interventions were implemented. With further discussion at 2:54 p.m., with the administrator and director of nursing (DON), voiced the facility thought Resident #75 petted down Resident #40's back and kissed her because he thought she was his daughter and she looked like his daughter. She further added that Resident #75 did not like Resident #40 talking to the black lady he perceived to be a male (identified by the DON as Resident #51). The care plan, reviewed on 08/24/16 at 9:17 a.m. noted a focus of cognitive impairment and indicated interventions included: monitor for behaviors, underlying causes, monitor for pain, monitor and evaluate types of changes in cognitive status, evaluate behavioral symptoms for underlying causes, evaluate for the need of a behavioral/psychological consult. The care plan did not address the use of [MEDICATION NAME] for anxiety, sexual behaviors, elopement attempts or Resident #75's actual agitated and aggressive behavior. The care plan did not address Resident #75's belief that Resident #40 was his daughter or his dislike of her talking to Resident #51. Licensed Practical Nurse (LPN) #45 interviewed on 08/24/16 at 10:48 a.m., stated that Resident #75 did not like people who were black, was always looking for a way to get out of the facility, and seemed upset with his daughter for bringing him to the facility. The nurse related the resident could hold a good conversation, was aggressive at times, wandered, would go to the doors, curse sometimes, but was not aware of sexual behaviors. LPN #45 said she thought other residents were fearful of him and would say to her, Be careful. Don't (do not) let him hurt you. Upon inquiry as to which residents were fearful, the nurse related she could not remember. The medical record, reviewed with Registered Nurse (RN) #68 at 12:00 p.m. on 08/25/16, confirmed Resident #75 had received [MEDICAL CONDITION] medication from the time of admission on 06/10/16 and included [MEDICATION NAME], an antianxiety medication. The RN confirmed the care plan did not address the use of [MEDICATION NAME] medication, or of sexual behaviors toward female residents. Additionally, the care plan did not indicate the resident had developed an emotional connection to Resident #40 (thought she looked like/or was his daughter) or aversion to Resident #51 (who staff said Resident #75 identified as a black male.) The care plan indicated staff would monitor for behaviors, but did not identify active behaviors. Upon inquiry as to how often or when several occasions occurred, the nurse verified one would not know without asking the nurse. Nurse #68 confirmed the medical record did not provide a clear picture of Resident #75's behaviors, or how frequently the behaviors occurred. When asked which diversion interventions were acted upon and were successful and which interventions were not successful, RN #68 confirmed the medical record did specify how many times the resident was agitated, or which interventions were utilized and successful or failed. The lack of information about the resident's behaviors inhibited the facility's ability to identify the resident's escalating behaviors and provide effective interventions. d) The facility's abuse policy indicated the facility staff would do what was within their control to prevent occurrences of abuse and neglect and prevention included identifying, correcting, and intervening in situations in which abuse was more likely to occur and included patient to patient abuse. The policy required the resident to be protected during the investigation and would provide the resident with a safe environment by identifying persons with whom the resident felt safe and conditions that would be safe. It also noted a representative from social services or designee would monitor the patient's feelings concerning the incident, as well as the resident's involvement in the investigation. e) No evidence was provided to indicate the facility had adequately intervened and monitored Resident #75 to ensure the safety of other residents. No evidence was present to indicate which interventions the facility had tried and found ineffective, when or how frequently Resident #75 exhibited signs/symptoms of agitation and what those signs and symptoms included, or that a plan was developed related to his possible sexual behaviors, or his possible dislike of black individuals. No evidence was provided to indicate the facility monitored for changes that would trigger abusive behavior or ensured that staff had knowledge of Resident #75's behavioral care needs. Progress notes dated 06/17/16, 06/18/16 and 06/19/16 noted the resident had several episodes of agitated behavior and did not like to be directed, but no evidence was presented to indicate the facility had actively sought a resolution prior to the assault on Resident #51. f) The administrator, interviewed on 08/30/16 at 1:22 p.m. acknowledged no evidence was present to indicate the facility actively sought a resolution to Resident #40's concern and that telling Resident #40 to stay away from Resident #75 was not an adequate intervention as she required the use of a wheelchair and Resident #75 was ambulatory. Additionally, the facility provided no evidence to indicate Resident #40's fear had been address during the perpetrator's stay at the facility.

Based on observation, resident interviews, staff interviews, clinical record review, review of facility records, and facility policy and procedure review, the facility failed to ensure the safety of residents after an allegation of resident to resident sexual abuse. Resident #72 alleged Resident #79 touched her inappropriately. She reported it to a licensed practical nurse (LPN) on 06/13/15; however, the nurse did not report the allegation and an investigation was not immediately initiated. In addition, no efforts were made to protect other facility residents from sexual abuse from Resident #79, who was able to move freely throughout the facility. Investigation during the survey revealed the allegation was brought to the facility's attention in a morning meeting on 06/15/15. Although the facility initiated an investigation at that time, the facility did not put measures in place to protect the residents from sexual abuse by Resident #79. As of 06/16/15, during the survey, measures to protect the residents had not been put into place. Another resident, Resident #2, stated she was made aware of the situation by Resident #79 (the perpetrator). She said she was afraid Resident #79 would do something to her also. On 06/16/15 at 6:58 p.m., the Administrator and Director of nursing (DON) were notified of an Immediate Jeopardy (IJ) situation as the result of the facility's failure to protect residents during the investigation of an allegation of abuse. On 06/16/15 at 8:43 p.m., the facility provided an acceptable plan of correction (POC) and the IJ was abated. The POC included: Immediate Jeopardy has been identified based on failure to report an allegation of sexual abuse in a timely manner; to protect residents from potential harm during the investigative process; and, to implement the facility policy and procedure regarding abuse. On 06/15/15 at approximately 9:15 AM, the Director of Nursing informed Administrator of a progress note written on 6/13/15 by LPN stating that a female resident had reported to her that a male resident had touched her breast. Social Worker immediately interviewed resident and resident reported that it had happened on 06/13/15 at approximately 6:30 PM. After Social Worker confirmed the resident's statement, Social Worker reported this allegation to state agencies at approximately 11 AM. Shortly after reporting the initial reportable, female resident told Social Worker that same male resident had come into her room on the night of 06/14/15 at approximately 11 PM and touched her vagina. Social Worker then called the police and spoke to dispatch about the allegation and (name of) County dispatch said they would send an officer right away. After waiting approximately 45 minutes for the officer to come, Administrator phoned (county name) dispatch to see if they had dispatched an officer and they confirmed they had. Shortly after Administrator phoned the dispatch, Officer #1 arrived at the facility to interview the residents involved in the allegation. Officer #1 took female resident ' s statement and came back 2-3 hours later to complete male resident ' s statement with another officer, Officer #2. While the officer was out of the facility, female resident was under constant supervision and male resident stayed in his room. Female resident was then sent to (name of hospital) for a sexual assault medical examination. Licensed nurse who failed to report allegation of abuse immediately to supervisor was suspended pending investigation on 06/16/15 by Director of Nursing. Social Worker who failed to properly report allegation to the appropriate state agencies was reeducated on 06/16/15 by Administrator. Reeducation of all staff on abuse reporting has started on 06/16/15 by Nurse Practice Educator and/or designee and will be completed by 06/17/15 or prior to working next shift. Staff interviews regarding alleged abuse investigation have started on 06/16/15 by Nurse Practice Educator/management designee and will be completed by 06/17/15 or prior to working next shift. All interviewable residents were interviewed on 06/16/15 by Nurse Practice Educator and/or designee with no additional findings. Male resident involved in allegation was moved to a private room and different hall on 06/16/15 at 5:30 p.m Male resident involved in allegation will be placed on one-on-one supervision beginning on 06/16/15 at 8:48 p.m. and will be on one-on-one supervision until the sexual assault medical investigation results are received by the facility. On 06/17/15 at 9:45 p.m., Resident #79 was observed in a private room on a different unit. A staff member was sitting outside the room. After the plan of correction for the immediate jeopardy was implemented, a deficient practice at a scope and severity of D remained for failure of staff to immediately report the allegation, and failure of the facility to implement its policies. This deficit affected two (2) residents, but had the potential to affect more than a limited number of residents. Resident identifiers: #72, #2, and #79. Facility census: 55 Findings include: a) Resident #72 The resident's clinical record review, on 06/16/15 at 4:00 p.m., revealed an 08/27/14 physician's determination the resident had capacity to make health care decisions. According to the minimum data set (MDS) assessment, with an assessment reference date (ARD) of 05/29/15, Resident #72 had a score of 15 on the Brief Interview for Mental Status (BIMS). A score of 15, the highest possible score on the BIMS, indicated the resident was cognitively intact. Review of a nurse's note, dated 06/13/15 8:42 p.m., revealed Resident #72, . told me also this morning that another resident touched her boob. She said it was not the first. I educated her to please stay away from that resident. The nurse's note was written by Licensed Practical Nurse (LPN) #64. In an interview on 06/16/15 at 3:38 p.m., Social Worker (SW) #8 stated she became aware of the abuse allegation on 06/15/15 at the morning meeting. SW #8 stated Resident #72 reported to her during an interview, that Resident #79 touched her left breast on 06/13/15. The SW said Resident #72 stated she reported the incident to LPN #64 that same day. SW #8 stated she had not completed any further investigation with any residents or staff regarding the allegation. b) Resident #2 The resident's clinical record review was conducted on 06/16/15 at 4:00 p.m. An 04/25/15 quarterly MDS indicated the resident had a BIMS score of 15, identifying the resident was assessed as cognitively intact. During an interview, on 06/16/15 at 3:34 p.m., Resident #2 stated Resident #79 told her he touched Resident #72 inappropriately and raped her. Resident #2 stated, I am afraid to sleep, because he might do something to me. c) Resident #79 On 06/16/15 at 3:42 p.m., Resident #79 was observed lying on his bed in his room. Review of the resident's medical record on 06/15/15 at 3:30 p.m., found his admission MDS, with an ARD of 05/07/15, identified his BIMS score was 15, indicating he was cognitively intact. It also identified he was independently mobile. At 4:08 p.m., on 06/16/15, the Director of Nursing (DON) stated the facility instructed Resident #79 to stay away from Resident #72. The DON confirmed Resident #79 resided on the same hall as Residents #72 and #2. Upon inquiry, the DON stated she became aware of the abuse allegation on 06/15/15 in the morning. She said she informed the day nurse of the allegation, but provided no instruction to staff for protection of residents during the investigation. During an interview on 06/16/15 at 4:20 p.m., the Administrator and DON stated they became aware of the abuse allegation on 06/15/15 in the morning. They confirmed LPN #64 should have reported the allegation immediately on 06/13/15. The Administrator stated Resident #72 was sent to the hospital for evaluation and police were notified of the allegation. The Administrator and DON confirmed Resident #2 was ambulatory both in and out of the facility. They confirmed they put no protective measures in place for residents during the facility's investigation. d) Review of the facility's policy and procedure entitled Abuse Prohibition, dated as revised on 07/16/13, was conducted on 06/16/15 at 6:25 p.m. The policy stated . If the suspected abuse is patient to patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation. Options for room changes will be provided based on the situation. The policy also stated the center would . conduct an immediate and thorough investigation. According to the policy, The Center will protect patients from further harm during the investigation. Provide the patient with a safe environment by identifying persons with whom he/she feels safe and conditions that would feel safe. e) In a follow-up interview on 06/17/15 at 10:40 a.m., SW #8 indicated she would now interview the victim immediately and then wait for further instruction from the administrator. SW #8 stated she reported Resident #72's allegation against Resident #79 to OHFLAC on 06/16/15 in the evening. Review of facility records revealed a fax receipt to OHFLAC on 06/16/15 at 5:06 p.m. f) During an interview, on 06/17/15 at 11:15 a.m., Assistant Director of Nursing (ADON) #16 stated she was on call the weekend of Resident #72's allegation on 06/13/15. ADON #16 stated LPN #64 did not report the allegation to her as required by facility policy. g) On 6/17/15 at 11:29 a.m., Nurse Practice Educator (NPE) #65 stated she provided new education for staff regarding abuse and neglect starting 06/16/15. NPE #65 stated she conducted interviews of staff and residents since 06/16/15, but did not identify any new allegations of resident abuse. h) Review of in-service records on 06/17/15 at 1:40 p.m., revealed 43 staff members had completed in-service training regarding abuse and neglect since 06/15/15. i) On 06/17/15 at 1:40 p.m., 42 staff statements conducted by the facility were reviewed. No additional concerns of resident abuse or neglect were indicated. j) During an interview on 06/17/15 at 12:36 p.m., LPN #64 indicated she had been trained to immediately report any allegation of resident abuse to the supervisor or other management staff. At that time, the LPN confirmed she had written the 06/13/15 at 8:43 p.m. nurse's note in Resident #72's clinical record. LPN #64 stated, When you think of abuse, I think staff to resident and didn't think about residents with capacity not so much as abuse. I should have reported it immediately.