Based on a tour of the kitchen, observations, interviews, and facility policy, the facility failed to ensure that beards were covered when handling food on the steam table. The findings included: During observations of meal service on 6/18/25 at 11:45 AM with the Dietary District Manager, the following was identified: Cook #1 was at the steam table prepping food items for food service delivery. [NAME] #1 was placing hamburgers, chicken, and condiments in the compartments on the steam table without the benefit of wearing a beard restraint. [NAME] #1 had visible facial hair in the form of a goatee beard. Dietary Assistant (DA) #1 assisted [NAME] #1 with placing items on the steam table and was in direct contact with food items. DA #1's beard restraint was partially covering his beard with the right side of his face not completely covered with exposed facial hair. An interview with the Dietary District Manager on 6/18/25 at 11:50 AM indicated that [NAME] #1 should have been wearing a beard restraint as he was in direct contact with food. In addition, DA #1 beard restraint should have covered all of his beard. Subsequent to surveyor inquiry, the Dietary District Manager instructed [NAME] #1 and DA #1 to cover their beards. An interview with the Food Service Director on 6/20/25 at 8:30 AM indicated that without a doubt the beards should have been covered. A review of the Staff Attire Policy dated May 2014, directed, in part, that all staff members have their hair off the shoulders, confined to a hair net or cap and facial hair properly restrained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #39, 54 and 60) reviewed for allegations of sexual abuse, the facility failed to immediately notify the physician and resident representatives when the residents reported they had been touched inappropriately by Resident #29, and for 1 resident (Resident #71) reviewed for dental services, the facility failed to ensure the physician and the resident representative were notified of multiple dental appointments and follow up dental recommendations, and for 1 resident (Resident #72) reviewed for hospitalization, the facility failed to notify the physician following a documented change in cognition. The findings include: 1. Resident #29 was admitted to the facility on [DATE] with diagnoses that included disorganized schizophrenia, intellectual disability and fluency disorder, and diabetes. The quarterly MDS dated [DATE] identified Resident #29 had intact cognition, was always continent of bowel and bladder, and was independent with transfers, dressing and toileting. The care plan dated 5/30/23 identified Resident #29 had a history of disorganized schizophrenia with psychotic symptoms including delusions of a sexual nature, disinhibited sexual speech, and disinhibited sexual behaviors. Interventions included to report any observed behavior/speech to the charge nurse, and if any behavior/speech was observed to ask the resident to stop, redirect and remind the resident why the behavior/speech was inappropriate. Interventions also included that if Resident #29 presented harm to any other residents of the facility, he/she may be placed on higher level of supervision which may include 2-person supervision during interactions with others. The psychiatric note dated 5/31/23 identified Resident #29 had a history of psychosis and Schizophrenia and required antipsychotic medications. The note further identified that Resident #29 was pleasant, engaging, had no reported behavioral issues, had been compliant with medications, denied any sleep disturbances, and that nursing had offered no concerns. The physician's orders dated 6/1/23 directed to administer Depakote (a mood stabilizer) twice daily, Clozapine (an antipsychotic medication) at night, and Haldol (an antipsychotic medication) every three weeks. The orders further directed behavior monitoring every shift related to delusions, hallucinations, physical aggression, and disinhibited sexual behavior. A written email from RN #4 dated 6/9/23 at 11:02 PM to the Administrator, the DNS, and SW #1 identified at 10:15 PM, Resident #29 was placed on every 15 minutes checks due to reports of the resident entering at least three different resident rooms (of the opposite sex) and behaving inappropriate with them. NA #2 went in Resident #60's room and found Resident #29 in that room behind the door (no time provided). Resident #60 was standing in the room with his/her walker, neither resident could explain why Resident #29 was in that room so resident #29 was sent back to his/her own room. NA #1 answered Resident #39's call light and the resident reported that another resident (of the opposite sex) was in his/her room. Resident #39 reported that the resident (Resident #29) was standing over him/her and told him/her he/she would not harm her and began to undo the buttons on Resident #39's blouse and fondle his/her breast. RN #4 indicated she and LPN #2 went to Resident #29's room to talk to him/her, but the resident's tone was so low they could not make sense of what he/she is saying except that he/she thought it was okay to do what he/she did. RN #4 indicated they instructed Resident #29 not to go into other resident rooms and he/she agreed. RN #4 indicated LPN #2 went into Resident #54's room and that resident reported that Resident #29 had come into his/her room and tried to fondle his/her breast and he/she chased Resident #29 out of the room. Review of reportable event documentation identified that on 6/9/23 at approximately 10:15 PM, Resident #29 was alleged to have inappropriately touched Resident #60 (a resident of the opposite sex) after entering his/her room. The reportable event documentation further identified that following the incident, the facility was also notified that between 10:05 PM and 10:15 PM, prior to the incident with Resident #60, Resident #29 was also alleged to have inappropriately touched Resident #39 and #54 (both residents of the opposite sex) after entering each of their rooms. The reportable event documentation also identified that MD #1 was notified of the incidents involving Resident #29 on 6/9/23 at 10:30 PM (this is in conflict with the interview with MD #1 who stated he had not been notified of these incidents until 6/12/23, 3 days later). The nurse's note dated 6/10/23 at 12:58 AM by RN #2 (11:00 PM - 7:00 AM nursing supervisor) identified that Resident #29 had been placed on 1:1 observation as a nursing measure related to intrusive behavior. The note further identified RN #2 had placed a referral in the psychiatric provider's book regarding Resident #29's behavior. Review of the Behavioral Health Visit Request book identified that a request for Resident #29 dated was dated 6/10/23 with the reason for request (Resident #29 went into 3 other residents' rooms, unbuttoned one resident's shirt and told them all I want to hurt you.) The request was signed off as seen by behavioral health on 6/13/23, 3 days later. A written statement completed by the Administrator on 6/10/23 identified that she was notified via text message by RN #8 on 6/10/23 of incidents involving Resident #29 on 6/9/23 during the 3-11 PM shift when RN #4 was the evening nursing supervisor. The Administrator further identified that she then contacted RN #4, who provided details of the incidents via email sent to the Administrator, DNS, and Social Worker #1. The statement further identified that RN #4 was educated that she should have contacted the Administrator via phone call regarding the incidents, not by email. The APRN note completed by APRN #1 dated 6/12/23 identified a medical work up had been requested by nursing staff for Resident #29 due to allegations of sexual assault of 3 residents of the facility. The note further identified that Resident #29 was observed to be delusional with a flat affect and was difficult to understand due to flow of mumbled speech. The assessment and plan identified Resident #29 had a change in behavior and would be worked up for evidence of infection or metabolic disarrangement. The psychiatric APRN note dated 6/12/23 identified that Resident #29 was seen for an allegation of abuse. The note further identified that Resident #29 reported visual hallucinations and appeared to having hallucinations nightly and that nursing staff had reported a change in Resident #29's behavior since 6/9/23. The note identified that Resident #28 appeared to have an exacerbation in Schizophrenia with perceptual disturbances and medications may be necessary to address acute psychosis in conjunction with the medical workup. The nurse's note dated 6/12/23 at 5:54 PM identified Resident #29's resident representative was notified of behavioral incidents that occurred on 6/9/23 and that Resident #29 had been seen by the medical and psychiatric APRNs on 6/12/23. Interview with the Administrator on 8/15/23 at 7:30 AM identified that she was made aware on 6/10/23 of the alleged incidents with Resident #29, she was not aware that the physician and resident representative had not been contacted and notified regarding the incidents until 6/12/23, 3 days later. The Administrator was unable to identify why the physician and resident representative were not notified until 6/12/23, 3 days after the incidents. Interview with APRN #1 on 8/15/23 at 11:53 AM identified she was notified of the allegations involving Resident #29 on 6/12/23 when she was in the building to see residents. APRN #1 identified that the facility should have completed a nursing assessment and contacted the on-call provider on 6/9/23 immediately following the incidents, and Resident #29 should have been placed on 1:1 observation right away. APRN #1 further identified that 1:1 monitoring would have been the most important intervention, and if the facility had notified her of the incidents on 6/9/23 when they occurred, APRN #1 would have sent Resident #29 to the hospital for further evaluation. APRN # 1 further identified Resident #29 had not had any allegations of inappropriate touch prior to 6/9/23 and the alleged behaviors were 'out of the blue'. Interview with MD #1 (Medical Director) on 8/16/23 at 10:29 AM identified that he was notified of allegations related to Resident #29 on 6/12/23, when APRN #1 was already scheduled to be at the facility to examine residents. MD #1 identified that he would have expected that if there were any allegations of assaults of a sexual nature that the facility should have contacted him on 6/9/23 at the time of the incidents. MD #1 further identified that if he had been notified of allegations on 6/9/23, he would have sent Resident #29 to the hospital for further evaluation. The facility policy on Abuse directed that allegations related to abuse, neglect, exploitation or mistreatment would be reported to the resident representative and attending physician by the RN supervisor. The facility policy on Physician Notification-Change in Condition directed that it was the policy of the facility to notify the physician when a resident's condition or status changed unexpectedly or substantially to ensure the physician was kept informed of changes in an appropriate and timely manner. The policy further directed that the resident representative would also be notified. 2. Resident #39 was admitted to the facility 10/20/21 with diagnosis that included dementia with behavioral disturbance, frontal lobe and executive function deficit following cerebral infarction, and anxiety disorder. The quarterly MDS dated [DATE] identified Resident #39 had intact cognition, required supervision with bed mobility and toilet use, extensive assistance with dressing and personal hygiene, used a walker for mobility, had cerebral palsy, and basal cell carcinoma of the skin. The care plan dated 5/4/23 had a focus on dementia secondary to traumatic brain injury and a stroke and indicated the resident required assistance with activities of daily living. Interventions included offering help daily and offer cueing/prompting or physical help to complete tasks. The nurse's note dated 6/11/23 at 11:25 AM identified that the RN Supervisor (RN #8) checked in with Resident #39 on 6/10/23 and 6/11/23 following an occurrence with another resident. Resident #39 noted that Resident #29 (another resident of the opposite sex) attempted to unbutton his/her blouse, but he/she yelled and told him/her to get out of the room and Resident #29 left as instructed. RN #8 reassured Resident #39 that we are here to provide support and to reach out to staff is needed for support or to talk. Resident #39 verbalized understanding and said thank you. Resident #39 reports he/she had a nice afternoon out with family yesterday, seated outside with peers having a cup of hot chocolate on the patio. RN #8 indicates she spoke privately with Resident #39, and Resident #39 denies being anxious or fearful, and slept great last night. The reportable event form dated 6/12/23 identified on 6/9/23 between 10:10 PM and 10:15 PM Resident #39 alleged he/she had been touched inappropriately by another resident (of the opposite sex, Resident #29). Resident #39 alleges Resident #29 entered his/her room and unbuttoned Resident 39's nightshirt. Resident #39 yelled at Resident #29 instructing him/her to leave. Resident #29 exited the room; Resident #39 used the call bell to seek assistance. A statement by RN #5 identified on 6/9/23 at approximately 10:15 PM Resident #39 came to the nurse's station and received reassurance about safety. RN #5 indicates Resident #39 did not appear to be upset, mood appropriate, however with the reassurance of safety, Resident #39 refused to go back to bed. Interview with RN #2 the RN Supervisor on 8/14/23 at 1:54 PM (who worked the 11:00 PM - 7:00 AM shift on 6/9/23) identified she was not aware of the inappropriate touch and had only known of Resident #29's wandering into various rooms during the 3:00 PM - 11:00 PM shift the evening of 6/9/23. Wanting additional monitoring for Resident #29, RN #2 reached out to the ADNS on 6/9/23 at approximately 10:50 PM and secured the 1:1 authorization for the 11:00 PM - 7:00 AM shift. Interview with NA #1 on 8/15/23 at 2:20 PM identified she responded to Resident #39's call bell and upon entering the room Resident #39 was seated on the bed and reported and described a person who had entered the room. NA #1 indicated Resident #39's night shirt was unbuttoned down to the waist. Resident #39 wore an athletic undergarment which was visible. Resident #39 indicated the intruder was ordered to get out of the room, and the intruder left. NA #1 indicated she offered assurance to Resident #39, encouraging Resident #39 to go back to bed, and proceeded to leave the room to report the incident to the supervisor. Upon arrival at the nurse's station, RN #5, LPN #2, and RN #4 (Nurse Supervisor) were discussing a resident entering other resident's room (Resident #54 and Resident #60). NA #1 indicated as she spent 5 minutes with Resident #39, was at the nurse's desk with staff for 3 - 4 minutes, then Resident #39 approached the nurse's station. 3. Resident #54 was admitted to the facility in November 2017, with diagnoses that included major depressive disorder, anxiety disorder, and paranoid schizophrenia. The quarterly MDS dated [DATE] identified Resident #54 had intact cognition, had no behaviors, and was independent with bed mobility, transfers, walking in room, and walking in corridor. Physician's orders dated June 2023 directed that Resident #54 was independent with transfers, and ambulation without an assistive device. A written email from RN #4 dated 6/9/23 at 11:02 PM to the Administrator, the DNS, and SW #1 identified that on 6/9/23 at 10:15 PM, Resident #29 was placed on every 15 minutes monitoring due to reports of entering at least three different female resident rooms and behaving inappropriate with them. RN #4 indicated she and LPN #2 went to Resident #29's room to talk with the resident, but his/her tone was so low they could not make sense of what he/she was saying, except that he/she thought it was okay to do so. RN #4 indicated they instructed Resident #29 not to go into other resident rooms and the resident agreed. RN #4 indicated LPN #2 went into Resident #54's room and the resident reported that Resident #29 came into his/her room and tried to fondle his/her breast, and that he/she chased Resident #29 out of the room. A written statement from the Administrator dated 6/10/23 identified on 6/10/23 at 1:06 PM she received a text from RN #8 asking about the incident that occurred on 6/9/23 during the 3:00 PM - 11:00 PM shift. The Administrator indicated RN #8 provided her limited details of the alleged incident. The Administrator indicated she called RN #4 and inquired about what had occurred. The Administrator indicated RN #4 identified that she had sent an email to the Administrator, DNS and the SW #1 the night before (6/9/23) with details. The Administrator indicated she educated RN #4 that the alleged incident warranted a phone call and not an email. The Administrator indicated RN #4 indicated to her the reason she did not call her, or the DNS is because RN #4 did not feel anyone was harmed or injured. The Administrator indicated she stressed to RN #4 the importance of proper channels of communication needed in this case. The Administrator indicated she asked RN #4 to provide a written statement of the alleged occurrence. The Administrator indicated RN #4 was removed off the schedule during the investigation. The nurse's note dated 6/11/23 at 9:30 AM identified a follow up note due to occurrence with another resident. RN #8 indicated she spoke with Resident #54 on 6/10/23 and on the morning of 6/11/23. Resident #54 was ambulating on the unit with peers. Resident #54 was in good spirits, smiling, and asked what was on the menu for lunch. RN #8 indicated she spoke privately with Resident #54 who stated he/she was fine and does not feel afraid or anxious. Resident #54 indicated he/she was surprised that it happened because he/she is married. RN #8 indicated she explained to Resident #54 if he/she wanted to talk to reach out to the staff for support. A written statement from Resident #54 dated 6/11/23 at 7:30 AM identified he/she woke up and used the bathroom. Resident #54 indicated he/she went back to bed and fell asleep. Resident #54 indicated a large man (Resident #29) was standing over him/her and touched his/her breast. Resident #54 indicated he/she pushed Resident #29 out of the room. Review of the Department of Public Health, Facility Licensing and Investigations Sections (FLIS) reportable events portal identified the allegation was reported on 6/12/23, 3 days after it occurred. This is for the failure to report tag. 609 The APRN progress note dated 6/12/23 identified she was asked to see Resident #54 who alleged a resident (Resident #29) on the unit came into his/her room in the middle of the night and asked him/her to unbutton his/her shirt and touched his/her breasts. Resident #54 was able to chase Resident #29 away by yelling and pushing him/her. Resident #54 was seen and examined. No evidence of trauma noted. Resident #54 has a significant history of paranoid schizophrenia and anxiety. The nurse's notes dated 6/2/23 through 6/11/23 failed to reflect documentation of resident representative was notified of Resident #54 had reported an allegation of inappropriate touching of his/her breast by Resident #29 on 6/9/23 on the 3:00 PM - 11:00 PM shift. The nurse's note dated 6/12/23 at 11:52 AM identified APRN #1 performed a body assessment with no redness, no bruising, and no injuries was noted. Resident #54 had no complaints of pain or discomfort. The resident representative was notified. A message was left for APRN #2. The nurse's note dated 6/12/23 through 6/24/23 failed to reflect documentation the resident representative had been notified of Resident #54's allegation of abuse by Resident #29 on 6/9/23 on the 3:00 PM - 11:00 PM shift by. A written statement from LPN #2 dated 6/12/23 at 2:45 PM identified she was approached by Resident #54 while walking down the hallway. LPN #2 indicated Resident #54 called out to her and Resident #54 indicated a man (Resident #29) was in his/her room and he/she indicated to Resident #29 you are not supposed to be in here. Resident #54 had just come out of the bathroom and got into bed and Resident #29 touched his/her breast and walked away. LPN #2 indicated she provided Resident #54 with reassurance and emotional support after the interaction on Friday 6/9/23. The psychiatric APRN note dated 6/12/23 at 8:44 PM identified she was asked to see Resident #54 due to an allegation of sexual assault. Resident #54 reported a male resident (Resident #29) entered his/her room and touched his/her breast. Resident #54 reported he/she asked Resident #29 to stop and leave the room. Resident #54 reported Resident #29 continued to touch his/her breast, and he/she pinched Resident #29 on the back then he/she got up and left. Resident #54 reported seeing Resident #29 in the dining room this afternoon which made his/her nervous until he/she noticed Resident #29 had someone watching him/her and that is when he/she calmed down. Resident #54 reported that he/she feels safe at the facility. Resident #54 is not currently a danger to self or others. Resident #54 reported he/she can get help by using the call light or scream out if he/she needs to. Would recommend continuing Ativan as prescribed as Resident #54 has residual symptoms of anxiety. Recommend psychotherapy so that Resident #54 can continue to process his/her feelings. The psychotherapy initial assessment dated [DATE] at 1:54 PM identified Resident #54 was alert, oriented times three and coherent. Met with Resident #54 for support and difficulty with anxiety with alleged sexual abuse issue. Resident #54 reported that he/she had some difficulty with a male resident (Resident #29) coming into his/her room and inappropriately touching his/her breast. Resident #54 reported she informed the staff about the issue. Resident #54 report that he/she has some difficulty with anxiety. Will continue to monitor Resident #54 and provide support and validation for resident. The reportable event form dated 6/13/23 at 10:00 PM, identified the date and time of the event first known was on 6/9/23 at 11:05 PM, 4 days prior. Resident #54 alleged that Resident #29 came into his/her room, and he/she woke up with Resident #29 standing over him/her at bedside touching his/her breast. Resident #54 got up and pushed Resident #29 out of the room. Resident to resident abuse without injury. Resident #54 mood was stable with no changes in behavior. Resident #54 ambulates without device. The reportable event form identified the physician was notified on 6/9/23 at 11:20 PM (this is in conflict with an interview with the physician (MD #1) who identified he did not receive a call from the facility on 6/9/23 at 11:20 PM and was not notified of the incident until Monday 6/12/23, 3 days later). The reportable event form identified the resident representative, the police, and the Administrator were all notified, however, there is no date or time of notification. Further, the facility staff did not notify the police, and the Administrator was not notified until 6/10/23, the next day. Review of the summary report dated 6/13/23 identified upon investigation on the evening of 6/9/23 at approximately 10:20 PM, LPN #2 was walking down the hallway and Resident #54 called out to her. LPN #2 approached Resident #54 and he/she told LPN #2 that after waking up and using the bathroom he/she fell back asleep. Resident #54 indicated a large man (Resident #29) was standing over his/her bed and touched his/her breast. Resident #54 indicated he/she pushed Resident #29 away and out of the room. Resident #54 indicated he/she is married. LPN #2 reported the allegation to RN #4. No physical or psychosocial harm was identified. Resident #29 denies ever physically touching Resident #54. Upon further investigation NA #2 indicated seeing Resident #29 in his/her room in bed at approximately 10:00 PM - 10:05 PM. During the same time NA #2 noted Resident #54 coming out of his/her bathroom and getting back into bed. Given this information, the facility believe that this encounter must have happened between 10:05 PM and 10:15 PM when Resident #29 was found by NA #2 in another resident's room at approximately 10:15 PM. At 10:15 PM Resident #29 was directed to his/her room and was observed in bed. Resident #29 was then put on close supervision and noted to remain in his/her bed until the end of the shift. RN assessment completed, medical assessment completed, psychiatric assessment completed. Psychosocial assessment and support completed and ongoing. Interview with Resident #54 on 8/13/23 at 10:55 AM identified he/she was almost raped by a man (Resident #29). Resident #54 indicated Resident #29 came into his/her room and touched his/her breast. Resident #54 indicated he/she kicked Resident #29 out of the room. Resident #54 indicated Resident #29 has not been back in his/her room. Resident #54 indicated he/she is not afraid of him. Resident #54 indicated LPN #2 was going down the hallway the same night it happened, and he/she called out for LPN #2. Resident #54 indicated when LPN #2 came to the room he/she told LPN #2 about Resident #29 was in his/her room and touched his/her breast. Resident #54 indicated LPN #2 did not assess his/her body. Resident #54 indicated RN #4 did not assess his/her body. Resident #54 indicated he/she told LPN #2 the night it happened and told SW #1 on Monday (6/12/23) about Resident #29 coming into the room and touching his/her breast. Resident #54 indicated on Monday, APRN #1 came and assessed his/her body and talked to him/her. Interview and review of the clinical record with the ADNS on 8/14/23 at 10:59 AM failed to provide documentation that an RN assessment had been completed on 6/9/23, or that the physician and the resident representative had been notified of the allegation on 6/9/23. The ADNS indicated an RN assessment should have been completed and documented in Resident #54's clinical record at the time of the allegation. The ADNS indicated RN #4 failed to call her, the DNS, and the Administrator on 6/9/23 at the time of the allegation of the inappropriate touch. The ADNS indicated the expectation of the facility is that RN #4 should have notified her and the Administrator that Resident #29 had inappropriately touched Resident #54 breast. Interview with the Administrator on 8/15/23 at 7:30 AM identified she was not aware of the issue on 6/9/23 at 10:15 PM. The Administrator indicated she texted RN #8 on Saturday 6/10/23 at approximately 1:00 PM regarding staffing at the end of the text RN #8 texted her asking how long Resident #29 is going to be on 1:1. The Administrator indicated she texted RN #8 to call her on the phone. The Administrator indicated she called the facility and spoke to RN #8. The Administrator indicated RN #8 stated to her I thought you knew the details. RN #8 indicated that Resident #60 had called the police. The Administrator indicated she called RN #4 who indicated she emailed me the details of the event on 6/9/23 at 11:06 PM. The Administrator indicated she hung up the phone with RN #4 and read her email. The Administrator indicated RN #4 should had call her via phone and notified her of the allegation of inappropriate touch. The Administrator indicated she contacted her Chief Operating Officer, Chief Clinical Office, and the RN Director of Quality of Life and Specialty Programs (the Regional Nurse Educator). The Administrator indicated they had a collaboration, they immediately started investigation by interviewing the staff that was present on 6/9/23 on the 3:00 PM - 11:00 PM shift via phone. The Administrator indicated on Sunday 6/11/23 she had a conference call with the Chief Clinical Office and the RN Director of Quality of Life and Specialty Programs. The plan was to report the allegation on Monday morning on 6/12/23 entering the incident on the FLIS portal with the state agency. The Administrator indicated the facility should have reported the allegation earlier. The Administrator indicated she was not aware that the RN assessment was not completed and documented in the resident clinical record. The Administrator indicated she was not aware the physician and the resident representative were not notified on 6/9/23. The Administrator indicated the expectation of the facility is that the RN supervisor should have notified the physician and the resident representative of the allegation. The Administrator indicated the facility has in-serviced the licensed nurses. Interview with MD #1 on 8/16/23 at 10:26 AM identified the facility did not notify him on Friday 6/9/23 or the weekend of Resident #54's allegation of being touched inappropriately by Resident #29. MD #1 indicated the facility notified him on Monday 6/12/23 of the allegation of inappropriate touch. MD #1 indicated APRN #1 was going to be at the facility on Monday 6/12/23 and she would assess the resident. MD #1 indicated his expectation is that the facility should have notified him of the allegation of inappropriate touch. Interview with APRN #1 on 8/15/23 at 11:53 AM identified she did not receive a phone call from the facility on Friday 6/9/23 regarding the allegation of inappropriate touch. APRN #1 indicated the facility notified her on Monday 6/12/23 regarding the allegation of inappropriate touch. APRN #1 indicated she assessed Resident #54 on 6/12/23. APRN #1 indicated her expectation is the facility should have contacted and notified the physician, and the APRN of the allegation of inappropriate touch. APRN #1 indicated the RN supervisor should have performed an RN assessment after Resident #54 allegation of inappropriate touch. Interview with RN #4 on 8/16/23 at 3:27 PM indicated she has been with the facility since 7/20/22. RN #4 indicated she is the RN supervisor for the 3:00 PM - 11:00 PM shift. RN #4 indicated on 6/9/23 at approximately 10:15 PM she was notified by LPN #2 that Resident #29 was observed in Resident #60's room. RN #4 indicated she went to the unit and spoke to Resident #29 who was in his/her room. RN #4 indicated while she and LPN #2 were walking in the hallway Resident #54 called out to LPN #2 in the hallway. RN #4 indicated LPN #2 went to see what the resident wanted. RN #4 indicated Resident #54 indicated a man (Resident #29) had come into his/her room and he/she yelled at him/her and Resident #29 left. RN #4 indicated she proceeded to the nurse's station and placed Resident #29 on every 15 minutes monitoring. RN #4 indicated since she has been at the facility, she was informed to email the Administrator, the DNS, and the ADNS with any changes at the facility during her shift. RN #4 indicated the Administrator, the DNS, and the ADNS do not answer their phone when called. RN #4 indicated she did not document the incident Resident #54's clinical record. RN #4 indicated she did not perform a body assessment and did not call the physician or the resident representative. RN #4 indicated LPN #2 should have documented in Resident #54 clinical record regarding the allegation of inappropriate touch. RN #4 indicated she was taken off the schedule pending investigation. A written statement from the Administrator dated 8/16/23 identified the facility acknowledges discrepancies in the FLIS reporting system regarding the event on 6/9/23 of Resident #54. The physician, APRN, and psychiatric APRN were notified on 6/12/23 and the resident was assessed by both APRN's on 6/12/23. The facility completed an RN assessment on 6//12/23. Review of the facility physician notification - change of condition policy identified the policy of the facility is to notify the physician when the resident condition or status changes unexpectedly or substantially. This will ensure that the physician will be kept informed of changes in an appropriate and timely manner. The physician (or alternate) will be contacted to report findings. The resident and/or responsible party will be notified. The nurse will document in the nurse's notes regarding assessments, findings, changes, physician notification and resident and/or responsible party notification. 4. Resident #60 was admitted to the facility 6/19/19 with diagnosis that included multiple sclerosis, dementia, and Parkinson's disease. The quarterly MDS dated [DATE] identified Resident #60 had intact cognition, required supervision with ambulation on the unit, was independent with transfers, locomotion on the unit, dressing, eating, toilet use and personal hygiene. Resident #60 utilized a walker for mobility, with active diagnosis of bipolar disorder, and psychotic disorder. The care plan dated 7/13/23 identified the resident had a desire for an intimate relationship. Interventions included education regarding maintaining appropriate personal boundaries and not to engage in any physical contact until it has been determined by the facility that the resident's choice to be in such a relationship is consensual by both parties. The nurse's note dated 6/11/23 at 2:25 PM identified that RN Supervisor, RN #8 checked in with Resident #60 on 6/10/23 and 6/11/23 following an occurrence with another resident. RN #8 identified Resident #60 is getting her hair done by staff per request. Resident #60 had meals in the dining room with peers and is in good spirits. RN #8 indicates she spoke privately with Resident #60 and the resident reports[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interview for 2 residents (Resident #39 and 87) reviewed for abuse, the facility failed to revise the care plans after Resident #87 inappropriately touched Resident #39. The findings include: 1. Resident #87 was admitted to the facility in February 2023 with diagnoses that included dementia, and anxiety disorder. The care plan dated 2/11/23 identified Resident #87 has a history of disinhibited sexual behaviors and physical aggression. Interventions included to ask the resident to stop the disinhibited sexual behaviors if he/she exhibits such, redirect to a quiet space, attempt to explain to the resident why the behavior is not appropriate and notify the nurse. The 5-day MDS dated [DATE] identified Resident #87 had severely impaired cognition, exhibited no behaviors, required supervision with transfers and was independent with bed mobility, walking in room, and walking in corridor. Physician's orders dated March 2023 directed Resident #87 was independent with transfers, and ambulation with rolling walker, and to monitor for disinhibited sexual behaviors every shift. A reportable event form dated 3/15/23 at 2:00 PM identified a resident (of the opposite sex, Resident #39), reported that Resident #87 had made physical contact with him/her while sitting in the lounge. Resident #87 is alert, oriented. A written statement by SW #1 dated 3/15/23 at 3:30 PM identified it was reported to SW #1 that Resident #39 reported that Resident #87 had made physical contact with him/her about 2 weeks ago. SW #1 met with Resident #87 who denied making physical contact any other residents. SW #1 indicated Resident #87 reported he/she tries to stay to him/herself and would engage verbally with peers but never physically. Review of the 24-hour report dated 3/15/23 failed to reflect documentation that Resident #87 had physically touched another resident of the opposite sex while sitting in the lounge. The nurse's notes dated 3/15/23 through 3/30/23 failed to reflect documentation that Resident #87 had physically touched another resident of the opposite sex while sitting in the lounge. The social worker form dated 3/17/23 identified on 3/15/23 it was reported to SW #1 that Resident #87 allegedly made physical contact with another resident of the opposite sex on the unit. SW #1 indicated she met with Resident #87 who could not recall any physical interaction with any peer on or off the unit. SW #1 indicated she spoke with Resident #87 about maintaining appropriate boundaries which he/she understood. SW #1 indicated she notified the resident representative. SW #1 indicated she will continue to monitor Resident #87 mood and behaviors and will remain available as needed. The care plan failed to reflect revision after Resident #87 allegedly made physical contact with another resident of the opposite sex while sitting in the lounge. Interview with the ADNS on 8/16/23 at 1:40 PM identified she was aware that Resident #39 reported to staff that Resident #87 had touched him/her under the breast. The ADNS indicated Resident #87 denied touching Resident #39 and identified the facility did not report the incident to the State Agency because Resident #39 reported Resident #87 did not touch his/her breast but touched his/her right mid abdomen. The ADNS indicated the APRN, and the resident representative were notified of Resident #87's physical contact with another resident of the opposite sex on the unit. The ADNS indicated she should have documented the incident and notifications in the clinical record. Interview and clinical record review with the ADNS on 8/16/23 at 1:50 PM , failed to provide documentation to reflect that the care plan was revised after an allegation that resident had allegedly touched a female resident under the breast while sitting in the lounge. Although requested, a facility policy was not provided. 2. Resident #39 was admitted to the facility in October 2021 with diagnoses that included dementia, anxiety disorder, and depressive disorder. The quarterly MDS dated [DATE] identified Resident #39 had intact cognition, had no behaviors, and was independent with bed mobility, transfers, walking in room, walking in corridor, and locomotion on the unit. The care plan dated 2/3/23 identified Resident #39 had dementia due to a traumatic brain injury post stroke resulting in sometimes needing help with care. Resident #39 usually does not like to be touched, thus will wash and dress self without help. There are times that the resident will ask for help. Interventions included to reapproach when the resident decides to not get washed/dressed. Offer to help daily to complete ADLS. The resident may need a lot of cueing/prompting or physical help to complete tasks. The resident transfers and ambulates independently using a walker. Physician's orders dated March 2023 directed Resident #39 was independent with transfers, walked with a four-wheel walker, and to monitor behavior of verbal outbursts every shift. A reportable event form dated 3/15/23 at 2:00 PM identified Resident #39 reported to the ADNS that another resident had touched him/her under the breast while sitting in the lounge. Resident #39 was not sure exactly when the incident occurred, but thought it was a few days ago. No distress or discomfort. Resident #39 is alert and confused at times. Extensive assistance with dressing and bathing. APRN and resident representative was notified. Investigation initiated. A statement written by the ADNS on 3/15/23 identified the ADNS met with Resident #39 after being made aware of the report that another resident had touched him/her under the breast. The ADNS indicated Resident #39 reported and pointed that he/she was touched on the right side of the mid abdomen area. The ADNS indicated Resident #39 denied being touched on the breast. The ADNS indicated Resident #39 reports that he/she is not upset about the incident and feels safe around Resident #87 and on the unit. A statement written by SW #1 on 3/15/23 at 3:30 PM identified SW #1 met with Resident #39 who reported that another resident touched him/her above her abdomen underneath the breast. SW #1 indicated Resident #39 reported it happened approximately 2 weeks ago and he/she did not feel uncomfortable. SW #1 indicated Resident #39 reported it happened in the lounge while they were talking. SW #1 indicated Resident #39 reported he/she held Resident #87 hands because Resident #87 held his/her hands. SW #1 indicated Resident #39 denied any other physical encounters. SW #1 indicated Resident #39 reported she feel comfortable and safe at the facility, and around Resident #87. Review of the 24-hour report dated 3/15/23 failed to reflect documentation Resident #39's report that another resident had touched him/her under the breast while sitting in the lounge. The nurse's note dated 3/15/23 through 3/31/23 failed to reflect documentation of Resident #39 that another resident had touched him/her under the breast while sitting in the lounge. The social worker form dated 3/17/23 identified on 3/15/23 it was reported to SW #1 that Resident #39 informed a staff member that another resident made physical contact with him/her. SW #1 met with Resident #39 who explained about 2 weeks ago another resident touched him/her above her abdomen, under his/her breast while they were sitting together and talking in a common area. SW #1 indicated Resident #39 reported he/she was not uncomfortable with the interaction. SW #1 indicated Resident #39 reported he/she felt comfortable and safe on the unit and around his/her peers and including Resident #87. SW #1 indicated she observed no sign of distress. SW #1 indicated she informed Resident #39 to inform the staff should any person made physical contact with him/her to ensure all involved are safe and comfortable in their environment. SW #1 indicated she spoke to resident representative about Resident #39's report that another resident had touched him/her under the breast while sitting in the lounge. SW #1 indicated the resident representative reported that Resident #39 never mentioned anything. SW #1 indicated she will monitor Resident #39 for signs of distress and will remain available as needed. Review of the APRN progress note for the month of March 2023 failed to reflect documentation of Resident #39's report that another resident had touched him/her under the breast while sitting in the lounge. Review of the psychiatric APRN progress note for the month of March 2023 failed to reflect documentation of Resident #39's report that another resident had touched him/her under the breast while sitting in the lounge. Interview with the ADNS on 8/16/23 at 1:30 PM identified she was aware Resident #39 reported to staff that another resident had touched him/her under the breast. The ADNS indicated she completed the RN assessment while interviewing and having Resident #39 demonstrate where the other resident touched him/her. The ADNS indicated Resident #39 showed her that the other resident touched his/her right mid abdomen and did not touch his/her breast. The ADNS indicated after the investigation the facility did not report the incident to the State Agency because Resident #39 reported the other resident did not touch his/her breast but touched his/her right mid abdomen. The ADNS indicated she should have documented the RN assessment in the clinical record. The ADNS indicated the APRN, and the resident representative were notified of Resident #39 reports, and she indicated she should have documented the notifications in the clinical record. Interview and clinical record review with the ADNS on 8/16/23 at 1:50 PM , failed to provide documentation to reflect that the care plan was revised after an allegation that another resident had touched him/her under the breast while sitting in the lounge. Although requested, a facility policy was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #51) reviewed for accidents, the facility failed to ensure the nurse followed standards of practice during medication administration. The findings include: Resident #51 was admitted to the facility on [DATE] with diagnoses that included cirrhosis of the liver, constipation, and major depressive disorder. A physician's order dated 1/31/23 directed to administer Lactulose 30ml three times daily, for constipation. The annual MDS dated [DATE] identified Resident #51 had intact cognition and was independent with bed mobility, transfers, and locomotion on the unit. The care plan dated 7/6/23 identified a PASARR recommended that Resident #51 receive specific services, including interventions to provide medication education. Review of the August 2023 MAR identified the morning dose of Lactulose was administered on 8/13/23. Observation on 8/13/23 at 9:38 AM identified an unsupervised medication cup containing a clear liquid, which Resident #51 identified as Lactulose, sitting on his/her bedside table. Resident #51 indicated he/she was waiting until later to take the medication. Interview with LPN #4 on 8/13/23 at 9:40 AM identified that the medication cup containing Lactulose was left at the bedside, and Resident #51 should have taken the Lactulose before breakfast. LPN #4 further identified that she should have ensured that the mediation was administered before she had left the room or she should have removed the medication from the room and come back with it later. Subsequent to surveyor inquiry, LPN #4 removed the Lactulose from the bedside table. Interview with the DNS on 8/16/23 at 2:46 PM indicated that she would expect the charge nurse to stay with the resident until he/she had taken the medication. If the resident had refused to take the medication, she would have expected the nurse to discard the medication and document the refusal. The DNS further identified that the medication should not have been left on the bedside table. The DNS indicated that she would provide education to the licensed nursing staff that medication is not to be left, unsupervised, at the bedside. Review of the facility's, Administration Procedures for All Medications, policy directed that any unused or partial doses of medication should be disposed of in accordance with the medication destruction policy, once it was removed from the package or container, and medication refusals were to be documented on the MAR or TAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #39, 54 and 60) reviewed for allegations of sexual abuse, the facility failed to conduct an RN assessment after the residents reported an allegation of sexual abuse by Resident #29, and for 1 resident (Resident #72) reviewed for hospitalization, the facility failed to ensure a change of condition assessment was completed for a resident with documented change in cognition. The findings include. 1. Resident #29 was admitted to the facility on [DATE] with diagnoses that included disorganized schizophrenia, intellectual disability and fluency disorder, and diabetes. The quarterly MDS dated [DATE] identified Resident #29 had intact cognition, was always continent of bowel and bladder, and was independent with transfers, dressing and toileting. The care plan dated 5/30/23 identified Resident #29 had a history of disorganized schizophrenia with psychotic symptoms including delusions of a sexual nature, disinhibited sexual speech, and disinhibited sexual behaviors. Interventions included to report any observed behavior/speech to the charge nurse, and if any behavior/speech was observed to ask the resident to stop, redirect and remind the resident why the behavior/speech was inappropriate. Interventions also included that if Resident #29 presented harm to any other residents of the facility, he/she may be placed on higher level of supervision which may include 2-person supervision during interactions with others. The psychiatric note dated 5/31/23 identified Resident #29 had a history of psychosis and Schizophrenia and required antipsychotic medications. The note further identified that Resident #29 was pleasant, engaging, had no reported behavioral issues, had been compliant with medications, denied any sleep disturbances, and that nursing had offered no concerns. The physician's orders dated 6/1/23 directed to administer Depakote (a mood stabilizer) twice daily, Clozapine (an antipsychotic medication) at night, and Haldol (an antipsychotic medication) every three weeks. The orders further directed behavior monitoring every shift related to delusions, hallucinations, physical aggression, and disinhibited sexual behavior. A written email from RN #4 dated 6/9/23 at 11:02 PM to the Administrator, the DNS, and SW #1 identified at 10:15 PM, Resident #29 was placed on every 15 minutes checks due to reports of the resident entering at least three different resident rooms (of the opposite sex) and behaving inappropriate with them. NA #2 went in Resident #60's room and found Resident #29 in that room behind the door (no time provided). Resident #60 was standing in the room with his/her walker, neither resident could explain why Resident #29 was in that room so resident #29 was sent back to his/her own room. NA #1 answered Resident #39's call light and the resident reported that another resident (of the opposite sex) was in his/her room. Resident #39 reported that the resident (Resident #29) was standing over him/her and told him/her he/she would not harm her and began to undo the buttons on Resident #39's blouse and fondle his/her breast. RN #4 indicated she and LPN #2 went to Resident #29's room to talk to him/her, but the resident's tone was so low they could not make sense of what he/she is saying except that he/she thought it was okay to do what he/she did. RN #4 indicated they instructed Resident #29 not to go into other resident rooms and he/she agreed. RN #4 indicated LPN #2 went into Resident #54's room and that resident reported that Resident #29 had come into his/her room and tried to fondle his/her breast and he/she chased Resident #29 out of the room. Review of reportable event documentation identified that on 6/9/23 at approximately 10:15 PM, Resident #29 was alleged to have inappropriately touched Resident #60 (a resident of the opposite sex) after entering his/her room. The reportable event documentation further identified that following the incident, the facility was also notified that between 10:05 PM and 10:15 PM, prior to the incident with Resident #60, Resident #29 was also alleged to have inappropriately touched Resident #39 and #54 (both residents of the opposite sex) after entering each of their rooms. The reportable event documentation also identified that MD #1 was notified of the incidents involving Resident #29 on 6/9/23 at 10:30 PM (this is in conflict with the interview with MD #1 who stated he had not been notified of these incidents until 6/12/23, 3 days later). The nurse's note dated 6/10/23 at 12:58 AM by RN #2 (11:00 PM - 7:00 AM nursing supervisor) identified that Resident #29 had been placed on 1:1 observation as a nursing measure related to intrusive behavior. The note further identified RN #2 had placed a referral in the psychiatric provider's book regarding Resident #29's behavior. Review of the Behavioral Health Visit Request book identified that a request for Resident #29 dated was dated 6/10/23 with the reason for request (Resident #29 went into 3 other residents' rooms, unbuttoned one resident's shirt and told them all I want to hurt you.) The request was signed off as seen by behavioral health on 6/13/23, 3 days later. A written statement completed by the Administrator on 6/10/23 identified that she was notified via text message by RN #8 on 6/10/23 of incidents involving Resident #29 on 6/9/23 during the 3-11 PM shift when RN #4 was the evening nursing supervisor. The Administrator further identified that she then contacted RN #4, who provided details of the incidents via email sent to the Administrator, DNS, and Social Worker #1. The statement further identified that RN #4 was educated that she should have contacted the Administrator via phone call regarding the incidents, not by email. The APRN note completed by APRN #1 dated 6/12/23 identified a medical work up had been requested by nursing staff for Resident #29 due to allegations of sexual assault of 3 residents of the facility. The note further identified that Resident #29 was observed to be delusional with a flat affect and was difficult to understand due to flow of mumbled speech. The assessment and plan identified Resident #29 had a change in behavior and would be worked up for evidence of infection or metabolic disarrangement. The psychiatric APRN note dated 6/12/23 identified that Resident #29 was seen for an allegation of abuse. The note further identified that Resident #29 reported visual hallucinations and appeared to having hallucinations nightly and that nursing staff had reported a change in Resident #29's behavior since 6/9/23. The note identified that Resident #28 appeared to have an exacerbation in Schizophrenia with perceptual disturbances and medications may be necessary to address acute psychosis in conjunction with the medical workup. The nurse's note dated 6/12/23 at 5:54 PM identified Resident #29's resident representative was notified of behavioral incidents that occurred on 6/9/23 and that Resident #29 had been seen by the medical and psychiatric APRNs on 6/12/23. Interview with the Administrator on 8/15/23 at 7:30 AM identified that she was made aware on 6/10/23 of the alleged incidents with Resident #29, she was not aware that the physician and resident representative had not been contacted and notified regarding the incidents until 6/12/23, 3 days later. The Administrator was unable to identify why the physician and resident representative were not notified until 6/12/23, 3 days after the incidents. Interview with APRN #1 on 8/15/23 at 11:53 AM identified she was notified of the allegations involving Resident #29 on 6/12/23 when she was in the building to see residents. APRN #1 identified that the facility should have completed a nursing assessment and contacted the on-call provider on 6/9/23 immediately following the incidents, and Resident #29 should have been placed on 1:1 observation right away. APRN #1 further identified that 1:1 monitoring would have been the most important intervention, and if the facility had notified her of the incidents on 6/9/23 when they occurred, APRN #1 would have sent Resident #29 to the hospital for further evaluation. APRN # 1 further identified Resident #29 had not had any allegations of inappropriate touch prior to 6/9/23 and the alleged behaviors were 'out of the blue'. Interview with MD #1 (Medical Director) on 8/16/23 at 10:29 AM identified that he was notified of allegations related to Resident #29 on 6/12/23, when APRN #1 was already scheduled to be at the facility to examine residents. MD #1 identified that he would have expected that if there were any allegations of assaults of a sexual nature that the facility should have contacted him on 6/9/23 at the time of the incidents. MD #1 further identified that if he had been notified of allegations on 6/9/23, he would have sent Resident #29 to the hospital for further evaluation. The facility policy on Physician Notification-Change in Condition directed that it was the policy of the facility to notify the physician when a resident's condition or status changed unexpectedly or substantially to ensure the physician was kept informed of changes in an appropriate and timely manner. The policy further directed that resident would be evaluated by the change nurse and if determined to have a change in condition, the charge nurse would notify the RN Supervisor on duty, and the RN supervisor would complete a follow up assessment and ensure the assessment was documented and reported to the physician. The policy also directed the resident representative would also be notified regarding change of condition. Although requested, the facility failed to provide a policy on RN Assessments. 2. Resident #39 was admitted to the facility 10/20/21 with diagnosis that included dementia with behavioral disturbance, frontal lobe and executive function deficit following cerebral infarction, and anxiety disorder. The quarterly MDS dated [DATE] identified Resident #39 had intact cognition, required supervision with bed mobility and toilet use, extensive assistance with dressing and personal hygiene, used a walker for mobility, had cerebral palsy, and basal cell carcinoma of the skin. The care plan dated 5/4/23 had a focus on dementia secondary to traumatic brain injury and a stroke and indicated the resident required assistance with activities of daily living. Interventions included offering help daily and offer cueing/prompting or physical help to complete tasks. The nurse's note dated 6/11/23 at 11:25 AM identified that the RN Supervisor (RN #8) checked in with Resident #39 on 6/10/23 and 6/11/23 following an occurrence with another resident. Resident #39 noted that Resident #29 (another resident of the opposite sex) attempted to unbutton his/her blouse, but he/she yelled and told him/her to get out of the room and Resident #29 left as instructed. RN #8 reassured Resident #39 that we are here to provide support and to reach out to staff is needed for support or to talk. Resident #39 verbalized understanding and said thank you. Resident #39 reports he/she had a nice afternoon out with family yesterday, seated outside with peers having a cup of hot chocolate on the patio. RN #8 indicates she spoke privately with Resident #39, and Resident #39 denies being anxious or fearful, and slept great last night. The reportable event form dated 6/12/23 identified on 6/9/23 between 10:10 PM and 10:15 PM Resident #39 alleged he/she had been touched inappropriately by another resident (of the opposite sex, Resident #29). Resident #39 alleges Resident #29 entered his/her room and unbuttoned Resident 39's nightshirt. Resident #39 yelled at Resident #29 instructing him/her to leave. Resident #29 exited the room; Resident #39 used the call bell to seek assistance. A statement by RN #5 identified on 6/9/23 at approximately 10:15 PM Resident #39 came to the nurse's station and received reassurance about safety. RN #5 indicates Resident #39 did not appear to be upset, mood appropriate, however with the reassurance of safety, Resident #39 refused to go back to bed. Interview with RN #2 the RN Supervisor on 8/14/23 at 1:54 PM (who worked the 11:00 PM - 7:00 AM shift on 6/9/23) identified she was not aware of the inappropriate touch and had only known of Resident #29's wandering into various rooms during the 3:00 PM - 11:00 PM shift the evening of 6/9/23. Wanting additional monitoring for Resident #29, RN #2 reached out to the ADNS on 6/9/23 at approximately 10:50 PM and secured the 1:1 authorization for the 11:00 PM - 7:00 AM shift. Interview with NA #1 on 8/15/23 at 2:20 PM identified she responded to Resident #39's call bell and upon entering the room Resident #39 was seated on the bed and reported and described a person who had entered the room. NA #1 indicated Resident #39's night shirt was unbuttoned down to the waist. Resident #39 wore an athletic undergarment which was visible. Resident #39 indicated the intruder was ordered to get out of the room, and the intruder left. NA #1 indicated she offered assurance to Resident #39, encouraging Resident #39 to go back to bed, and proceeded to leave the room to report the incident to the supervisor. Upon arrival at the nurse's station, RN #5, LPN #2, and RN #4 (Nurse Supervisor) were discussing a resident entering other resident's room (Resident #54 and Resident #60). NA #1 indicated as she spent 5 minutes with Resident #39, was at the nurse's desk with staff for 3 - 4 minutes, then Resident #39 approached the nurse's station. The facility policy on Physician Notification-Change in Condition directed that it was the policy of the facility to notify the physician when a resident's condition or status changed unexpectedly or substantially to ensure the physician was kept informed of changes in an appropriate and timely manner. The policy further directed that resident would be evaluated by the change nurse and if determined to have a change in condition, the charge nurse would notify the RN Supervisor on duty, and the RN supervisor would complete a follow up assessment and ensure the assessment was documented and reported to the physician. The policy also directed the resident representative would also be notified regarding change of condition. Although requested, the facility failed to provide a policy on RN Assessments. 3. Resident #54 was admitted to the facility in November 2017 with diagnoses that included major depressive disorder, anxiety disorder, and paranoid schizophrenia. The quarterly MDS dated [DATE] identified Resident #54 had intact cognition, no behaviors, and was independent with bed mobility, transfers, walking in room, and walking in corridor. Physician's orders dated June 2023, directed that Resident #54 was independent with transfers, and ambulation without an assistive device. A written statement from the Administrator dated 6/10/23 identified on 6/10/23 at 1:06 PM she received a text from RN #8 asking about the incident that occurred on 6/9/23 on the 3:00 PM - 11:00 PM shift. The Administrator indicated RN #8 provided her limited details of the alleged incident. The Administrator indicated she called RN #4 and inquired about what had occurred. The Administrator indicated RN #4 identified that she had sent me an email along with the DNS and the SW #1 the night before (6/9/23) with details. The Administrator indicated she educated RN #4 that the alleged incident warranted a phone call and not an email. The Administrator indicated RN #4 indicated to her the reason she did not call her, or the DNS is because RN #4 did not feel anyone was harmed or injured. The Administrator indicated she stressed to RN #4 the importance of proper channels of communication needed in this case. The Administrator indicated she asked RN #4 to provide a written statement of the alleged occurrence. The Administrator indicated RN #4 was removed off the schedule during the investigation. The nurse's note dated 6/11/23 at 9:30 AM identified a follow up note due to occurrence with another resident. RN #8 indicated she spoke with Resident #54 on 6/10/23 and on the morning of 6/11/23. Resident #54 was ambulating on the unit with peers. Resident #54 was in good spirits, smiling, and asked what was on the menu for lunch. RN #8 indicated she spoke privately with Resident #54 who stated he/she was fine and does not feel afraid or anxious. Resident #54 indicated he/she was surprised that it happened because he/she is married. RN #8 indicated she explained to Resident #54 if he/she wanted to talk, to reach out to the staff for support. A written statement from Resident #54 dated 6/11/23 at 7:30 AM identified he/she woke up and used the bathroom. Resident #54 indicated he/she went back to bed and fell asleep. Resident #54 indicated another resident (of the opposite sex, Resident #29) was standing over him/her and touched his/her breast. Resident #54 indicated he/she pushed Resident #29 out of the room. Review of the facility 24-hour report dated 6/9/23 through 6/12/23 failed to reflect documentation that Resident #54 had reported to LPN #2 the allegation that another resident (of the opposite sex, Resident #29) was standing over him/her and touched his/her breast on 6/9/23 on the 3:00 PM - 11:00 PM shift. Review of the Department of Public Health Facility Licensing and Investigations Sections (FLIS) reportable events portal report dated 6/12/23, (3 days after the incident) identified the facility reported Resident #54's allegation that Resident #29 came into his/her room and Resident #29 stood over him/her at bedside and touched his/her breast. The APRN progress note dated 6/12/23 identified that she was asked to see Resident #54 who alleged another resident (of the opposite sex, Resident #29) came into his/her room in the middle of the night and asked him/her to unbutton his/her shirt and touched his/her breasts. Resident #54 was able to chase Resident #29 away by yelling and pushing him/her. Resident #54 was seen and examined. No evidence of trauma noted. Resident #54 has a significant history of paranoid schizophrenia and anxiety. The nurse's note dated 6/12/23 at 11:52 AM identified APRN #1 performed a body assessment with no redness, no bruising, and no injuries noted. Resident #54 had no complaints of pain or discomfort. The resident representative was notified. A message was left for APRN #2. The nurse's note dated 6/12/23 through 6/24/23 failed to reflect documentation of Resident #54's report that another resident (of the opposite sex, Resident #29) came into his/her room in the middle of the night and asked him/her to unbutton his/her shirt and touched his/her breasts on 6/9/23 during the 3:00 PM - 11:00 PM shift. The care plan dated 6/12/23 identified resident to resident - Resident #54 alleged that another resident (of the opposite sex, Resident #29) made inappropriate physical contact. Interventions included to offer psychiatric therapy and medication management. Offer 1:1 visit by the social worker so that Resident #54 can discuss concerns/issues about others. The social worker note dated 6/12/23 identified she met with Resident #54 regarding an allegation of mistreatment. SW #1 indicated a follow up of an alleged incident between Resident #54 and Resident #29 that happened on Friday (6/9/23). SW #1 indicated Resident #54 reported that Resident #29 knocked on the door and proceeded to just walk into the room. Resident #54 told him/her to get out, and he/she did not. SW #1 indicated Resident #54 reported Resident #29 touched him/her inappropriately by putting his/her hands on his/her breasts and fondling them. SW #1 indicated Resident #54 reported she told him/her to get out of the room, he/she kicked and hit him/her on the back until Resident #29 left the room. SW #1 indicated she assured Resident #54 that the allegation is being taken seriously and staff want to make sure that all residents feel safe. SW #1 indicated Resident #54 reported that he/she feels safe and secure. A written statement from LPN #2 dated 6/12/23 at 2:45 PM identified she was approached by Resident #54 while walking down the hallway on 6/9/23. LPN #2 indicated Resident #54 called out to her and Resident #54 indicated another resident (of the opposite sex, Resident #29) was in his/her room and he/she indicated to Resident #29 you are not supposed to be in here. Resident #54 had just come out of the bathroom and got into bed and Resident #29 touched his/her breast and walked away. LPN #2 indicated she provided Resident #54 with reassurance and emotional support after the interaction on Friday 6/9/23. The psychiatric APRN note dated 6/12/23 at 8:44 PM identified that she was asked to see Resident #54 due to allegation of sexual assault. Resident #54 reported another resident (of the opposite sex, Resident #29) entered his/her room and touched his/her breast. Resident #54 reported he/she asked Resident #29 to stop and leave the room. Resident #54 reported he continued to touch his/her breast, and he/she pinched Resident #29 on the back then he/she got up and left. Resident #54 reported seeing Resident #29 in the dining room this afternoon which made his/her nervous until he/she noticed Resident #29 had someone watching him/her and that is when he/she calmed down. Resident #54 reported that he/she feels safe at the facility. Resident #54 reported he/she can get help by using the call light or scream out if he/she needs to. Would recommend continuing Ativan as prescribed as Resident #54 has residual symptoms of anxiety. Recommend psychotherapy so that Resident #54 can continue to process his/her feelings. The psychotherapy initial assessment dated [DATE] at 1:54 PM identified Resident #54 was alert, oriented times three and coherent. Met with Resident #54 for support and difficulty with anxiety with alleged sexual abuse issue. Resident #54 reported that he/she had some difficulty with another resident (of the opposite sex, Resident #29) coming into his/her room and inappropriately touching his/her breast. Resident #54 reported she informed the staff about the issue. Resident #54 report that he/she has some difficulty with anxiety. Will continue to monitor Resident #54 and provide support and validation for resident. The reportable event form dated 6/13/23 at 10:00 PM, identified the date and time of the event first known was on 6/9/23 at 11:05 PM, 4 days prior. Resident #54 alleged that Resident #29 came into his/her room, and he/she woke up with Resident #29 standing over him/her at bedside touching his/her breast. Resident #54 got up and pushed Resident #29 out of the room. Resident to resident abuse without injury. Resident #54 mood was stable with no changes in behavior. Resident #54 ambulates without device. The reportable event form identified the physician was notified on 6/9/23 at 11:20 PM (this is in conflict with an interview with the physician (MD #1) who identified he did not receive a call from the facility on 6/9/23 at 11:20 PM and was not notified of the incident until Monday 6/12/23, 3 days later). The reportable event form identified the resident representative, the police, and the Administrator were all notified, however, there is no date or time of notification. Further, the facility staff did not notify the police, and the Administrator was not notified until 6/10/23, the next day. Interview with Resident #54 on 8/13/23 at 10:55 AM identified he/she was almost raped by another resident (of the opposite sex, Resident #29). Resident #54 indicated Resident #29 came into his/her room and touched his/her breast. Resident #54 indicated he/she kicked Resident #29 out of the room. Resident #54 indicated Resident #29 has not been back in his/her room. Resident #54 indicated LPN #2 was going down the hallway the same night it happened, and he/she called out for LPN #2. Resident #54 indicated when LPN #2 came to the room he/she told LPN #2 about Resident #29 was in his/her room and touched his/her breast. Resident #54 indicated LPN #2 did not assess his/her body. Resident #54 indicated RN #4 did not assess his/her body. Resident #54 indicated he/she told LPN #2 the night it happened and told SW #1 on Monday (6/12/23) about Resident #29 coming into the room and touching his/her breast. Resident #54 indicated on Monday APRN #1 came and assessed his/her body and talked to him/her. Interview and review of the clinical record with the ADNS on 8/14/23 at 10:59 AM failed to provide documentation that an RN assessment had been completed on 6/9/23 at the time of the report. Further, the clinical record failed to reflect that the physician and the resident representative had been notified on 6/9/23. The ADNS indicated RN #4 should have completed an RN assessment and documented that assessment in Resident #54's clinical record at the time of the allegation. The ADNS indicated RN #4 should have notified the physician and the resident representative. The ADNS indicated she was not aware notification had not been made or an assessment done at the time of the allegation. The ADNS indicated documentation is by exception. The ADNS indicated RN #4 failed to call her, the DNS, and the Administrator on 6/9/23 at the time of the allegation. The ADNS indicated the expectation of the facility is that RN #4 should have notified her and the Administrator that Resident #29 had inappropriately touched Resident #54's breast. Interview with the Administrator on 8/15/23 at 7:30 AM identified she was not aware of the allegation of sexual assault on 6/9/23 at 10:15 PM. The Administrator indicated she texted RN #8 on Saturday 6/10/23 at approximately 1:00 PM regarding staffing, and at the end of the text RN #8 texted back asking how long Resident #29 was going to be on 1:1. The Administrator indicated she texted RN #8 to call her on the phone. The Administrator indicated she called the facility and spoke to RN #8. The Administrator indicated RN #8 identified she thought the Administrator knew the details of the incident on 6/9/23. RN #8 indicated that Resident #60 (one of the 3 residents that Resident #29 had touched on 6/9/23) had called the police. The Administrator indicated she called RN #4 who indicated she had sent an email regarding the details of the event on 6/9/23 at 11:06 PM. The Administrator indicated she hung up the phone with RN #4 and read the email. The Administrator indicated RN #4 should have called her via phone and notified her of the allegation at the time it happened. The Administrator indicated she contacted her Chief Operating Officer, Chief Clinical Office, and the RN Director of Quality of Life and Specialty Programs (the Regional Nurse Educator). The Administrator indicated they had a collaboration meeting, they immediately started investigation by interviewing the staff that was present on 6/9/23 on the 3:00 PM - 11:00 PM shift via phone. The Administrator indicated on Sunday 6/11/23 she had a conference call with the Chief Clinical Office and the RN Director of Quality of Life and Specialty Programs. The plan was to report the allegation on Monday morning 6/12/23 by entering the incident into the FLIS portal with the State Agency, however, the Administrator indicated the facility should have reported the allegation earlier. The Administrator indicated she was not aware that the RN assessment was not completed and documented in the resident's clinical record. The Administrator indicated she was not aware the physician and the resident representative had not been notified on 6/9/23. The Administrator indicated the expectation of the facility is that the RN supervisor should have notified the physician and the resident representative of the allegation. The Administrator indicated the facility has in-service the licensed nurses. Interview with APRN #1 on 8/15/23 at 11:53 AM identified she did not receive a phone call from the facility on Friday 6/9/23 regarding the allegation of that Resident #29 inappropriately touched Resident #54 and indicated she was notified on Monday 6/12/23, 3 days after the incident, and she assessed Resident #54 on 6/12/23. APRN #1 indicated her expectation is the facility should have contacted and notified the physician, and/or the APRN at the time of the allegation and that the RN Supervisor should have performed an RN assessment. Interview with MD #1 on 8/16/23 at 10:26 AM identified the facility did not notify him on Friday 6/9/23 or over the weekend of Resident #54's allegation of being touch inappropriately. MD #1 indicated the facility notified him on Monday 6/12/23, 3 days after the incident. MD #1 indicated APRN #1 was going to be at the facility on Monday 6/12/23 and she would assess the resident. MD #1 indicated his expectation is that the facility should have notified him of the allegation at the time in happened. Interview with RN #4 on 8/16/23 at 3:27 PM indicated she has been with the facility since 7/20/22. RN #4 indicated she is the RN supervisor for the 3:00 PM - 11:00 PM shift. RN #4 indicated on 6/9/23 at approximately 10:15 PM she was notified by LPN #2 that Resident #29 was observed in Resident #60's room. RN #4 indicated she went to the unit and spoke to Resident #29 who was in his/her room. RN #4 indicated while she and LPN #2 were walking in the hallway Resident #54 called out to LPN #2 in the hallway. RN #4 indicated LPN #2 went to see what the resident wanted. RN #4 indicated Resident #54 indicated another resident (of the opposite sex, Resident #29) had come into his/her room and he/she yelled at him/her and Resident #29 left. RN #4 indicated she proceeded to the nurse's station and placed Resident #29 on every 15 minutes monitoring. RN #4 indicated since she has been at the facility, she was informed to email the Administrator, the DNS, and the ADNS with any changes at the facility during her shift. RN #4 indicated the Administrator, the DNS, and the ADNS do not answer their phone when you call them. RN #4 indicated she did not document in Resident #54's clinical record. RN #4 indicated she did not perform a body assessment and did not call the physician or the resident representative. RN #4 indicated LPN #2 should have documented in Resident #54 clinical record regarding the allegation of inappropriate touch. RN #4 indicated she was taken off the schedule pending investigation. A written statement from the Administrator dated 8/16/23 identified the facility acknowledges discrepancies in the FLIS reporting system regarding the event on 6/9/23 regarding Resident #54. The physician, APRN, and psychiatric APRN were notified on 6/12/23 and assessed by both APRN's on 6/12/23. The facility completed an RN assessment on 6//12/23. Review of the facility abuse policy identified each resident has the right to be free from abuse, neglect, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. Sexual abuse - includes but is not limited to, non-consensual sexual contact of any type with a resident, sexual harassment, sexual coercion or sexual assault. Allegations of abuse will be reported promptly and thoroughly investigated. Facility in-house reporting - Whenever there is a witnessed, suspected or alleged abuse action involving a resident, as defined above, the following is initiated: The staff member who hears allegation of abuse, or suspects or witnesses abuse will report immediately to their supervisor. The Administrator or on-call designee and Director of Nursing Services are to be notified immediately. The facility policy on Physician Notification-Change in Condition directed that it was the policy of the facility to notify the physician when a resident's condition or status changed unexpectedly or substantially to ensure the physician was kept informed of changes in an appropriate and timely manner. The policy further directed that resident would be evaluated by the change nurse and if determined to have a change in condition, the charge nurse would notify the RN Supervisor on duty, and the RN supervisor would complete a follow up assessment and ensure the assess[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy and interview for 1 of 2 residents (Resident #8) reviewed for accidents, the facility failed to ensure a resident was assessed and monitored following discontinuation of close monitoring due to a documented history of elopements. The findings include: Resident #8 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, schizoaffective disorder, and chronic kidney disease. A physician's order dated 1/11/23 directed for Resident #8 to have a wander guard placed and check placement every shift. The nurse's note dated 1/11/23 at 10:10 PM identified Resident #8 was placed on 1:1 observation due to risk of elopement and refusal of wander guard placement. The nurse's note dated 1/13/23 at 12:08 PM identified Resident #8 had verbalized he/she did not want to be at the facility and could not be forced to stay at the facility. The note further identified Resident #8 remained on 1:1 supervision as he/she was very mobile and voiced he/she did not want to be in the facility and would not be staying. The social service note dated 1/13/23 at 12:49 PM identified Resident #8 remained 1:1 due to refusal of wander guard placement and history of exit seeking behaviors. The care plan dated 1/13/23 identified Resident #8 was at risk of his/her psychosocial well-being due to chronic medical and psychological conditions vascular dementia with behavioral disturbances, bipolar disorder with psychotic features, and schizophrenia (resident believed he/she was in his/her 20's or 30's and did not need to live at the facility). Interventions included nursing staff would refer any newly identified psychosocial conditions or concerns to social work as needed and social work would have periodic contact with the resident to assess and document any significant concerns or changes. The admission MDS dated [DATE] identified Resident #8 had moderately impaired cognition, was always continent of bowel and bladder, was independent with transfers, dressing, toilet use, and personal hygiene. The 1/18/23 capacity to meet minimum needs interview note completed by SW #2 identified Resident #8 had a history of, or any other known behaviors which placed him/her at risk of, seeking unescorted exit from a supervised setting. The note further identified Resident #8 believed he/she was in his/her 20's or 30's, could live alone and work, and had a history of disappearing to other states and then found to be living on the streets. The note further identified Resident #8 had been able to board trains and planes to other locations in the United States and had a wander guard in place. The nurse's note dated 2/21/23 at 1:09 PM identified every 15-minute checks had been discontinued for Resident #8 after discussion with the interdisciplinary team as Resident #8 had not made any attempt to exit the facility and behaviors had been stable over the past several days. The note further identified that Resident #8 would continue to be monitored for any exit seeking behaviors. Review of the clinical record failed to identify nursing documentation related to assessment of, or monitoring for, any behaviors related to exit seeking or elopement risk after 2/21/23. The 4/18/23 and 5/8/23 capacity to meet minimum needs interview notes completed by SW #2 identified Resident #8 did not have a known history of, or any other known behaviors which placed him/her at risk of, seeking unescorted exit from a supervised setting. The note further identified Resident #8 was unable to meet his/her minimal basic needs but was not at risk for exit seeking behaviors. The 7/18/23 capacity to meet minimum needs interview note completed by SW #2 identified Resident had a history of, or any other known behaviors which placed him/her at risk of, seeking unescorted exit from a supervised setting. The note further identified that Resident #8 previously had a wander guard on but refused continued placement and had not exhibited any exit seeking behaviors. The 8/7/23 capacity to meet minimum needs interview note completed by SW #2 identified Resident #8 had not shown any exit seeking behaviors in quite some time and was deemed not to be at risk for exit seeking behaviors. The note further identified that Resident #8 would sometimes express plans to return to the community and live in his/her old apartment. Review of Resident #8's care card identified that Resident #8 had exit seeking behaviors, and if Resident # 8 was observed exhibited exit seeking behaviors such as going towards doors to notify the charge nurse or nursing supervisor immediately. Interview with Resident #8's resident representative on 8/13/23 at 2:50 PM identified that Resident #8 had an extensive history of attempted and actual elopements from previous facilities over a 40-year period, including Resident #8's facility prior to admission on [DATE]. Resident #8's resident representative identified that Resident #8 had not had any issues with attempted or actual elopements since admission to the facility on 1/11/23 per discussions with the facility staff. Resident #8's resident representative further identified that Resident #8 had been transferred to the facility, based in part, to his/her previous elopement history and the facility's ability to monitor Resident #8 for any exit seeking behaviors. Resident #8's resident representative identified the facility had implemented several interventions for Resident #8 to attempt to prevent elopements, including direct monitoring and bedazzling his/her wander guard in an effort for Resident #8 to allow a wander guard to be placed. Interview with the Administrator on 8/15/23 at 12:50 PM identified that she had spoken with Resident #8's resident representative following Resident #8's admission to the facility, and Resident #8's resident representative had expressed concerns about exit seeking behaviors and inability to place a wander guard on admission. The Administrator identified that Resident #8's resident representative was concerned Resident #8 would be able to walk out of the facility, but that he/she was reassured that the facility had a monitored entrance point. The Administrator identified she was also aware of Resident #8's history of elopement. The Administrator identified that based on Resident #8's history at the facility, the interdisciplinary team felt he/she was not an elopement risk. The Administrator was unable to provide any specifics regarding how Resident #8 currently was being monitored for any possible exit seeking behaviors, or if behaviors were monitored by nursing staff after every 15-minute monitoring was discontinued on 2/21/23. The Administrator identified it was the responsibility of the social services department to assess Resident #8's risk for exit seeking and document on admission and quarterly. The Administrator further identified she felt based on her prior discussion with Resident #8's resident representative that he/she was satisfied with the interventions the facility had in place, including 1:1 monitoring, wander guard placement, and the monitored facility entrance point. The Administrator further identified that she had not had any other discussion with Resident #8's resident representative regarding the facility's determination that Resident #8 was no longer an elopement risk. Interview with SW #2 on 8/16/23 at 2:47 PM identified that she was responsible for completing the initial and quarterly assessments related to exit seeking behaviors for residents of the facility, including Resident #8. SW #2 identified she completed all of the elopement assessments for Resident #8 since admission, including the most recent from 8/7/23 and identified while Resident #8 did report he/she would like to return to his/her old apartment he/she has no apartment to return to, and SW #2 had not been notified of any exit seeking behaviors for Resident #8 by nursing and so she did not feel Resident #8 was an elopement risk. SW #2 further identified she was not responsible for any actual clinical assessments related to Resident #8's exit seeking behaviors, but no issues had been reported to her by the clinical staff. SW #2 identified that if there were issues related to attempted elopements or exit seeking behaviors, the issues would be observed by nursing staff on the unit, and the nursing staff would notify the Administrator or DNS. SW #2 identified that nursing staff would only reach out to her directly if Resident #8 needed other items, such as a travel pass to leave the facility, but not if Resident #8 had any issues with exit seeking behaviors, rather, she would be notified by the Administrator, and since there had not been any issues reported to her of issues, she did not feel Resident #8 had any risk of elopement, even with Resident #8's previous history. SW #2 identified she had not discussed with Resident #8's resident representative that she had determined Resident #8 was no longer an elopement risk. The facility policy on Capacity to Meet Minimal Basic Needs directed on admission and quarterly resident would be evaluated regarding their capacity to meet their minimal basic needs outside a skilled nursing facility. The policy further directed that if a resident was not capable of meeting his/her basic needs, the resident would be further evaluated for risk of exit seeking utilizing the Capacity to meet minimal basic needs form. Although requested, the facility failed to provide any policies related to residents identified as risk for exit seeking. Although requested, the facility failed to provide a policy on RN Assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation and interviews for 1 resident (Resident #71), the facility failed to follow a dental recommendation for over 16 months. The findings include: Resident #71 was admitted to the facility in September 2020 with diagnoses that included schizophrenia, anxiety disorders, and dementia. Review of a dental consultation form dated 4/1/22 identified Resident #71 had a dental examination that reveals buccal decay, maxillary anteriors and fractured tooth #12. Resident #71 was referred to outside dentist to restore the buccal surfaces of the maxillary anteriors, and to repair fractured tooth #12 with sedation. Review of the facility patient appointment/transportation form dated 4/5/22 identified Resident #71 has an appointment on 12/2/22 at 9:30 AM with a dental specialty. Reason for appointment; restore the buccal surface of the maxillary anteriors, repair fracture tooth #12, and need sedation. Review of the clinical record failed to reflect the resident had gone to the scheduled follow up dental appointment on 12/2/22 at 9:00 AM. Review of the dental consultation form dated 5/26/23 identified Resident #71 was scheduled to be treated today but was not treated. Resident #71 was unavailable. The quarterly MDS dated [DATE] identified Resident #71 had severely impaired cognition and required extensive assistance with personal hygiene, and independent with eating. The care plan dated 6/20/23 identified Resident #71 has some missing teeth, and some teeth have blackish spots. History of drooling. Interventions include supervision with oral hygiene. Will see dentistry as indicated. Uses a special toothpaste. Review of the hygienist schedule for 6/23/23 identified Resident #71 was scheduled to be seen by the hygienist. Review of the dental consultation form dated 6/23/23 identified Resident #71 was scheduled to be treated today but was not treated. Resident #71 was unavailable. Resident #71 was on leave of absence. The physician's order dated August 2023 directed to provide Denta 5000 Plus Cream (Prevadent) with Fluoride Toothpaste when brushing teeth. The physician's order dated 8/3/23 directed to provide Regular National Dysphagia Diet Level 3 (NDD3) Soft. Continue with thin liquids. Interview with Person #1 on 8/13/23 at 3:14 PM identified he/she has been concerned regarding Resident #71's mouth and teeth. Person #1 indicated he/she would like for Resident #71 to see a dentist for his/her teeth. Person #1 indicated he/she had spoken to the supervisors and SW #1 regarding Resident #71 being seen by a dentist but he/she has not heard from the facility regarding any dental appointments and Resident #71 has not seen a dentist as requested. The nurse's note dated 8/15/23 at 1:46 PM identified the ADNS notified Person #1 that Resident #71 has a dental appointment to restore the buccal surfaces of tooth #12 that was noted to be fractured. Resident #71 needs sedation for this procedure due to attention span and mental illness. The ADNS ensured Person #1 that any concerns will be brought up with the dentist at the appointment. Interview and review of the clinical record with the ADNS on 8/15/23 at 2:00 PM identified she was not aware of the issues. The ADNS indicated the follow up dental recommendation appointment should have been done in the year 2022. The ADNS indicated the follow up dental recommendation was not followed through timely, and she will address the issue immediately. The ADNS indicated the licensed nurses should have notified the physician and the resident representative with every scheduled dental appointment, missed appointments, and document in the resident clinical record. Subsequent to surveyor inquiry the facility scheduled an appointment for Resident #71 on 8/31/23 at 9:00 AM for follow up recommendations from 4/1/22 (1 year and 4 months prior). Review of the facility oral hygiene policy identified to remove soft plaque deposits and calculus from the teeth, clean and massage gums, reduce mouth odor, help prevent infection and identify changes in oral health status. Nursing will provide oral hygiene in the morning and at bedtime. Review of the facility dental exam policy identified it is the policy of the facility to follow the CT Public Health Code for dental requirements. Yearly dental examination and evaluation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy review, and interviews for 1 of 2 residents (Resident #8) reviewed for accidents, the facility failed to ensure that elopement assessments were accurately documented for a resident with a documented history of elopements, and for1 resident (Resident #39) reviewed for an allegation of sexual abuse, the facility failed to document the incident in the clinical record, and for 1 resident (Resident #87) who inappropriately touched Resident #39, the facility failed to document the incident in the clinical record. The findings 1. Resident #8 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, schizoaffective disorder, and chronic kidney disease. The care plan dated 1/13/23 identified Resident #8 was at risk of his/her psychosocial well-being due to chronic medical and psychological conditions, vascular dementia with behavioral disturbances, bipolar disorder with psychotic features, and schizophrenia (Resident believed he/she was in his/her 20's or 30's and did not need to live at the facility). Interventions included nursing staff would refer any newly identified psychosocial conditions or concerns to social work as needed and social work would have periodic contact with the resident to assess and document any significant concerns or changes. The admission MDS dated [DATE] identified Resident #8 had moderately impaired cognition, was always continent of bowel and bladder, was independent with transfers, dressing, toilet use, and personal hygiene. The MDS further identified that Resident #8 had no wandering behaviors. The 1/18/23 capacity to meet minimum needs interview note completed by SW #2 identified Resident #8 had a history of, or any other known behaviors which placed him/her at risk of seeking unescorted exit from a supervised setting. The note further identified Resident #8 believed he/she was in his/her 20's or 30's, could live alone and work, and had a history of disappearing to other states and then found to be living on the streets. The note further identified Resident #8 had been able to board trains and planes to other locations in the United States and had a wander guard in place. The 4/18/23 and 5/8/23 capacity to meet minimum needs interview notes completed by SW #2 identified Resident #8 did not have a known history of, or any other known behaviors which placed him/her at risk of, seeking unescorted exit from a supervised setting. The note further identified Resident #8 was unable to meet his/her minimal basic needs but was not at risk for exit seeking behaviors. The 7/18/23 capacity to meet minimum needs interview note completed by SW #2 identified Resident had a history of, or any other known behaviors which placed him/her at risk of, seeking unescorted exit from a supervised setting. The note further identified that Resident #8 previously had a wander guard on but refused continued placement and had not exhibited any exit seeking behaviors. The 8/7/23 capacity to meet minimum needs interview note completed by SW #2 identified Resident #8 had not shown any exit seeking behaviors in quite some time and was deemed not to be at risk for exit seeking behaviors. The note further identified that Resident #8 would sometimes express plans to return to the community and live in his/her old apartment. Interview with the Administrator on 8/15/23 at 12:50 PM identified it was the responsibility of the social services department to assess Resident #8's risk for exit seeking and document on admission and quarterly. Interview with SW #2 on 8/16/23 at 2:47 PM identified that she was responsible for completing the initial and quarterly assessments related to exit seeking behaviors for residents of the facility, including Resident #8. SW #2 identified she completed all of the elopement assessments for Resident #8 since admission, including the most recent from 8/7/23 and identified while Resident #8 did report he/she would like to return to his/her old apartment he/she has no apartment to return to, and SW #2 had not been notified of any exit seeking behaviors for Resident #8 by nursing and so she did not feel Resident #8 was an elopement risk. SW #2 further identified she was not responsible for any actual clinical assessments related to Resident #8's exit seeking behaviors, but no issues had been reported to her by the clinical staff. SW #2 identified that if there were issues related to attempted elopements or exit seeking behaviors, the issues would be observed by nursing staff on the unit, and the nursing staff would notify the Administrator or DNS. SW #2 identified that nursing staff would only reach out to her directly if Resident #8 needed other items, such as a travel pass to leave the facility, but not if Resident #8 had any issues with exit seeking behaviors, rather, she would be notified by the Administrator, and since there had not been any issues reported to her of issues, she did not feel Resident #8 had any risk of elopement, even with Resident #8's previous history. SW #2 identified she had not discussed with Resident #8's resident representative that she had determined Resident #8 was no longer an elopement risk. SW #2 was also unable to identify why there were discrepancies related to her documentation of the elopement assessments in Resident #8's clinical record. 2. Resident #39 was admitted to the facility in October 2021 with diagnoses that included dementia, anxiety disorder, and depressive disorder. The quarterly MDS dated [DATE] identified Resident #39 had intact cognition, had no behaviors, and was independent with bed mobility, transfers, walking in room, walking in corridor, and locomotion on the unit. The care plan dated 2/3/23 identified Resident #39 had dementia due to a traumatic brain injury post stroke resulting in sometimes needing help with care. Resident #39 usually does not like to be touched, thus will wash and dress self without help. There are times that the resident will ask for help. Interventions included to reapproach when the resident decides to not get washed/dressed. Offer to help daily to complete ADLS. The resident may need a lot of cueing/prompting or physical help to complete tasks. The resident transfers and ambulates independently using a walker. Physician's orders dated March 2023 directed Resident #39 was independent with transfers, walked with a four-wheel walker, and to monitor behavior of verbal outbursts every shift. A reportable event form dated 3/15/23 at 2:00 PM identified Resident #39 reported to the ADNS that another resident had touched him/her under the breast while sitting in the lounge. Resident #39 was not sure exactly when the incident occurred, but thought it was a few days ago. No distress or discomfort. Resident #39 is alert and confused at times, requires extensive assistance with dressing and bathing. APRN and resident representative were notified. Investigation initiated. A statement written by the ADNS on 3/15/23 identified the ADNS met with Resident #39 after being made aware of the report that another resident had touched him/her under the breast. The ADNS indicated Resident #39 reported and pointed that he/she was touched on the right side of the mid abdomen area. The ADNS indicated Resident #39 denied being touched on the breast. The ADNS indicated Resident #39 reports that he/she is not upset about the incident and feels safe around Resident #87 and on the unit. A statement written by SW #1 on 3/15/23 at 3:30 PM identified SW #1 met with Resident #39 who reported that another resident touched him/her above the abdomen underneath the breast. SW #1 indicated Resident #39 reported it happened approximately 2 weeks ago and he/she did not feel uncomfortable. SW #1 indicated Resident #39 reported it happened in the lounge while they were talking. SW #1 indicated Resident #39 reported he/she held Resident #87 hands because Resident #87 held his/her hands. SW #1 indicated Resident #39 denied any other physical encounters. SW #1 indicated Resident #39 reported he/she feels comfortable and safe at the facility, and around Resident #87. Review of the 24-hour report dated 3/15/23 failed to reflect documentation Resident #39's report that another resident had touched him/her under the breast while sitting in the lounge. The nurse's note dated 3/15/23 through 3/31/23 failed to reflect documentation of Resident #39 that another resident had touched him/her under the breast while sitting in the lounge. The social worker form dated 3/17/23 identified on 3/15/23 it was reported to SW #1 that Resident #39 informed a staff member that another resident (of the opposite sex) made physical contact with him/her. SW #1 met with Resident #39 who explained about 2 weeks ago another resident touched him/her above the abdomen, under his/her breast while they were sitting together and talking in a common area. SW #1 indicated Resident #39 reported he/she was not uncomfortable with the interaction. SW #1 indicated Resident #39 reported he/she felt comfortable and safe on the unit and around his/her peers and including Resident #87. SW #1 indicated she observed no sign of distress. SW #1 indicated she informed Resident #39 to inform the staff should any person make physical contact with him/her to ensure all involved are safe and comfortable in their environment. SW #1 indicated she spoke to the resident representative about Resident #39's report that another resident had touched him/her under the breast while sitting in the lounge. SW #1 indicated the resident representative reported that Resident #39 never mentioned anything. SW #1 indicated she will monitor Resident #39 for signs of distress and will remain available as needed. Review of the APRN progress note for the month of March 2023 failed to reflect documentation of Resident #39's report that another resident had touched him/her under the breast while sitting in the lounge. Review of the psychiatric APRN progress note for the month of March 2023 failed to reflect documentation of Resident #39's report that another resident had touched him/her under the breast while sitting in the lounge. Interview with the ADNS on 8/16/23 at 1:30 PM identified she was aware Resident #39 reported to staff that another resident had touched him/her under the breast. The ADNS indicated she completed the RN assessment while interviewing and having Resident #39 demonstrate where the other resident touched him/her. The ADNS indicated Resident #39 showed her that the other resident touched his/her right mid abdomen and did not touch his/her breast. The ADNS indicated after the investigation the facility did not report the incident to the State Agency because Resident #39 reported the other resident did not touch his/her breast but touched his/her right mid abdomen. The ADNS indicated she should have documented the RN assessment in the clinical record. The ADNS indicated the APRN, and the resident representative were notified of Resident #39 reports, and she indicated she should have documented the notifications in the clinical record. 3. Resident #87 was admitted to the facility in February 2023 with diagnoses that included dementia, and anxiety disorder. The care plan dated 2/11/23 identified Resident #87 has a history of disinhibited sexual behaviors and physical aggression. Interventions included to ask the resident to stop the disinhibited sexual behaviors if he/she exhibits such, redirect to a quiet space, attempt to explain to the resident why the behavior is not appropriate and notify the nurse. The 5-day MDS dated [DATE] identified Resident #87 had severely impaired cognition, exhibited no behaviors, required supervision with transfers and was independent with bed mobility, walking in room, and walking in corridor. Physician's orders dated March 2023 directed Resident #87 was independent with transfers, and ambulation with rolling walker, and to monitor for disinhibited sexual behaviors every shift. A reportable event form dated 3/15/23 at 2:00 PM identified a resident (of the opposite sex, Resident #39), reported that Resident #87 had made physical contact with him/her while sitting in the lounge. Resident #87 is alert and oriented. A written statement by SW #1 dated 3/15/23 at 3:30 PM identified it was reported to SW #1 that Resident #39 reported that Resident #87 had made physical contact with him/her about 2 weeks ago. SW #1 met with Resident #87 who denied making physical contact with any other residents. SW #1 indicated Resident #87 reported he/she tries to stay to him/herself and would engage verbally with peers but never physically. Review of the 24-hour report dated 3/15/23 failed to reflect documentation that Resident #87 had physically touched another resident of the opposite sex while sitting in the lounge. The nurse's notes dated 3/15/23 through 3/30/23 failed to reflect documentation that Resident #87 had physically touched another resident of the opposite sex while sitting in the lounge. The social worker form dated 3/17/23 identified on 3/15/23 it was reported to SW #1 that Resident #87 allegedly made physical contact with another resident of the opposite sex on the unit. SW #1 indicated she met with Resident #87 who could not recall any physical interaction with any peer on or off the unit. SW #1 indicated she spoke with Resident #87 about maintaining appropriate boundaries which he/she understood. SW #1 indicated she notified the resident representative. SW #1 indicated she will continue to monitor Resident #87's mood and behaviors and will remain available as needed. The care plan failed to reflect revision after Resident #87 allegedly made physical contact with another resident of the opposite sex while sitting in the lounge. Interview with the ADNS on 8/16/23 at 1:40 PM identified she was aware that Resident #39 reported to staff that Resident #87 had touched him/her under the breast. The ADNS indicated Resident #87 denied touching Resident #39 and identified the facility did not report the incident to the State Agency because Resident #39 reported Resident #87 did not touch his/her breast but touched his/her right mid abdomen. The ADNS indicated the APRN, and the resident representative were notified of Resident #87's physical contact with another resident of the opposite sex on the unit. The ADNS indicated she should have documented the incident and notifications in the clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #39, 54 and 60) reviewed for allegations of sexual abuse, the facility failed to ensure that the residents were free from inappropriate touching by Resident #29, and for 1 resident (Resident #36) reviewed for an allegation of abuse, the facility failed to ensure the resident was free from physical abuse by Resident #41. The findings include. 1. Resident #29 was admitted to the facility on [DATE] with diagnoses that included disorganized schizophrenia, intellectual disability and fluency disorder, and diabetes. The quarterly MDS dated [DATE] identified Resident #29 had intact cognition, was always continent of bowel and bladder, and was independent with transfers, dressing and toileting. The care plan dated 5/30/23 identified Resident #29 had a history of disorganized schizophrenia with psychotic symptoms including delusions of a sexual nature, disinhibited sexual speech, and disinhibited sexual behaviors. Interventions included to report any observed behavior/speech to the charge nurse, and if any behavior/speech was observed to ask the resident to stop, redirect and remind the resident why the behavior/speech was inappropriate. Interventions also included that if Resident #29 presented harm to any other residents of the facility, he/she may be placed on higher level of supervision which may include 2-person supervision during interactions with others. The psychiatric note dated 5/31/23 identified Resident #29 had a history of psychosis and Schizophrenia and required antipsychotic medications. The note further identified that Resident #29 was pleasant, engaging, had no reported behavioral issues, had been compliant with medications, denied any sleep disturbances, and that nursing had offered no concerns. The physician's orders dated 6/1/23 directed to administer Depakote (a mood stabilizer) twice daily, Clozapine (an antipsychotic medication) at night, and Haldol (an antipsychotic medication) every three weeks. The orders further directed behavior monitoring every shift related to delusions, hallucinations, physical aggression, and disinhibited sexual behavior. A written email from RN #4 dated 6/9/23 at 11:02 PM to the Administrator, the DNS, and SW #1 identified at 10:15 PM, Resident #29 was placed on every 15 minutes checks due to reports of the resident entering at least three different resident rooms (of the opposite sex) and behaving inappropriate with them. NA #2 went in Resident #60's room and found Resident #29 in that room behind the door (no time provided). Resident #60 was standing in the room with his/her walker, neither resident could explain why Resident #29 was in that room so resident #29 was sent back to his/her own room. NA #1 answered Resident #39's call light and the resident reported that another resident (of the opposite sex) was in his/her room. Resident #39 reported that the resident (Resident #29) was standing over him/her and told him/her he/she would not harm her and began to undo the buttons on Resident #39's blouse and fondle his/her breast. RN #4 indicated she and LPN #2 went to Resident #29's room to talk to him/her, but the resident's tone was so low they could not make sense of what he/she is saying except that he/she thought it was okay to do what he/she did. RN #4 indicated they instructed Resident #29 not to go into other resident rooms and he/she agreed. RN #4 indicated LPN #2 went into Resident #54's room and that resident reported that Resident #29 had come into his/her room and tried to fondle his/her breast and he/she chased Resident #29 out of the room. Review of reportable event documentation identified that on 6/9/23 at approximately 10:15 PM, Resident #29 was alleged to have inappropriately touched Resident #60 (a resident of the opposite sex) after entering his/her room. The reportable event documentation further identified that following the incident, the facility was also notified that between 10:05 PM and 10:15 PM, prior to the incident with Resident #60, Resident #29 was also alleged to have inappropriately touched Resident #39 and #54 (both residents of the opposite sex) after entering each of their rooms. The reportable event documentation also identified that MD #1 was notified of the incidents involving Resident #29 on 6/9/23 at 10:30 PM (this is in conflict with the interview with MD #1 who stated he had not been notified of these incidents until 6/12/23, 3 days later). The nurse's note dated 6/10/23 at 12:58 AM by RN #2 (11:00 PM - 7:00 AM nursing supervisor) identified that Resident #29 had been placed on 1:1 observation as a nursing measure related to intrusive behavior. The note further identified RN #2 had placed a referral in the psychiatric provider's book regarding Resident #29's behavior. Review of the Behavioral Health Visit Request book identified that a request for Resident #29 dated was dated 6/10/23 with the reason for request (Resident #29 went into 3 other residents' rooms, unbuttoned one resident's shirt and told them all I want to hurt you.) The request was signed off as seen by behavioral health on 6/13/23, 3 days later. A written statement completed by the Administrator on 6/10/23 identified that she was notified via text message by RN #8 on 6/10/23 of incidents involving Resident #29 on 6/9/23 during the 3-11 PM shift when RN #4 was the evening nursing supervisor. The Administrator further identified that she then contacted RN #4, who provided details of the incidents via email sent to the Administrator, DNS, and Social Worker #1. The statement further identified that RN #4 was educated that she should have contacted the Administrator via phone call regarding the incidents, not by email. The APRN note completed by APRN #1 dated 6/12/23 identified a medical work up had been requested by nursing staff for Resident #29 due to allegations of sexual assault of 3 residents of the facility. The note further identified that Resident #29 was observed to be delusional with a flat affect and was difficult to understand due to flow of mumbled speech. The assessment and plan identified Resident #29 had a change in behavior and would be worked up for evidence of infection or metabolic disarrangement. The psychiatric APRN note dated 6/12/23 identified that Resident #29 was seen for an allegation of abuse. The note further identified that Resident #29 reported visual hallucinations and appeared to having hallucinations nightly and that nursing staff had reported a change in Resident #29's behavior since 6/9/23. The note identified that Resident #28 appeared to have an exacerbation in Schizophrenia with perceptual disturbances and medications may be necessary to address acute psychosis in conjunction with the medical workup. The nurse's note dated 6/12/23 at 5:54 PM identified Resident #29's resident representative was notified of behavioral incidents that occurred on 6/9/23 and that Resident #29 had been seen by the medical and psychiatric APRNs on 6/12/23. Interview with the Administrator on 8/15/23 at 7:30 AM identified that she was made aware on 6/10/23 of the alleged incidents with Resident #29, she was not aware that the physician and resident representative had not been contacted and notified regarding the incidents until 6/12/23, 3 days later. The Administrator was unable to identify why the physician and resident representative were not notified until 6/12/23, 3 days after the incidents. Interview with APRN #1 on 8/15/23 at 11:53 AM identified she was notified of the allegations involving Resident #29 on 6/12/23 when she was in the building to see residents. APRN #1 identified that the facility should have completed a nursing assessment and contacted the on-call provider on 6/9/23 immediately following the incidents, and Resident #29 should have been placed on 1:1 observation right away. APRN #1 further identified that 1:1 monitoring would have been the most important intervention, and if the facility had notified her of the incidents on 6/9/23 when they occurred, APRN #1 would have sent Resident #29 to the hospital for further evaluation. APRN # 1 further identified Resident #29 had not had any allegations of inappropriate touch prior to 6/9/23 and the alleged behaviors were 'out of the blue'. Interview with MD #1 (Medical Director) on 8/16/23 at 10:29 AM identified that he was notified of allegations related to Resident #29 on 6/12/23, when APRN #1 was already scheduled to be at the facility to examine residents. MD #1 identified that he would have expected that if there were any allegations of assaults of a sexual nature that the facility should have contacted him on 6/9/23 at the time of the incidents. MD #1 further identified that if he had been notified of allegations on 6/9/23, he would have sent Resident #29 to the hospital for further evaluation. The facility policy on Abuse directed that allegations related to abuse, neglect, exploitation or mistreatment would be reported to the resident representative and attending physician by the RN supervisor. Review of the facility abuse policy identified each resident has the right to be free from abuse, neglect, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. Sexual abuse - includes but is not limited to, non-consensual sexual contact of any type with a resident, sexual harassment, sexual coercion or sexual assault. Allegations of abuse will be reported promptly and thoroughly investigated. Facility in-house reporting - Whenever there is a witnessed, suspected or alleged abuse action involving a resident, as defined above, the following is initiated: The staff member who hears allegation of abuse, or suspects or witnesses abuse will report immediately to their supervisor. The Administrator or on-call designee and Director of Nursing Services are to be notified immediately. 2. Resident #39 was admitted to the facility 10/20/21 with diagnosis that included dementia with behavioral disturbance, frontal lobe and executive function deficit following cerebral infarction, and anxiety disorder. The quarterly MDS dated [DATE] identified Resident #39 had intact cognition, required supervision with bed mobility and toilet use, extensive assistance with dressing and personal hygiene, used a walker for mobility, had cerebral palsy, and basal cell carcinoma of the skin. The care plan dated 5/4/23 had a focus on dementia secondary to traumatic brain injury and a stroke and indicated the resident required assistance with activities of daily living. Interventions included offering help daily and offer cueing/prompting or physical help to complete tasks. The nurse's note dated 6/11/23 at 11:25 AM identified that the RN Supervisor (RN #8) checked in with Resident #39 on 6/10/23 and 6/11/23 following an occurrence with another resident. Resident #39 noted that Resident #29 (another resident of the opposite sex) attempted to unbutton his/her blouse, but he/she yelled and told him/her to get out of the room and Resident #29 left as instructed. RN #8 reassured Resident #39 that we are here to provide support and to reach out to staff is needed for support or to talk. Resident #39 verbalized understanding and said thank you. Resident #39 reports he/she had a nice afternoon out with family yesterday, seated outside with peers having a cup of hot chocolate on the patio. RN #8 indicates she spoke privately with Resident #39, and Resident #39 denies being anxious or fearful, and slept great last night. The reportable event form dated 6/12/23 identified on 6/9/23 between 10:10 PM and 10:15 PM Resident #39 alleged he/she had been touched inappropriately by another resident (of the opposite sex, Resident #29). Resident #39 alleges Resident #29 entered his/her room and unbuttoned Resident 39's nightshirt. Resident #39 yelled at Resident #29 instructing him/her to leave. Resident #29 exited the room; Resident #39 used the call bell to seek assistance. A statement by RN #5 identified on 6/9/23 at approximately 10:15 PM Resident #39 came to the nurse's station and received reassurance about safety. RN #5 indicates Resident #39 did not appear to be upset, mood appropriate, however with the reassurance of safety, Resident #39 refused to go back to bed. Interview with RN #2 the RN Supervisor on 8/14/23 at 1:54 PM (who worked the 11:00 PM - 7:00 AM shift on 6/9/23) identified she was not aware of the inappropriate touch and had only known of Resident #29's wandering into various rooms during the 3:00 PM - 11:00 PM shift the evening of 6/9/23. Wanting additional monitoring for Resident #29, RN #2 reached out to the ADNS on 6/9/23 at approximately 10:50 PM and secured the 1:1 authorization for the 11:00 PM - 7:00 AM shift. Interview with NA #1 on 8/15/23 at 2:20 PM identified she responded to Resident #39's call bell and upon entering the room Resident #39 was seated on the bed and reported and described a person who had entered the room. NA #1 indicated Resident #39's night shirt was unbuttoned down to the waist. Resident #39 wore an athletic undergarment which was visible. Resident #39 indicated the intruder was ordered to get out of the room, and the intruder left. NA #1 indicated she offered assurance to Resident #39, encouraging Resident #39 to go back to bed, and proceeded to leave the room to report the incident to the supervisor. Upon arrival at the nurse's station, RN #5, LPN #2, and RN #4 (Nurse Supervisor) were discussing a resident entering other resident's room (Resident #54 and Resident #60). NA #1 indicated as she spent 5 minutes with Resident #39, was at the nurse's desk with staff for 3 - 4 minutes, then Resident #39 approached the nurse's station. Review of the facility abuse policy identified each resident has the right to be free from abuse, neglect, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. Sexual abuse - includes but is not limited to, non-consensual sexual contact of any type with a resident, sexual harassment, sexual coercion or sexual assault. Allegations of abuse will be reported promptly and thoroughly investigated. Facility in-house reporting - Whenever there is a witnessed, suspected or alleged abuse action involving a resident, as defined above, the following is initiated: The staff member who hears allegation of abuse, or suspects or witnesses abuse will report immediately to their supervisor. The Administrator or on-call designee and Director of Nursing Services are to be notified immediately. 3. Resident #54 was admitted to the facility in November 2017 with diagnoses that included major depressive disorder, anxiety disorder, and paranoid schizophrenia. The quarterly MDS dated [DATE] identified Resident #54 had intact cognition, no behaviors, and was independent with bed mobility, transfers, walking in room, and walking in corridor. Physician's orders dated June 2023, directed that Resident #54 was independent with transfers, and ambulation without an assistive device. A written statement from the Administrator dated 6/10/23 identified on 6/10/23 at 1:06 PM she received a text from RN #8 asking about the incident that occurred on 6/9/23 on the 3:00 PM - 11:00 PM shift. The Administrator indicated RN #8 provided her limited details of the alleged incident. The Administrator indicated she called RN #4 and inquired about what had occurred. The Administrator indicated RN #4 identified that she had sent me an email along with the DNS and the SW #1 the night before (6/9/23) with details. The Administrator indicated she educated RN #4 that the alleged incident warranted a phone call and not an email. The Administrator indicated RN #4 indicated to her the reason she did not call her, or the DNS is because RN #4 did not feel anyone was harmed or injured. The Administrator indicated she stressed to RN #4 the importance of proper channels of communication needed in this case. The Administrator indicated she asked RN #4 to provide a written statement of the alleged occurrence. The Administrator indicated RN #4 was removed off the schedule during the investigation. The nurse's note dated 6/11/23 at 9:30 AM identified a follow up note due to occurrence with another resident. RN #8 indicated she spoke with Resident #54 on 6/10/23 and on the morning of 6/11/23. Resident #54 was ambulating on the unit with peers. Resident #54 was in good spirits, smiling, and asked what was on the menu for lunch. RN #8 indicated she spoke privately with Resident #54 who stated he/she was fine and does not feel afraid or anxious. Resident #54 indicated he/she was surprised that it happened because he/she is married. RN #8 indicated she explained to Resident #54 if he/she wanted to talk, to reach out to the staff for support. A written statement from Resident #54 dated 6/11/23 at 7:30 AM identified he/she woke up and used the bathroom. Resident #54 indicated he/she went back to bed and fell asleep. Resident #54 indicated another resident (of the opposite sex, Resident #29) was standing over him/her and touched his/her breast. Resident #54 indicated he/she pushed Resident #29 out of the room. Review of the facility 24-hour report dated 6/9/23 through 6/12/23 failed to reflect documentation that Resident #54 had reported to LPN #2 the allegation that another resident (of the opposite sex, Resident #29) was standing over him/her and touched his/her breast on 6/9/23 on the 3:00 PM - 11:00 PM shift. Review of the Department of Public Health Facility Licensing and Investigations Sections (FLIS) reportable events portal report dated 6/12/23, (3 days after the incident) identified the facility reported Resident #54's allegation that Resident #29 came into his/her room and Resident #29 stood over him/her at bedside and touched his/her breast. The APRN progress note dated 6/12/23 identified that she was asked to see Resident #54 who alleged another resident (of the opposite sex, Resident #29) came into his/her room in the middle of the night and asked him/her to unbutton his/her shirt and touched his/her breasts. Resident #54 was able to chase Resident #29 away by yelling and pushing him/her. Resident #54 was seen and examined. No evidence of trauma noted. Resident #54 has a significant history of paranoid schizophrenia and anxiety. The nurse's note dated 6/12/23 at 11:52 AM identified APRN #1 performed a body assessment with no redness, no bruising, and no injuries noted. Resident #54 had no complaints of pain or discomfort. The resident representative was notified. A message was left for APRN #2. The nurse's note dated 6/12/23 through 6/24/23 failed to reflect documentation of Resident #54's report that another resident (of the opposite sex, Resident #29) came into his/her room in the middle of the night and asked him/her to unbutton his/her shirt and touched his/her breasts on 6/9/23 during the 3:00 PM - 11:00 PM shift. The care plan dated 6/12/23 identified resident to resident - Resident #54 alleged that another resident (of the opposite sex, Resident #29) made inappropriate physical contact. Interventions included to offer psychiatric therapy and medication management. Offer 1:1 visit by the social worker so that Resident #54 can discuss concerns/issues about others. The social worker note dated 6/12/23 identified she met with Resident #54 regarding an allegation of mistreatment. SW #1 indicated a follow up of an alleged incident between Resident #54 and Resident #29 that happened on Friday (6/9/23). SW #1 indicated Resident #54 reported that Resident #29 knocked on the door and proceeded to just walk into the room. Resident #54 told him/her to get out, and he/she did not. SW #1 indicated Resident #54 reported Resident #29 touched him/her inappropriately by putting his/her hands on his/her breasts and fondling them. SW #1 indicated Resident #54 reported she told him/her to get out of the room, he/she kicked and hit him/her on the back until Resident #29 left the room. SW #1 indicated she assured Resident #54 that the allegation is being taken seriously and staff want to make sure that all residents feel safe. SW #1 indicated Resident #54 reported that he/she feels safe and secure. A written statement from LPN #2 dated 6/12/23 at 2:45 PM identified she was approached by Resident #54 while walking down the hallway on 6/9/23. LPN #2 indicated Resident #54 called out to her and Resident #54 indicated another resident (of the opposite sex, Resident #29) was in his/her room and he/she indicated to Resident #29 you are not supposed to be in here. Resident #54 had just come out of the bathroom and got into bed and Resident #29 touched his/her breast and walked away. LPN #2 indicated she provided Resident #54 with reassurance and emotional support after the interaction on Friday 6/9/23. The psychiatric APRN note dated 6/12/23 at 8:44 PM identified that she was asked to see Resident #54 due to allegation of sexual assault. Resident #54 reported another resident (of the opposite sex, Resident #29) entered his/her room and touched his/her breast. Resident #54 reported he/she asked Resident #29 to stop and leave the room. Resident #54 reported he continued to touch his/her breast, and he/she pinched Resident #29 on the back then he/she got up and left. Resident #54 reported seeing Resident #29 in the dining room this afternoon which made his/her nervous until he/she noticed Resident #29 had someone watching him/her and that is when he/she calmed down. Resident #54 reported that he/she feels safe at the facility. Resident #54 reported he/she can get help by using the call light or scream out if he/she needs to. Would recommend continuing Ativan as prescribed as Resident #54 has residual symptoms of anxiety. Recommend psychotherapy so that Resident #54 can continue to process his/her feelings. The psychotherapy initial assessment dated [DATE] at 1:54 PM identified Resident #54 was alert, oriented times three and coherent. Met with Resident #54 for support and difficulty with anxiety with alleged sexual abuse issue. Resident #54 reported that he/she had some difficulty with another resident (of the opposite sex, Resident #29) coming into his/her room and inappropriately touching his/her breast. Resident #54 reported she informed the staff about the issue. Resident #54 report that he/she has some difficulty with anxiety. Will continue to monitor Resident #54 and provide support and validation for resident. The reportable event form dated 6/13/23 at 10:00 PM, identified the date and time of the event first known was on 6/9/23 at 11:05 PM, 4 days prior. Resident #54 alleged that Resident #29 came into his/her room, and he/she woke up with Resident #29 standing over him/her at bedside touching his/her breast. Resident #54 got up and pushed Resident #29 out of the room. Resident to resident abuse without injury. Resident #54 mood was stable with no changes in behavior. Resident #54 ambulates without device. The reportable event form identified the physician was notified on 6/9/23 at 11:20 PM (this is in conflict with an interview with the physician (MD #1) who identified he did not receive a call from the facility on 6/9/23 at 11:20 PM and was not notified of the incident until Monday 6/12/23, 3 days later). The reportable event form identified the resident representative, the police, and the Administrator were all notified, however, there is no date or time of notification. Further, the facility staff did not notify the police, and the Administrator was not notified until 6/10/23, the next day. Interview with Resident #54 on 8/13/23 at 10:55 AM identified he/she was almost raped by another resident (of the opposite sex, Resident #29). Resident #54 indicated Resident #29 came into his/her room and touched his/her breast. Resident #54 indicated he/she kicked Resident #29 out of the room. Resident #54 indicated Resident #29 has not been back in his/her room. Resident #54 indicated LPN #2 was going down the hallway the same night it happened, and he/she called out for LPN #2. Resident #54 indicated when LPN #2 came to the room he/she told LPN #2 about Resident #29 was in his/her room and touched his/her breast. Resident #54 indicated LPN #2 did not assess his/her body. Resident #54 indicated RN #4 did not assess his/her body. Resident #54 indicated he/she told LPN #2 the night it happened and told SW #1 on Monday (6/12/23) about Resident #29 coming into the room and touching his/her breast. Resident #54 indicated on Monday APRN #1 came and assessed his/her body and talked to him/her. Interview and review of the clinical record with the ADNS on 8/14/23 at 10:59 AM failed to provide documentation that an RN assessment had been completed on 6/9/23 at the time of the report. Further, the clinical record failed to reflect that the physician and the resident representative had been notified on 6/9/23. The ADNS indicated RN #4 should have completed an RN assessment and documented that assessment in Resident #54's clinical record at the time of the allegation. The ADNS indicated RN #4 should have notified the physician and the resident representative. The ADNS indicated she was not aware notification had not been made or an assessment done at the time of the allegation. The ADNS indicated documentation is by exception. The ADNS indicated RN #4 failed to call her, the DNS, and the Administrator on 6/9/23 at the time of the allegation. The ADNS indicated the expectation of the facility is that RN #4 should have notified her and the Administrator that Resident #29 had inappropriately touched Resident #54's breast. Interview with the Administrator on 8/15/23 at 7:30 AM identified she was not aware of the allegation of sexual assault on 6/9/23 at 10:15 PM. The Administrator indicated she texted RN #8 on Saturday 6/10/23 at approximately 1:00 PM regarding staffing, and at the end of the text RN #8 texted back asking how long Resident #29 was going to be on 1:1. The Administrator indicated she texted RN #8 to call her on the phone. The Administrator indicated she called the facility and spoke to RN #8. The Administrator indicated RN #8 identified she thought the Administrator knew the details of the incident on 6/9/23. RN #8 indicated that Resident #60 (one of the 3 residents that Resident #29 had touched on 6/9/23) had called the police. The Administrator indicated she called RN #4 who indicated she had sent an email regarding the details of the event on 6/9/23 at 11:06 PM. The Administrator indicated she hung up the phone with RN #4 and read the email. The Administrator indicated RN #4 should have called her via phone and notified her of the allegation at the time it happened. The Administrator indicated she contacted her Chief Operating Officer, Chief Clinical Office, and the RN Director of Quality of Life and Specialty Programs (the Regional Nurse Educator). The Administrator indicated they had a collaboration meeting, they immediately started investigation by interviewing the staff that was present on 6/9/23 on the 3:00 PM - 11:00 PM shift via phone. The Administrator indicated on Sunday 6/11/23 she had a conference call with the Chief Clinical Office and the RN Director of Quality of Life and Specialty Programs. The plan was to report the allegation on Monday morning 6/12/23 by entering the incident into the FLIS portal with the State Agency, however, the Administrator indicated the facility should have reported the allegation earlier. The Administrator indicated she was not aware that the RN assessment was not completed and documented in the resident's clinical record. The Administrator indicated she was not aware the physician and the resident representative had not been notified on 6/9/23. The Administrator indicated the expectation of the facility is that the RN supervisor should have notified the physician and the resident representative of the allegation. The Administrator indicated the facility has in-service the licensed nurses. Interview with APRN #1 on 8/15/23 at 11:53 AM identified she did not receive a phone call from the facility on Friday 6/9/23 regarding the allegation of that Resident #29 inappropriately touched Resident #54 and indicated she was notified on Monday 6/12/23, 3 days after the incident, and she assessed Resident #54 on 6/12/23. APRN #1 indicated her expectation is the facility should have contacted and notified the physician, and/or the APRN at the time of the allegation and that the RN Supervisor should have performed an RN assessment. Interview with MD #1 on 8/16/23 at 10:26 AM identified the facility did not notify him on Friday 6/9/23 or over the weekend of Resident #54's allegation of being touch inappropriately. MD #1 indicated the facility notified him on Monday 6/12/23, 3 days after the incident. MD #1 indicated APRN #1 was going to be at the facility on Monday 6/12/23 and she would assess the resident. MD #1 indicated his expectation is that the facility should have notified him of the allegation at the time in happened. Interview with RN #4 on 8/16/23 at 3:27 PM indicated she has been with the facility since 7/20/22. RN #4 indicated she is the RN supervisor for the 3:00 PM - 11:00 PM shift. RN #4 indicated on 6/9/23 at approximately 10:15 PM she was notified by LPN #2 that Resident #29 was observed in Resident #60's room. RN #4 indicated she went to the unit and spoke to Resident #29 who was in his/her room. RN #4 indicated while she and LPN #2 were walking in the hallway Resident #54 called out to LPN #2 in the hallway. RN #4 indicated LPN #2 went to see what the resident wanted. RN #4 indicated Resident #54 indicated another resident (of the opposite sex, Resident #29) had come into his/her room and he/she yelled at him/her and Resident #29 left. RN #4 indicated she proceeded to the nurse's station and placed Resident #29 on every 15 minutes monitoring. RN #4 indicated since she has been at the facility, she was informed to email the Administrator, the DNS, and the ADNS with any changes at the facility during her shift. RN #4 indicated the Administrator, the DNS, and the ADNS do not answer their phone when you call them. RN #4 indicated she did not document in Resident #54's clinical record. RN #4 indicated she did not perform a body assessment and did not call the physician or the resident representative. RN #4 indicated LPN #2 should have documented in Resident #54 clinical record regarding the allegation of inappropriate touch. RN #4 indicated she was taken off the schedule pending investigation. A written statement from the Administrator dated 8/16/23 identified the facility acknowledges discrepancies in the FLIS reporting system regarding the event on 6/9/23 regarding Resident #54. The physician, APRN, and psychiatric APRN were notified on 6/12/23 and assessed by both APRN's on 6/12/23. The facility completed an RN assessment on 6//12/23. Review of the facility abuse policy identified each resident has the right to be free from abuse, neglect, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. Sexual abuse - includes but is not limited to, non-consensual sexual contact of any type with a resident, sexual harassment, sexual coercion or sexual assault. Allegations of abuse will be reported promptly and thoroughly investigated. Facility in-house reporting - Whenever there is a witnessed, suspected or alleged abuse action involving a resident, as defined above, the following is initiated: The staff member who hears allegation of abuse, or suspects or witnesses abuse will report immediately to their supervisor. The Administrator or on-call designee and Director of Nursing Services are to be notified immediately. Review of the facility reportable events-reporting allegations and incidents policy identified it is the policy of the facility to report all allegations and events for which reports are required under state and federal laws. Any employee who fails to report an incident of abuse immediately to the appropriate supervisor [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #39, 54 and 60) reviewed for allegations of sexual abuse, the facility failed to immediately report allegations of sexual abuse by Resident #29. The findings include. 1. Resident #29 was admitted to the facility on [DATE] with diagnoses that included disorganized schizophrenia, intellectual disability and fluency disorder, and diabetes. The quarterly MDS dated [DATE] identified Resident #29 had intact cognition, was always continent of bowel and bladder, and was independent with transfers, dressing and toileting. The care plan dated 5/30/23 identified Resident #29 had a history of disorganized schizophrenia with psychotic symptoms including delusions of a sexual nature, disinhibited sexual speech, and disinhibited sexual behaviors. Interventions included to report any observed behavior/speech to the charge nurse, and if any behavior/speech was observed to ask the resident to stop, redirect and remind the resident why the behavior/speech was inappropriate. Interventions also included that if Resident #29 presented harm to any other residents of the facility, he/she may be placed on higher level of supervision which may include 2-person supervision during interactions with others. The psychiatric note dated 5/31/23 identified Resident #29 had a history of psychosis and Schizophrenia and required antipsychotic medications. The note further identified that Resident #29 was pleasant, engaging, had no reported behavioral issues, had been compliant with medications, denied any sleep disturbances, and that nursing had offered no concerns. The physician's orders dated 6/1/23 directed to administer Depakote (a mood stabilizer) twice daily, Clozapine (an antipsychotic medication) at night, and Haldol (an antipsychotic medication) every three weeks. The orders further directed behavior monitoring every shift related to delusions, hallucinations, physical aggression, and disinhibited sexual behavior. A written email from RN #4 dated 6/9/23 at 11:02 PM to the Administrator, the DNS, and SW #1 identified at 10:15 PM, Resident #29 was placed on every 15 minutes checks due to reports of the resident entering at least three different resident rooms (of the opposite sex) and behaving inappropriate with them. NA #2 went in Resident #60's room and found Resident #29 in that room behind the door (no time provided). Resident #60 was standing in the room with his/her walker, neither resident could explain why Resident #29 was in that room so resident #29 was sent back to his/her own room. NA #1 answered Resident #39's call light and the resident reported that another resident (of the opposite sex) was in his/her room. Resident #39 reported that the resident (Resident #29) was standing over him/her and told him/her he/she would not harm her and began to undo the buttons on Resident #39's blouse and fondle his/her breast. RN #4 indicated she and LPN #2 went to Resident #29's room to talk to him/her, but the resident's tone was so low they could not make sense of what he/she is saying except that he/she thought it was okay to do what he/she did. RN #4 indicated they instructed Resident #29 not to go into other resident rooms and he/she agreed. RN #4 indicated LPN #2 went into Resident #54's room and that resident reported that Resident #29 had come into his/her room and tried to fondle his/her breast and he/she chased Resident #29 out of the room. Review of reportable event documentation identified that on 6/9/23 at approximately 10:15 PM, Resident #29 was alleged to have inappropriately touched Resident #60 (a resident of the opposite sex) after entering his/her room. The reportable event documentation further identified that following the incident, the facility was also notified that between 10:05 PM and 10:15 PM, prior to the incident with Resident #60, Resident #29 was also alleged to have inappropriately touched Resident #39 and #54 (both residents of the opposite sex) after entering each of their rooms. The reportable event documentation also identified that MD #1 was notified of the incidents involving Resident #29 on 6/9/23 at 10:30 PM (this is in conflict with the interview with MD #1 who stated he had not been notified of these incidents until 6/12/23, 3 days later). The nurse's note dated 6/10/23 at 12:58 AM by RN #2 (11:00 PM - 7:00 AM nursing supervisor) identified that Resident #29 had been placed on 1:1 observation as a nursing measure related to intrusive behavior. The note further identified RN #2 had placed a referral in the psychiatric provider's book regarding Resident #29's behavior. Review of the Behavioral Health Visit Request book identified that a request for Resident #29 dated was dated 6/10/23 with the reason for request (Resident #29 went into 3 other residents' rooms, unbuttoned one resident's shirt and told them all I want to hurt you.) The request was signed off as seen by behavioral health on 6/13/23, 3 days later. A written statement completed by the Administrator on 6/10/23 identified that she was notified via text message by RN #8 on 6/10/23 of incidents involving Resident #29 on 6/9/23 during the 3-11 PM shift when RN #4 was the evening nursing supervisor. The Administrator further identified that she then contacted RN #4, who provided details of the incidents via email sent to the Administrator, DNS, and Social Worker #1. The statement further identified that RN #4 was educated that she should have contacted the Administrator via phone call regarding the incidents, not by email. The APRN note completed by APRN #1 dated 6/12/23 identified a medical work up had been requested by nursing staff for Resident #29 due to allegations of sexual assault of 3 residents of the facility. The note further identified that Resident #29 was observed to be delusional with a flat affect and was difficult to understand due to flow of mumbled speech. The assessment and plan identified Resident #29 had a change in behavior and would be worked up for evidence of infection or metabolic disarrangement. The psychiatric APRN note dated 6/12/23 identified that Resident #29 was seen for an allegation of abuse. The note further identified that Resident #29 reported visual hallucinations and appeared to having hallucinations nightly and that nursing staff had reported a change in Resident #29's behavior since 6/9/23. The note identified that Resident #28 appeared to have an exacerbation in Schizophrenia with perceptual disturbances and medications may be necessary to address acute psychosis in conjunction with the medical workup. The nurse's note dated 6/12/23 at 5:54 PM identified Resident #29's resident representative was notified of behavioral incidents that occurred on 6/9/23 and that Resident #29 had been seen by the medical and psychiatric APRNs on 6/12/23. Interview with the Administrator on 8/15/23 at 7:30 AM identified that she was made aware on 6/10/23 of the alleged incidents with Resident #29, she was not aware that the physician and resident representative had not been contacted and notified regarding the incidents until 6/12/23, 3 days later. The Administrator was unable to identify why the physician and resident representative were not notified until 6/12/23, 3 days after the incidents. Interview with APRN #1 on 8/15/23 at 11:53 AM identified she was notified of the allegations involving Resident #29 on 6/12/23 when she was in the building to see residents. APRN #1 identified that the facility should have completed a nursing assessment and contacted the on-call provider on 6/9/23 immediately following the incidents, and Resident #29 should have been placed on 1:1 observation right away. APRN #1 further identified that 1:1 monitoring would have been the most important intervention, and if the facility had notified her of the incidents on 6/9/23 when they occurred, APRN #1 would have sent Resident #29 to the hospital for further evaluation. APRN # 1 further identified Resident #29 had not had any allegations of inappropriate touch prior to 6/9/23 and the alleged behaviors were 'out of the blue'. Interview with MD #1 (Medical Director) on 8/16/23 at 10:29 AM identified that he was notified of allegations related to Resident #29 on 6/12/23, when APRN #1 was already scheduled to be at the facility to examine residents. MD #1 identified that he would have expected that if there were any allegations of assaults of a sexual nature that the facility should have contacted him on 6/9/23 at the time of the incidents. MD #1 further identified that if he had been notified of allegations on 6/9/23, he would have sent Resident #29 to the hospital for further evaluation. The facility policy on Abuse directed that allegations related to abuse, neglect, exploitation or mistreatment would be reported to the resident representative and attending physician by the RN supervisor. Review of the facility abuse policy identified each resident has the right to be free from abuse, neglect, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. Sexual abuse - includes but is not limited to, non-consensual sexual contact of any type with a resident, sexual harassment, sexual coercion or sexual assault. Allegations of abuse will be reported promptly and thoroughly investigated. Facility in-house reporting - Whenever there is a witnessed, suspected or alleged abuse action involving a resident, as defined above, the following is initiated: The staff member who hears allegation of abuse, or suspects or witnesses abuse will report immediately to their supervisor. The Administrator or on-call designee and Director of Nursing Services are to be notified immediately. 2. Resident #39 was admitted to the facility 10/20/21 with diagnosis that included dementia with behavioral disturbance, frontal lobe and executive function deficit following cerebral infarction, and anxiety disorder. The quarterly MDS dated [DATE] identified Resident #39 had intact cognition, required supervision with bed mobility and toilet use, extensive assistance with dressing and personal hygiene, used a walker for mobility, had cerebral palsy, and basal cell carcinoma of the skin. The care plan dated 5/4/23 had a focus on dementia secondary to traumatic brain injury and a stroke and indicated the resident required assistance with activities of daily living. Interventions included offering help daily and offer cueing/prompting or physical help to complete tasks. The nurse's note dated 6/11/23 at 11:25 AM identified that the RN Supervisor (RN #8) checked in with Resident #39 on 6/10/23 and 6/11/23 following an occurrence with another resident. Resident #39 noted that Resident #29 (another resident of the opposite sex) attempted to unbutton his/her blouse, but he/she yelled and told him/her to get out of the room and Resident #29 left as instructed. RN #8 reassured Resident #39 that we are here to provide support and to reach out to staff is needed for support or to talk. Resident #39 verbalized understanding and said thank you. Resident #39 reports he/she had a nice afternoon out with family yesterday, seated outside with peers having a cup of hot chocolate on the patio. RN #8 indicates she spoke privately with Resident #39, and Resident #39 denies being anxious or fearful, and slept great last night. The reportable event form dated 6/12/23 identified on 6/9/23 between 10:10 PM and 10:15 PM Resident #39 alleged he/she had been touched inappropriately by another resident (of the opposite sex, Resident #29). Resident #39 alleges Resident #29 entered his/her room and unbuttoned Resident 39's nightshirt. Resident #39 yelled at Resident #29 instructing him/her to leave. Resident #29 exited the room; Resident #39 used the call bell to seek assistance. A statement by RN #5 identified on 6/9/23 at approximately 10:15 PM Resident #39 came to the nurse's station and received reassurance about safety. RN #5 indicates Resident #39 did not appear to be upset, mood appropriate, however with the reassurance of safety, Resident #39 refused to go back to bed. Interview with RN #2 the RN Supervisor on 8/14/23 at 1:54 PM (who worked the 11:00 PM - 7:00 AM shift on 6/9/23) identified she was not aware of the inappropriate touch and had only known of Resident #29's wandering into various rooms during the 3:00 PM - 11:00 PM shift the evening of 6/9/23. Wanting additional monitoring for Resident #29, RN #2 reached out to the ADNS on 6/9/23 at approximately 10:50 PM and secured the 1:1 authorization for the 11:00 PM - 7:00 AM shift. Interview with NA #1 on 8/15/23 at 2:20 PM identified she responded to Resident #39's call bell and upon entering the room Resident #39 was seated on the bed and reported and described a person who had entered the room. NA #1 indicated Resident #39's night shirt was unbuttoned down to the waist. Resident #39 wore an athletic undergarment which was visible. Resident #39 indicated the intruder was ordered to get out of the room, and the intruder left. NA #1 indicated she offered assurance to Resident #39, encouraging Resident #39 to go back to bed, and proceeded to leave the room to report the incident to the supervisor. Upon arrival at the nurse's station, RN #5, LPN #2, and RN #4 (Nurse Supervisor) were discussing a resident entering other resident's room (Resident #54 and Resident #60). NA #1 indicated as she spent 5 minutes with Resident #39, was at the nurse's desk with staff for 3 - 4 minutes, then Resident #39 approached the nurse's station. Review of the facility abuse policy identified each resident has the right to be free from abuse, neglect, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. Sexual abuse - includes but is not limited to, non-consensual sexual contact of any type with a resident, sexual harassment, sexual coercion or sexual assault. Allegations of abuse will be reported promptly and thoroughly investigated. Facility in-house reporting - Whenever there is a witnessed, suspected or alleged abuse action involving a resident, as defined above, the following is initiated: The staff member who hears allegation of abuse, or suspects or witnesses abuse will report immediately to their supervisor. The Administrator or on-call designee and Director of Nursing Services are to be notified immediately. 3. Resident #54 was admitted to the facility in November 2017 with diagnoses that included major depressive disorder, anxiety disorder, and paranoid schizophrenia. The quarterly MDS dated [DATE] identified Resident #54 had intact cognition, no behaviors, and was independent with bed mobility, transfers, walking in room, and walking in corridor. Physician's orders dated June 2023, directed that Resident #54 was independent with transfers, and ambulation without an assistive device. A written statement from the Administrator dated 6/10/23 identified on 6/10/23 at 1:06 PM she received a text from RN #8 asking about the incident that occurred on 6/9/23 on the 3:00 PM - 11:00 PM shift. The Administrator indicated RN #8 provided her limited details of the alleged incident. The Administrator indicated she called RN #4 and inquired about what had occurred. The Administrator indicated RN #4 identified that she had sent me an email along with the DNS and the SW #1 the night before (6/9/23) with details. The Administrator indicated she educated RN #4 that the alleged incident warranted a phone call and not an email. The Administrator indicated RN #4 indicated to her the reason she did not call her, or the DNS is because RN #4 did not feel anyone was harmed or injured. The Administrator indicated she stressed to RN #4 the importance of proper channels of communication needed in this case. The Administrator indicated she asked RN #4 to provide a written statement of the alleged occurrence. The Administrator indicated RN #4 was removed off the schedule during the investigation. The nurse's note dated 6/11/23 at 9:30 AM identified a follow up note due to occurrence with another resident. RN #8 indicated she spoke with Resident #54 on 6/10/23 and on the morning of 6/11/23. Resident #54 was ambulating on the unit with peers. Resident #54 was in good spirits, smiling, and asked what was on the menu for lunch. RN #8 indicated she spoke privately with Resident #54 who stated he/she was fine and does not feel afraid or anxious. Resident #54 indicated he/she was surprised that it happened because he/she is married. RN #8 indicated she explained to Resident #54 if he/she wanted to talk, to reach out to the staff for support. A written statement from Resident #54 dated 6/11/23 at 7:30 AM identified he/she woke up and used the bathroom. Resident #54 indicated he/she went back to bed and fell asleep. Resident #54 indicated another resident (of the opposite sex, Resident #29) was standing over him/her and touched his/her breast. Resident #54 indicated he/she pushed Resident #29 out of the room. Review of the facility 24-hour report dated 6/9/23 through 6/12/23 failed to reflect documentation that Resident #54 had reported to LPN #2 the allegation that another resident (of the opposite sex, Resident #29) was standing over him/her and touched his/her breast on 6/9/23 on the 3:00 PM - 11:00 PM shift. Review of the Department of Public Health Facility Licensing and Investigations Sections (FLIS) reportable events portal report dated 6/12/23, (3 days after the incident) identified the facility reported Resident #54's allegation that Resident #29 came into his/her room and Resident #29 stood over him/her at bedside and touched his/her breast. The APRN progress note dated 6/12/23 identified that she was asked to see Resident #54 who alleged another resident (of the opposite sex, Resident #29) came into his/her room in the middle of the night and asked him/her to unbutton his/her shirt and touched his/her breasts. Resident #54 was able to chase Resident #29 away by yelling and pushing him/her. Resident #54 was seen and examined. No evidence of trauma noted. Resident #54 has a significant history of paranoid schizophrenia and anxiety. The nurse's note dated 6/12/23 at 11:52 AM identified APRN #1 performed a body assessment with no redness, no bruising, and no injuries noted. Resident #54 had no complaints of pain or discomfort. The resident representative was notified. A message was left for APRN #2. The nurse's note dated 6/12/23 through 6/24/23 failed to reflect documentation of Resident #54's report that another resident (of the opposite sex, Resident #29) came into his/her room in the middle of the night and asked him/her to unbutton his/her shirt and touched his/her breasts on 6/9/23 during the 3:00 PM - 11:00 PM shift. The care plan dated 6/12/23 identified resident to resident - Resident #54 alleged that another resident (of the opposite sex, Resident #29) made inappropriate physical contact. Interventions included to offer psychiatric therapy and medication management. Offer 1:1 visit by the social worker so that Resident #54 can discuss concerns/issues about others. The social worker note dated 6/12/23 identified she met with Resident #54 regarding an allegation of mistreatment. SW #1 indicated a follow up of an alleged incident between Resident #54 and Resident #29 that happened on Friday (6/9/23). SW #1 indicated Resident #54 reported that Resident #29 knocked on the door and proceeded to just walk into the room. Resident #54 told him/her to get out, and he/she did not. SW #1 indicated Resident #54 reported Resident #29 touched him/her inappropriately by putting his/her hands on his/her breasts and fondling them. SW #1 indicated Resident #54 reported she told him/her to get out of the room, he/she kicked and hit him/her on the back until Resident #29 left the room. SW #1 indicated she assured Resident #54 that the allegation is being taken seriously and staff want to make sure that all residents feel safe. SW #1 indicated Resident #54 reported that he/she feels safe and secure. A written statement from LPN #2 dated 6/12/23 at 2:45 PM identified she was approached by Resident #54 while walking down the hallway on 6/9/23. LPN #2 indicated Resident #54 called out to her and Resident #54 indicated another resident (of the opposite sex, Resident #29) was in his/her room and he/she indicated to Resident #29 you are not supposed to be in here. Resident #54 had just come out of the bathroom and got into bed and Resident #29 touched his/her breast and walked away. LPN #2 indicated she provided Resident #54 with reassurance and emotional support after the interaction on Friday 6/9/23. The psychiatric APRN note dated 6/12/23 at 8:44 PM identified that she was asked to see Resident #54 due to allegation of sexual assault. Resident #54 reported another resident (of the opposite sex, Resident #29) entered his/her room and touched his/her breast. Resident #54 reported he/she asked Resident #29 to stop and leave the room. Resident #54 reported he continued to touch his/her breast, and he/she pinched Resident #29 on the back then he/she got up and left. Resident #54 reported seeing Resident #29 in the dining room this afternoon which made his/her nervous until he/she noticed Resident #29 had someone watching him/her and that is when he/she calmed down. Resident #54 reported that he/she feels safe at the facility. Resident #54 reported he/she can get help by using the call light or scream out if he/she needs to. Would recommend continuing Ativan as prescribed as Resident #54 has residual symptoms of anxiety. Recommend psychotherapy so that Resident #54 can continue to process his/her feelings. The psychotherapy initial assessment dated [DATE] at 1:54 PM identified Resident #54 was alert, oriented times three and coherent. Met with Resident #54 for support and difficulty with anxiety with alleged sexual abuse issue. Resident #54 reported that he/she had some difficulty with another resident (of the opposite sex, Resident #29) coming into his/her room and inappropriately touching his/her breast. Resident #54 reported she informed the staff about the issue. Resident #54 report that he/she has some difficulty with anxiety. Will continue to monitor Resident #54 and provide support and validation for resident. The reportable event form dated 6/13/23 at 10:00 PM, identified the date and time of the event first known was on 6/9/23 at 11:05 PM, 4 days prior. Resident #54 alleged that Resident #29 came into his/her room, and he/she woke up with Resident #29 standing over him/her at bedside touching his/her breast. Resident #54 got up and pushed Resident #29 out of the room. Resident to resident abuse without injury. Resident #54 mood was stable with no changes in behavior. Resident #54 ambulates without device. The reportable event form identified the physician was notified on 6/9/23 at 11:20 PM (this is in conflict with an interview with the physician (MD #1) who identified he did not receive a call from the facility on 6/9/23 at 11:20 PM and was not notified of the incident until Monday 6/12/23, 3 days later). The reportable event form identified the resident representative, the police, and the Administrator were all notified, however, there is no date or time of notification. Further, the facility staff did not notify the police, and the Administrator was not notified until 6/10/23, the next day. Interview with Resident #54 on 8/13/23 at 10:55 AM identified he/she was almost raped by another resident (of the opposite sex, Resident #29). Resident #54 indicated Resident #29 came into his/her room and touched his/her breast. Resident #54 indicated he/she kicked Resident #29 out of the room. Resident #54 indicated Resident #29 has not been back in his/her room. Resident #54 indicated LPN #2 was going down the hallway the same night it happened, and he/she called out for LPN #2. Resident #54 indicated when LPN #2 came to the room he/she told LPN #2 about Resident #29 was in his/her room and touched his/her breast. Resident #54 indicated LPN #2 did not assess his/her body. Resident #54 indicated RN #4 did not assess his/her body. Resident #54 indicated he/she told LPN #2 the night it happened and told SW #1 on Monday (6/12/23) about Resident #29 coming into the room and touching his/her breast. Resident #54 indicated on Monday APRN #1 came and assessed his/her body and talked to him/her. Interview and review of the clinical record with the ADNS on 8/14/23 at 10:59 AM failed to provide documentation that an RN assessment had been completed on 6/9/23 at the time of the report. Further, the clinical record failed to reflect that the physician and the resident representative had been notified on 6/9/23. The ADNS indicated RN #4 should have completed an RN assessment and documented that assessment in Resident #54's clinical record at the time of the allegation. The ADNS indicated RN #4 should have notified the physician and the resident representative. The ADNS indicated she was not aware notification had not been made or an assessment done at the time of the allegation. The ADNS indicated documentation is by exception. The ADNS indicated RN #4 failed to call her, the DNS, and the Administrator on 6/9/23 at the time of the allegation. The ADNS indicated the expectation of the facility is that RN #4 should have notified her and the Administrator that Resident #29 had inappropriately touched Resident #54's breast. Interview with the Administrator on 8/15/23 at 7:30 AM identified she was not aware of the allegation of sexual assault on 6/9/23 at 10:15 PM. The Administrator indicated she texted RN #8 on Saturday 6/10/23 at approximately 1:00 PM regarding staffing, and at the end of the text RN #8 texted back asking how long Resident #29 was going to be on 1:1. The Administrator indicated she texted RN #8 to call her on the phone. The Administrator indicated she called the facility and spoke to RN #8. The Administrator indicated RN #8 identified she thought the Administrator knew the details of the incident on 6/9/23. RN #8 indicated that Resident #60 (one of the 3 residents that Resident #29 had touched on 6/9/23) had called the police. The Administrator indicated she called RN #4 who indicated she had sent an email regarding the details of the event on 6/9/23 at 11:06 PM. The Administrator indicated she hung up the phone with RN #4 and read the email. The Administrator indicated RN #4 should have called her via phone and notified her of the allegation at the time it happened. The Administrator indicated she contacted her Chief Operating Officer, Chief Clinical Office, and the RN Director of Quality of Life and Specialty Programs (the Regional Nurse Educator). The Administrator indicated they had a collaboration meeting, they immediately started investigation by interviewing the staff that was present on 6/9/23 on the 3:00 PM - 11:00 PM shift via phone. The Administrator indicated on Sunday 6/11/23 she had a conference call with the Chief Clinical Office and the RN Director of Quality of Life and Specialty Programs. The plan was to report the allegation on Monday morning 6/12/23 by entering the incident into the FLIS portal with the State Agency, however, the Administrator indicated the facility should have reported the allegation earlier. The Administrator indicated she was not aware that the RN assessment was not completed and documented in the resident's clinical record. The Administrator indicated she was not aware the physician and the resident representative had not been notified on 6/9/23. The Administrator indicated the expectation of the facility is that the RN supervisor should have notified the physician and the resident representative of the allegation. The Administrator indicated the facility has in-service the licensed nurses. Interview with APRN #1 on 8/15/23 at 11:53 AM identified she did not receive a phone call from the facility on Friday 6/9/23 regarding the allegation of that Resident #29 inappropriately touched Resident #54 and indicated she was notified on Monday 6/12/23, 3 days after the incident, and she assessed Resident #54 on 6/12/23. APRN #1 indicated her expectation is the facility should have contacted and notified the physician, and/or the APRN at the time of the allegation and that the RN Supervisor should have performed an RN assessment. Interview with MD #1 on 8/16/23 at 10:26 AM identified the facility did not notify him on Friday 6/9/23 or over the weekend of Resident #54's allegation of being touch inappropriately. MD #1 indicated the facility notified him on Monday 6/12/23, 3 days after the incident. MD #1 indicated APRN #1 was going to be at the facility on Monday 6/12/23 and she would assess the resident. MD #1 indicated his expectation is that the facility should have notified him of the allegation at the time in happened. Interview with RN #4 on 8/16/23 at 3:27 PM indicated she has been with the facility since 7/20/22. RN #4 indicated she is the RN supervisor for the 3:00 PM - 11:00 PM shift. RN #4 indicated on 6/9/23 at approximately 10:15 PM she was notified by LPN #2 that Resident #29 was observed in Resident #60's room. RN #4 indicated she went to the unit and spoke to Resident #29 who was in his/her room. RN #4 indicated while she and LPN #2 were walking in the hallway Resident #54 called out to LPN #2 in the hallway. RN #4 indicated LPN #2 went to see what the resident wanted. RN #4 indicated Resident #54 indicated another resident (of the opposite sex, Resident #29) had come into his/her room and he/she yelled at him/her and Resident #29 left. RN #4 indicated she proceeded to the nurse's station and placed Resident #29 on every 15 minutes monitoring. RN #4 indicated since she has been at the facility, she was informed to email the Administrator, the DNS, and the ADNS with any changes at the facility during her shift. RN #4 indicated the Administrator, the DNS, and the ADNS do not answer their phone when you call them. RN #4 indicated she did not document in Resident #54's clinical record. RN #4 indicated she did not perform a body assessment and did not call the physician or the resident representative. RN #4 indicated LPN #2 should have documented in Resident #54 clinical record regarding the allegation of inappropriate touch. RN #4 indicated she was taken off the schedule pending investigation. A written statement from the Administrator dated 8/16/23 identified the facility acknowledges discrepancies in the FLIS reporting system regarding the event on 6/9/23 regarding Resident #54. The physician, APRN, and psychiatric APRN were notified on 6/12/23 and assessed by both APRN's on 6/12/23. The facility completed an RN assessment on 6//12/23. Review of the facility abuse policy identified each resident has the right to be free from abuse, neglect, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. Sexual abuse - includes but is not limited to, non-consensual sexual contact of any type with a resident, sexual harassment, sexual coercion or sexual assault. Allegations of abuse will be reported promptly and thoroughly investigated. Facility in-house reporting - Whenever there is a witnessed, suspected or alleged abuse action involving a resident, as defined above, the following is initiated: The staff member who hears allegation of abuse, or suspects or witnesses abuse will report immediately to their supervisor. The Administrator or on-call designee and Director of Nursing Services are to be notified immediately. Review of the facility reportable events-reporting allegations and incidents policy identified it is the policy of the facility to report all allegations and events for which reports are required under state and federal laws. Any employee who fails to report an incident of abuse immediately to the appropriate supervisor will receive disciplinary action. The Administrator and DNS are to be informed immediately of any class A, B, C, or events. The Medical Director will be made aware of reportable eve[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #39, 54 and 60) reviewed for allegations of sexual abuse, the facility failed to initiate a thorough investigation, according to their policy, into the allegations of sexual abuse by Resident #29 to prevent further abuse from occurring while the investigation was in progress. The findings include. 1. Resident #29 was admitted to the facility on [DATE] with diagnoses that included disorganized schizophrenia, intellectual disability and fluency disorder, and diabetes. The quarterly MDS dated [DATE] identified Resident #29 had intact cognition, was always continent of bowel and bladder, and was independent with transfers, dressing and toileting. The care plan dated 5/30/23 identified Resident #29 had a history of disorganized schizophrenia with psychotic symptoms including delusions of a sexual nature, disinhibited sexual speech, and disinhibited sexual behaviors. Interventions included to report any observed behavior/speech to the charge nurse, and if any behavior/speech was observed to ask the resident to stop, redirect and remind the resident why the behavior/speech was inappropriate. Interventions also included that if Resident #29 presented harm to any other residents of the facility, he/she may be placed on higher level of supervision which may include 2-person supervision during interactions with others. The psychiatric note dated 5/31/23 identified Resident #29 had a history of psychosis and Schizophrenia and required antipsychotic medications. The note further identified that Resident #29 was pleasant, engaging, had no reported behavioral issues, had been compliant with medications, denied any sleep disturbances, and that nursing had offered no concerns. The physician's orders dated 6/1/23 directed to administer Depakote (a mood stabilizer) twice daily, Clozapine (an antipsychotic medication) at night, and Haldol (an antipsychotic medication) every three weeks. The orders further directed behavior monitoring every shift related to delusions, hallucinations, physical aggression, and disinhibited sexual behavior. A written email from RN #4 dated 6/9/23 at 11:02 PM to the Administrator, the DNS, and SW #1 identified at 10:15 PM, Resident #29 was placed on every 15 minutes checks due to reports of the resident entering at least three different resident rooms (of the opposite sex) and behaving inappropriate with them. NA #2 went in Resident #60's room and found Resident #29 in that room behind the door (no time provided). Resident #60 was standing in the room with his/her walker, neither resident could explain why Resident #29 was in that room so resident #29 was sent back to his/her own room. NA #1 answered Resident #39's call light and the resident reported that another resident (of the opposite sex) was in his/her room. Resident #39 reported that the resident (Resident #29) was standing over him/her and told him/her he/she would not harm her and began to undo the buttons on Resident #39's blouse and fondle his/her breast. RN #4 indicated she and LPN #2 went to Resident #29's room to talk to him/her, but the resident's tone was so low they could not make sense of what he/she is saying except that he/she thought it was okay to do what he/she did. RN #4 indicated they instructed Resident #29 not to go into other resident rooms and he/she agreed. RN #4 indicated LPN #2 went into Resident #54's room and that resident reported that Resident #29 had come into his/her room and tried to fondle his/her breast and he/she chased Resident #29 out of the room. Review of reportable event documentation identified that on 6/9/23 at approximately 10:15 PM, Resident #29 was alleged to have inappropriately touched Resident #60 (a resident of the opposite sex) after entering his/her room. The reportable event documentation further identified that following the incident, the facility was also notified that between 10:05 PM and 10:15 PM, prior to the incident with Resident #60, Resident #29 was also alleged to have inappropriately touched Resident #39 and #54 (both residents of the opposite sex) after entering each of their rooms. The reportable event documentation also identified that MD #1 was notified of the incidents involving Resident #29 on 6/9/23 at 10:30 PM (this is in conflict with the interview with MD #1 who stated he had not been notified of these incidents until 6/12/23, 3 days later). The nurse's note dated 6/10/23 at 12:58 AM by RN #2 (11:00 PM - 7:00 AM nursing supervisor) identified that Resident #29 had been placed on 1:1 observation as a nursing measure related to intrusive behavior. The note further identified RN #2 had placed a referral in the psychiatric provider's book regarding Resident #29's behavior. Review of the Behavioral Health Visit Request book identified that a request for Resident #29 dated was dated 6/10/23 with the reason for request (Resident #29 went into 3 other residents' rooms, unbuttoned one resident's shirt and told them all I want to hurt you.) The request was signed off as seen by behavioral health on 6/13/23, 3 days later. A written statement completed by the Administrator on 6/10/23 identified that she was notified via text message by RN #8 on 6/10/23 of incidents involving Resident #29 on 6/9/23 during the 3-11 PM shift when RN #4 was the evening nursing supervisor. The Administrator further identified that she then contacted RN #4, who provided details of the incidents via email sent to the Administrator, DNS, and Social Worker #1. The statement further identified that RN #4 was educated that she should have contacted the Administrator via phone call regarding the incidents, not by email. The APRN note completed by APRN #1 dated 6/12/23 identified a medical work up had been requested by nursing staff for Resident #29 due to allegations of sexual assault of 3 residents of the facility. The note further identified that Resident #29 was observed to be delusional with a flat affect and was difficult to understand due to flow of mumbled speech. The assessment and plan identified Resident #29 had a change in behavior and would be worked up for evidence of infection or metabolic disarrangement. The psychiatric APRN note dated 6/12/23 identified that Resident #29 was seen for an allegation of abuse. The note further identified that Resident #29 reported visual hallucinations and appeared to having hallucinations nightly and that nursing staff had reported a change in Resident #29's behavior since 6/9/23. The note identified that Resident #28 appeared to have an exacerbation in Schizophrenia with perceptual disturbances and medications may be necessary to address acute psychosis in conjunction with the medical workup. The nurse's note dated 6/12/23 at 5:54 PM identified Resident #29's resident representative was notified of behavioral incidents that occurred on 6/9/23 and that Resident #29 had been seen by the medical and psychiatric APRNs on 6/12/23. Interview with the Administrator on 8/15/23 at 7:30 AM identified that she was made aware on 6/10/23 of the alleged incidents with Resident #29, she was not aware that the physician and resident representative had not been contacted and notified regarding the incidents until 6/12/23, 3 days later. The Administrator was unable to identify why the physician and resident representative were not notified until 6/12/23, 3 days after the incidents. Interview with APRN #1 on 8/15/23 at 11:53 AM identified she was notified of the allegations involving Resident #29 on 6/12/23 when she was in the building to see residents. APRN #1 identified that the facility should have completed a nursing assessment and contacted the on-call provider on 6/9/23 immediately following the incidents, and Resident #29 should have been placed on 1:1 observation right away. APRN #1 further identified that 1:1 monitoring would have been the most important intervention, and if the facility had notified her of the incidents on 6/9/23 when they occurred, APRN #1 would have sent Resident #29 to the hospital for further evaluation. APRN # 1 further identified Resident #29 had not had any allegations of inappropriate touch prior to 6/9/23 and the alleged behaviors were 'out of the blue'. Interview with MD #1 (Medical Director) on 8/16/23 at 10:29 AM identified that he was notified of allegations related to Resident #29 on 6/12/23, when APRN #1 was already scheduled to be at the facility to examine residents. MD #1 identified that he would have expected that if there were any allegations of assaults of a sexual nature that the facility should have contacted him on 6/9/23 at the time of the incidents. MD #1 further identified that if he had been notified of allegations on 6/9/23, he would have sent Resident #29 to the hospital for further evaluation. The facility policy on Abuse directed that allegations related to abuse, neglect, exploitation or mistreatment would be reported to the resident representative and attending physician by the RN supervisor. Review of the facility abuse policy identified each resident has the right to be free from abuse, neglect, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. Sexual abuse - includes but is not limited to, non-consensual sexual contact of any type with a resident, sexual harassment, sexual coercion or sexual assault. Allegations of abuse will be reported promptly and thoroughly investigated. Facility in-house reporting - Whenever there is a witnessed, suspected or alleged abuse action involving a resident, as defined above, the following is initiated: The staff member who hears allegation of abuse, or suspects or witnesses abuse will report immediately to their supervisor. The Administrator or on-call designee and Director of Nursing Services are to be notified immediately. The facility policy on abuse identified that residents will be protected from abuse by reporting mechanisms which include facility in-house reporting, notification to the Administrator or on-call designee and DNS immediately, who will be responsible for as needed reporting. The policy also states an investigation of the alleged abusive action will be initiated within 24 hours of its discovery. It is the responsibility of the facility Administrator or designee to initiate the investigation. The investigation may include but not limited to statements from witnesses and staff, consultation with family, physician and state agency, and consultation with local law enforcement for suspected crimes. 2. Resident #39 was admitted to the facility 10/20/21 with diagnosis that included dementia with behavioral disturbance, frontal lobe and executive function deficit following cerebral infarction, and anxiety disorder. The quarterly MDS dated [DATE] identified Resident #39 had intact cognition, required supervision with bed mobility and toilet use, extensive assistance with dressing and personal hygiene, used a walker for mobility, had cerebral palsy, and basal cell carcinoma of the skin. The care plan dated 5/4/23 had a focus on dementia secondary to traumatic brain injury and a stroke and indicated the resident required assistance with activities of daily living. Interventions included offering help daily and offer cueing/prompting or physical help to complete tasks. The nurse's note dated 6/11/23 at 11:25 AM identified that the RN Supervisor (RN #8) checked in with Resident #39 on 6/10/23 and 6/11/23 following an occurrence with another resident. Resident #39 noted that Resident #29 (another resident of the opposite sex) attempted to unbutton his/her blouse, but he/she yelled and told him/her to get out of the room and Resident #29 left as instructed. RN #8 reassured Resident #39 that we are here to provide support and to reach out to staff is needed for support or to talk. Resident #39 verbalized understanding and said thank you. Resident #39 reports he/she had a nice afternoon out with family yesterday, seated outside with peers having a cup of hot chocolate on the patio. RN #8 indicates she spoke privately with Resident #39, and Resident #39 denies being anxious or fearful, and slept great last night. The reportable event form dated 6/12/23 identified on 6/9/23 between 10:10 PM and 10:15 PM Resident #39 alleged he/she had been touched inappropriately by another resident (of the opposite sex, Resident #29). Resident #39 alleges Resident #29 entered his/her room and unbuttoned Resident 39's nightshirt. Resident #39 yelled at Resident #29 instructing him/her to leave. Resident #29 exited the room; Resident #39 used the call bell to seek assistance. A statement by RN #5 identified on 6/9/23 at approximately 10:15 PM Resident #39 came to the nurse's station and received reassurance about safety. RN #5 indicates Resident #39 did not appear to be upset, mood appropriate, however with the reassurance of safety, Resident #39 refused to go back to bed. Interview with RN #2 the RN Supervisor on 8/14/23 at 1:54 PM (who worked the 11:00 PM - 7:00 AM shift on 6/9/23) identified she was not aware of the inappropriate touch and had only known of Resident #29's wandering into various rooms during the 3:00 PM - 11:00 PM shift the evening of 6/9/23. Wanting additional monitoring for Resident #29, RN #2 reached out to the ADNS on 6/9/23 at approximately 10:50 PM and secured the 1:1 authorization for the 11:00 PM - 7:00 AM shift. Interview with NA #1 on 8/15/23 at 2:20 PM identified she responded to Resident #39's call bell and upon entering the room Resident #39 was seated on the bed and reported and described a person who had entered the room. NA #1 indicated Resident #39's night shirt was unbuttoned down to the waist. Resident #39 wore an athletic undergarment which was visible. Resident #39 indicated the intruder was ordered to get out of the room, and the intruder left. NA #1 indicated she offered assurance to Resident #39, encouraging Resident #39 to go back to bed, and proceeded to leave the room to report the incident to the supervisor. Upon arrival at the nurse's station, RN #5, LPN #2, and RN #4 (Nurse Supervisor) were discussing a resident entering other resident's room (Resident #54 and Resident #60). NA #1 indicated as she spent 5 minutes with Resident #39, was at the nurse's desk with staff for 3 - 4 minutes, then Resident #39 approached the nurse's station. Review of the facility abuse policy identified each resident has the right to be free from abuse, neglect, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. Sexual abuse - includes but is not limited to, non-consensual sexual contact of any type with a resident, sexual harassment, sexual coercion or sexual assault. Allegations of abuse will be reported promptly and thoroughly investigated. Facility in-house reporting - Whenever there is a witnessed, suspected or alleged abuse action involving a resident, as defined above, the following is initiated: The staff member who hears allegation of abuse, or suspects or witnesses abuse will report immediately to their supervisor. The Administrator or on-call designee and Director of Nursing Services are to be notified immediately. The facility policy on abuse identified that residents will be protected from abuse by reporting mechanisms which include facility in-house reporting, notification to the Administrator or on-call designee and DNS immediately, who will be responsible for as needed reporting. The policy also states an investigation of the alleged abusive action will be initiated within 24 hours of its discovery. It is the responsibility of the facility Administrator or designee to initiate the investigation. The investigation may include but not limited to statements from witnesses and staff, consultation with family, physician and state agency, and consultation with local law enforcement for suspected crimes. 3. Resident #54 was admitted to the facility in November 2017 with diagnoses that included major depressive disorder, anxiety disorder, and paranoid schizophrenia. The quarterly MDS dated [DATE] identified Resident #54 had intact cognition, no behaviors, and was independent with bed mobility, transfers, walking in room, and walking in corridor. Physician's orders dated June 2023, directed that Resident #54 was independent with transfers, and ambulation without an assistive device. A written statement from the Administrator dated 6/10/23 identified on 6/10/23 at 1:06 PM she received a text from RN #8 asking about the incident that occurred on 6/9/23 on the 3:00 PM - 11:00 PM shift. The Administrator indicated RN #8 provided her limited details of the alleged incident. The Administrator indicated she called RN #4 and inquired about what had occurred. The Administrator indicated RN #4 identified that she had sent me an email along with the DNS and the SW #1 the night before (6/9/23) with details. The Administrator indicated she educated RN #4 that the alleged incident warranted a phone call and not an email. The Administrator indicated RN #4 indicated to her the reason she did not call her, or the DNS is because RN #4 did not feel anyone was harmed or injured. The Administrator indicated she stressed to RN #4 the importance of proper channels of communication needed in this case. The Administrator indicated she asked RN #4 to provide a written statement of the alleged occurrence. The Administrator indicated RN #4 was removed off the schedule during the investigation. The nurse's note dated 6/11/23 at 9:30 AM identified a follow up note due to occurrence with another resident. RN #8 indicated she spoke with Resident #54 on 6/10/23 and on the morning of 6/11/23. Resident #54 was ambulating on the unit with peers. Resident #54 was in good spirits, smiling, and asked what was on the menu for lunch. RN #8 indicated she spoke privately with Resident #54 who stated he/she was fine and does not feel afraid or anxious. Resident #54 indicated he/she was surprised that it happened because he/she is married. RN #8 indicated she explained to Resident #54 if he/she wanted to talk, to reach out to the staff for support. A written statement from Resident #54 dated 6/11/23 at 7:30 AM identified he/she woke up and used the bathroom. Resident #54 indicated he/she went back to bed and fell asleep. Resident #54 indicated another resident (of the opposite sex, Resident #29) was standing over him/her and touched his/her breast. Resident #54 indicated he/she pushed Resident #29 out of the room. Review of the facility 24-hour report dated 6/9/23 through 6/12/23 failed to reflect documentation that Resident #54 had reported to LPN #2 the allegation that another resident (of the opposite sex, Resident #29) was standing over him/her and touched his/her breast on 6/9/23 on the 3:00 PM - 11:00 PM shift. Review of the Department of Public Health Facility Licensing and Investigations Sections (FLIS) reportable events portal report dated 6/12/23, (3 days after the incident) identified the facility reported Resident #54's allegation that Resident #29 came into his/her room and Resident #29 stood over him/her at bedside and touched his/her breast. The APRN progress note dated 6/12/23 identified that she was asked to see Resident #54 who alleged another resident (of the opposite sex, Resident #29) came into his/her room in the middle of the night and asked him/her to unbutton his/her shirt and touched his/her breasts. Resident #54 was able to chase Resident #29 away by yelling and pushing him/her. Resident #54 was seen and examined. No evidence of trauma noted. Resident #54 has a significant history of paranoid schizophrenia and anxiety. The nurse's note dated 6/12/23 at 11:52 AM identified APRN #1 performed a body assessment with no redness, no bruising, and no injuries noted. Resident #54 had no complaints of pain or discomfort. The resident representative was notified. A message was left for APRN #2. The nurse's note dated 6/12/23 through 6/24/23 failed to reflect documentation of Resident #54's report that another resident (of the opposite sex, Resident #29) came into his/her room in the middle of the night and asked him/her to unbutton his/her shirt and touched his/her breasts on 6/9/23 during the 3:00 PM - 11:00 PM shift. The care plan dated 6/12/23 identified resident to resident - Resident #54 alleged that another resident (of the opposite sex, Resident #29) made inappropriate physical contact. Interventions included to offer psychiatric therapy and medication management. Offer 1:1 visit by the social worker so that Resident #54 can discuss concerns/issues about others. The social worker note dated 6/12/23 identified she met with Resident #54 regarding an allegation of mistreatment. SW #1 indicated a follow up of an alleged incident between Resident #54 and Resident #29 that happened on Friday (6/9/23). SW #1 indicated Resident #54 reported that Resident #29 knocked on the door and proceeded to just walk into the room. Resident #54 told him/her to get out, and he/she did not. SW #1 indicated Resident #54 reported Resident #29 touched him/her inappropriately by putting his/her hands on his/her breasts and fondling them. SW #1 indicated Resident #54 reported she told him/her to get out of the room, he/she kicked and hit him/her on the back until Resident #29 left the room. SW #1 indicated she assured Resident #54 that the allegation is being taken seriously and staff want to make sure that all residents feel safe. SW #1 indicated Resident #54 reported that he/she feels safe and secure. A written statement from LPN #2 dated 6/12/23 at 2:45 PM identified she was approached by Resident #54 while walking down the hallway on 6/9/23. LPN #2 indicated Resident #54 called out to her and Resident #54 indicated another resident (of the opposite sex, Resident #29) was in his/her room and he/she indicated to Resident #29 you are not supposed to be in here. Resident #54 had just come out of the bathroom and got into bed and Resident #29 touched his/her breast and walked away. LPN #2 indicated she provided Resident #54 with reassurance and emotional support after the interaction on Friday 6/9/23. The psychiatric APRN note dated 6/12/23 at 8:44 PM identified that she was asked to see Resident #54 due to allegation of sexual assault. Resident #54 reported another resident (of the opposite sex, Resident #29) entered his/her room and touched his/her breast. Resident #54 reported he/she asked Resident #29 to stop and leave the room. Resident #54 reported he continued to touch his/her breast, and he/she pinched Resident #29 on the back then he/she got up and left. Resident #54 reported seeing Resident #29 in the dining room this afternoon which made his/her nervous until he/she noticed Resident #29 had someone watching him/her and that is when he/she calmed down. Resident #54 reported that he/she feels safe at the facility. Resident #54 reported he/she can get help by using the call light or scream out if he/she needs to. Would recommend continuing Ativan as prescribed as Resident #54 has residual symptoms of anxiety. Recommend psychotherapy so that Resident #54 can continue to process his/her feelings. The psychotherapy initial assessment dated [DATE] at 1:54 PM identified Resident #54 was alert, oriented times three and coherent. Met with Resident #54 for support and difficulty with anxiety with alleged sexual abuse issue. Resident #54 reported that he/she had some difficulty with another resident (of the opposite sex, Resident #29) coming into his/her room and inappropriately touching his/her breast. Resident #54 reported she informed the staff about the issue. Resident #54 report that he/she has some difficulty with anxiety. Will continue to monitor Resident #54 and provide support and validation for resident. The reportable event form dated 6/13/23 at 10:00 PM, identified the date and time of the event first known was on 6/9/23 at 11:05 PM, 4 days prior. Resident #54 alleged that Resident #29 came into his/her room, and he/she woke up with Resident #29 standing over him/her at bedside touching his/her breast. Resident #54 got up and pushed Resident #29 out of the room. Resident to resident abuse without injury. Resident #54 mood was stable with no changes in behavior. Resident #54 ambulates without device. The reportable event form identified the physician was notified on 6/9/23 at 11:20 PM (this is in conflict with an interview with the physician (MD #1) who identified he did not receive a call from the facility on 6/9/23 at 11:20 PM and was not notified of the incident until Monday 6/12/23, 3 days later). The reportable event form identified the resident representative, the police, and the Administrator were all notified, however, there is no date or time of notification. Further, the facility staff did not notify the police, and the Administrator was not notified until 6/10/23, the next day. Interview with Resident #54 on 8/13/23 at 10:55 AM identified he/she was almost raped by another resident (of the opposite sex, Resident #29). Resident #54 indicated Resident #29 came into his/her room and touched his/her breast. Resident #54 indicated he/she kicked Resident #29 out of the room. Resident #54 indicated Resident #29 has not been back in his/her room. Resident #54 indicated LPN #2 was going down the hallway the same night it happened, and he/she called out for LPN #2. Resident #54 indicated when LPN #2 came to the room he/she told LPN #2 about Resident #29 was in his/her room and touched his/her breast. Resident #54 indicated LPN #2 did not assess his/her body. Resident #54 indicated RN #4 did not assess his/her body. Resident #54 indicated he/she told LPN #2 the night it happened and told SW #1 on Monday (6/12/23) about Resident #29 coming into the room and touching his/her breast. Resident #54 indicated on Monday APRN #1 came and assessed his/her body and talked to him/her. Interview and review of the clinical record with the ADNS on 8/14/23 at 10:59 AM failed to provide documentation that an RN assessment had been completed on 6/9/23 at the time of the report. Further, the clinical record failed to reflect that the physician and the resident representative had been notified on 6/9/23. The ADNS indicated RN #4 should have completed an RN assessment and documented that assessment in Resident #54's clinical record at the time of the allegation. The ADNS indicated RN #4 should have notified the physician and the resident representative. The ADNS indicated she was not aware notification had not been made or an assessment done at the time of the allegation. The ADNS indicated documentation is by exception. The ADNS indicated RN #4 failed to call her, the DNS, and the Administrator on 6/9/23 at the time of the allegation. The ADNS indicated the expectation of the facility is that RN #4 should have notified her and the Administrator that Resident #29 had inappropriately touched Resident #54's breast. Interview with the Administrator on 8/15/23 at 7:30 AM identified she was not aware of the allegation of sexual assault on 6/9/23 at 10:15 PM. The Administrator indicated she texted RN #8 on Saturday 6/10/23 at approximately 1:00 PM regarding staffing, and at the end of the text RN #8 texted back asking how long Resident #29 was going to be on 1:1. The Administrator indicated she texted RN #8 to call her on the phone. The Administrator indicated she called the facility and spoke to RN #8. The Administrator indicated RN #8 identified she thought the Administrator knew the details of the incident on 6/9/23. RN #8 indicated that Resident #60 (one of the 3 residents that Resident #29 had touched on 6/9/23) had called the police. The Administrator indicated she called RN #4 who indicated she had sent an email regarding the details of the event on 6/9/23 at 11:06 PM. The Administrator indicated she hung up the phone with RN #4 and read the email. The Administrator indicated RN #4 should have called her via phone and notified her of the allegation at the time it happened. The Administrator indicated she contacted her Chief Operating Officer, Chief Clinical Office, and the RN Director of Quality of Life and Specialty Programs (the Regional Nurse Educator). The Administrator indicated they had a collaboration meeting, they immediately started investigation by interviewing the staff that was present on 6/9/23 on the 3:00 PM - 11:00 PM shift via phone. The Administrator indicated on Sunday 6/11/23 she had a conference call with the Chief Clinical Office and the RN Director of Quality of Life and Specialty Programs. The plan was to report the allegation on Monday morning 6/12/23 by entering the incident into the FLIS portal with the State Agency, however, the Administrator indicated the facility should have reported the allegation earlier. The Administrator indicated she was not aware that the RN assessment was not completed and documented in the resident's clinical record. The Administrator indicated she was not aware the physician and the resident representative had not been notified on 6/9/23. The Administrator indicated the expectation of the facility is that the RN supervisor should have notified the physician and the resident representative of the allegation. The Administrator indicated the facility has in-service the licensed nurses. Interview with APRN #1 on 8/15/23 at 11:53 AM identified she did not receive a phone call from the facility on Friday 6/9/23 regarding the allegation of that Resident #29 inappropriately touched Resident #54 and indicated she was notified on Monday 6/12/23, 3 days after the incident, and she assessed Resident #54 on 6/12/23. APRN #1 indicated her expectation is the facility should have contacted and notified the physician, and/or the APRN at the time of the allegation and that the RN Supervisor should have performed an RN assessment. Interview with MD #1 on 8/16/23 at 10:26 AM identified the facility did not notify him on Friday 6/9/23 or over the weekend of Resident #54's allegation of being touch inappropriately. MD #1 indicated the facility notified him on Monday 6/12/23, 3 days after the incident. MD #1 indicated APRN #1 was going to be at the facility on Monday 6/12/23 and she would assess the resident. MD #1 indicated his expectation is that the facility should have notified him of the allegation at the time in happened. Interview with RN #4 on 8/16/23 at 3:27 PM indicated she has been with the facility since 7/20/22. RN #4 indicated she is the RN supervisor for the 3:00 PM - 11:00 PM shift. RN #4 indicated on 6/9/23 at approximately 10:15 PM she was notified by LPN #2 that Resident #29 was observed in Resident #60's room. RN #4 indicated she went to the unit and spoke to Resident #29 who was in his/her room. RN #4 indicated while she and LPN #2 were walking in the hallway Resident #54 called out to LPN #2 in the hallway. RN #4 indicated LPN #2 went to see what the resident wanted. RN #4 indicated Resident #54 indicated another resident (of the opposite sex, Resident #29) had come into his/her room and he/she yelled at him/her and Resident #29 left. RN #4 indicated she proceeded to the nurse's station and placed Resident #29 on every 15 minutes monitoring. RN #4 indicated since she has been at the facility, she was informed to email the Administrator, the DNS, and the ADNS with any changes at the facility during her shift. RN #4 indicated the Administrator, the DNS, and the ADNS do not answer their phone when you call them. RN #4 indicated she did not document in Resident #54's clinical record. RN #4 indicated she did not perform a body assessment and did not call the physician or the resident representative. RN #4 indicated LPN #2 should have documented in Resident #54 clinical record regarding the allegation of inappropriate touch. RN #4 indicated she was taken off the schedule pending investigation. A written statement from the Administrator dated 8/16/23 identified the facility acknowledges discrepancies in the FLIS reporting system regarding the event on 6/9/23 regarding Resident [TRUNCATED]

Based on observations, review of facility documentation, facility policy and interviews, the facility failed to ensure dry food was stored in a clean and sanitary manner, failed to ensure that hot and cold food temperatures for meals were obtained and documented appropriately, failed to ensure that out of range rinse temperatures logged for a high temperature dish washer had corrective actions documented and implemented per protocol, and failed to ensure that food items stored for the emergency 3-day supply were within use by dates. The findings include. 1. During an initial tour of the kitchen with the Food Services Director on 8/13/23 at 7:50 AM, observations of the dry storage area identified a significant amount of fruit fly activity throughout the area. Multiple fruit flies were observed flying throughout the storage area, resting on the walls and metal shelving, and resting on the exterior packages of multiple food products which included unopened boxed snacks, bagged dinner rolls, unopened cartons of dry potato pearls, and individually bagged turkey gravy mix packages. During this observation, a previously opened bag of yellow cake mix which was not labeled with a date/time opened was observed to be partially tied in the original package with a loose knot with visible open areas to product within the bag. Interview with the Food Services Director immediately following this observation identified that the fruit flies had only been present since 8/10/23 and that the facility had regular pest control services to address the issue. The Food Services Director identified that the fruit fly activity was due to the increased heat from summer. The Food Services Director also identified that any opened food items that the facility planned to reuse, including the yellow cake mix, should have been placed in a secured container to ensure insects were unable to access the open items. Subsequent to surveyor inquiry, the Food Services Director discarded all previously opened items located in the dry storage area. The facility policy on dry food storage directed that all dry goods would be appropriately stored. The policy further directed that all packaged and canned food items would be properly sealed, and that the food storage area would be neat, arranged for easy identification, and would be regularly inspected to ensure it would not be subject to contamination by condensation, leakage, vermin or rodents. 2. Observation and review of the service line checklists on 8/13/23 at 7:50 AM with the Food Services Director identified that food temperatures had not been completed for 8/2, 8/7, 8/8 and 8/11/23. Further observations with the Food Services Director of the service line checklists for 8/2023 identified multiple incomplete food temperature logs with missing temperatures for main and alternate meals, as well as therapeutic preparations (ground and puree) and beverages served. Interview with the Food Services Director immediately following this observation identified he was unsure why the temperatures were partially logged or completely blank. The Food Services Director identified that he would expect the logs to be completed daily for each meal, including all preparations to ensure that all food temperatures were within guidelines. Subsequent to surveyor inquiry, the Food Services Director provided copies of the service temperature logs from 5/1/23 through 8/12/23 for review. The copies provided included a food temperature log filled in dated 9/2/23 (a future date), and partially completed logs for 8/7, 8/8, and 8/11/23 which were previously observed to be blank. Further review of the service line checklists from 5/1/23 through 7/31/23 identified additional incomplete food temperature logs with missing temperatures for all months reviewed. Additionally, there were no logs provided for 5/21, 7/24, 7/25, 7/26 and 7/27/23. Interview with the Food Services Director on 8/16/23 at 5:11 PM identified that he was aware the logs reviewed on 8/13/23 that were blank were completed and then provided to the survey team partially completed. The Food Services Director identified that his staff assisted him in making copies and I think they were trying to help me out by trying to fix the paperwork. The Food Services Director failed to identify which staff altered the documents prior to providing copies to the survey team. The facility policy on food preparation directed that Temperature Control for Safety (TCS) food would be recorded at the time of service and monitored periodically during meal service periods. The policy further identified when hot pureed, ground, or diced foods drop below the danger zone (135 degrees F), the mechanically altered foods must be reheated to 165 degrees F for 15 seconds for holding. 3. Observations on 8/13/23 at 7:50 AM with Food Services Director of the high temperature dish washer identified that the rinse temperature was 182 degrees F for the cycle observed. Additional observations of the dish washer temperature logs identified multiple rinse temperatures documented as lower than the required 180-degree F standard for high temperature dish machines. The log identified for 8/13/23, the breakfast rinse temperature was 160 degrees F. Further review of the August log identified rinse temperatures ranging between 158 F to 165 F degrees for 8 of 13 morning rinse cycles (8/3, 8/4, 8/5, 8/8, 8/9, 8/10, 8/11, 8/12, and 8/13/23) and 6 of 12 noontime wash cycles (8/4, 8/6, 8/8, 8/9, 8/11, and 8/12/23). Interview with the Food Services Director immediately following this observation identified that the facility had a backup low temperature chemical system for washing and rinsing dishes if the high temperature system failed. The Food Services Director identified that the facility staff would have to switch the system over but that it had not been an issue in over a year, and that the reason for the lower than normal rinse temperature was likely due to the rinse temperature being logged following initial start of the system instead of after a couple of cycles. The Food Services Director also identified that the facility staff should have documented any corrective actions on a deviation of temperature record form and attached it to the log for any out-of-range rinse temperatures. Subsequent to surveyor inquiry, the Food Services Director provided copies of the high temperature dish washer logs from 5/1/23 through 8/16/23 for review. The copies provided included the previously reviewed logs from 8/2023, which appeared to have been altered to reflect 180 on the dates previously identified below temperatures. Additional out of range rinse temperatures were identified on 5/1, 7/16, 8/14, 8/15, and 8/16/23. Interview with the Food Services Director on 8/16/23 at 5:11 PM identified that he was aware the high temperature dish washer logs had been altered to reflect temperatures in range. The Food Services Director identified that his staff assisted him in making copies and I think they were trying to help me out by trying to fix the paperwork. The Food Services Director failed to identify which staff altered the documents prior to providing copies to the survey team. The facility policy on ware washing directed that all dish machine water temperatures would be maintained for high temperature machines, and temperature logs would be completed as appropriate. The policy further directed the standard rinse temperature was 180 degrees F, and if the temperature did not meet standards, facility staff should stop washing and contact the Food Service Director or designee. The policy also directed actions for deviations of temperature form included drain, rinse, refill dish machine, recheck temperature and document. 4. During tour of the facility's 3-day emergency food supply stock with the Food Services Director on 8/13/23 at 8:55 AM observations identified multiple food items that were expired. Expired items included a 1-gallon container of mayonnaise expired 8/19/22, 2 large boxes of cookies expired 10/5/22, 1-2000 count box aspartame sweetener expired 3/1/23, 1 large 84 count box of 1 oz corn flakes expired 1/21/22. Interview with the Food Services Director immediately following this observation identified he was responsible for rotating the supply and ensuring any expired items were discarded. The Food Services Director identified he has last rotated the items one week prior but could not identify why multiple items that expired in 2022 were still within the food supply. The Food Services Director identified he had received some overstock items from a sister facility and that he had placed them in the 3-day supply storage area but was unable to provide the date or what items were received. The Food Services Director identified that none of the expired food items should have been with the 3-day supply and should have been discarded upon expiration. Although requested, the facility failed to provide a policy on the 3-day emergency supply or rotation of dry food storage.

Based on observation, review of facility documentation, facility policy and interview, the facility failed to ensure an effective pest control program in the food storage, preparation, and service areas. The findings include: During an initial tour of the facility kitchen with the Food Services Director on 8/13/23 at 7:50 AM, observations of the dry storage area identified a significant amount of fruit fly activity throughout the area. Multiple fruit flies were observed flying throughout the storage area, resting on the walls and metal shelving, and resting on the exterior packages of multiple food products which included unopened boxed snacks, dinner rolls, dry potato pearls, and turkey gravy mix. During this observation, a previously opened bag of yellow cake mix, which did not identify a date or time opened, was observed to be partially tied in the original package with a loose knot with visible open areas to the bag. The dry storage area was located directly adjacent to the cooking, food preparation, and steam table area of the kitchen with direct opening connecting the two areas. Interview with the Food Services Director immediately following this observation identified that the fruit flies had only been present since 8/10/23, 3 days prior, and that the facility had regular pest control services to address the issue. The Food Services Director identified that the fruit fly activity was due to the increased heat from summer. The Food Services Director also identified that any opened food items that the facility planned to reuse, including the yellow cake mix, should have been placed in a secured container to ensure insects were unable to access the open items. Subsequent to surveyor inquiry, the Food Services Director discarded all previously opened items located in the dry storage area. Interview with the Administrator on 8/13/23 at 9:25 AM identified that she was aware there was an issue with fruit flies in the kitchen and had been notified on approximately 8/10/23 by the Maintenance Director. The Administrator identified that the facility had regularly scheduled pest control services to address the issue but that she had not actually observed the fruit fly activity in the kitchen and was not aware of any issues with fruit flies prior to 8/10/23. Interview with the Maintenance Director on 8/13/23 at 10:25 AM identified the facility had monthly pest services and that the most recent visit was 7/31/23. The Maintenance Director identified that he was aware of the issue with fruit flies in the kitchen and that because of the location (the kitchen), the options for treating the area were limited. The Maintenance Director identified that the area could not be sprayed or fumigated and that the current treatment included use of Biomop in the kitchen drains to help with organic food waste, where the fruit flies could possibly be coming from. The Maintenance Director also identified that the fruit flies had been an ongoing issue in the kitchen for several months but that the number of flies increased over the last week as the temperatures outside had increased. Review of pest management invoices provided by the facility dated 3/2023 through 7/2023 identified that fruit flies had been present in the facility since at least 3/31/23. Treatment at that time included natural catch fruit fly traps and recommendations for all drains to be cleaned and treated with Biomop, a biological degrading agent. The 7/31/23 pest management invoice identified increasing fly activity, with recommendations to use Biomop at least twice weekly. Subsequent to surveyor inquiry, the facility provided multiple documents on 8/14/23 and 8/15/23, including plan of correction documentation related to increased pest activity, and a 8/15/23 pest management visit invoice. The facility policy on dry food storage directed that all dry goods would be appropriately stored. The policy further directed that all packaged and canned food items would be properly sealed, and that the food storage area would be neat, arranged for easy identification, and would be regularly inspected to ensure it would not be subject to contamination by condensation, leakage, vermin or rodents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one of two residents (Resident #67) reviewed for abuse, the facility failed to ensure a resident was free from mistreatment. The findings include: a. Resident #67 was admitted with diagnoses that included end stage renal disease and major depressive. The quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #67 was alert an oriented, independent with ambulation and had no history of falls in the prior 90 days. The Resident Care Plan (RCP) dated 2/1/2021 identified Resident #67 was alert and oriented, forgetful at times, and could become anxious when challenged with a new task or unexpected obstacle. Interventions directed to allow time for Resident #67 to process, and to assist with appropriate decision making one step at a time. b. Resident #184 was admitted with diagnoses that included diffuse traumatic brain injury (TBI) and dementia with behavioral disturbances. The quarterly MDS assessment dated [DATE] identified Resident #184 had severe cognitive impairment, had delusions, exhibited wandering behavior four to six out of the last seven days, and was independent with ambulation on and off the unit. The RCP dated 2/11/2021 identified Resident #184 had impaired cognition, limited insight, had poor judgement and safety awareness, and a history of previous resident to resident physical altercations. Interventions directed to provide direction and cueing as needed to redirect when Resident #184 displayed signs of aggression. A Reportable Event dated 2/13/2021 at 10:30 PM identified Resident #184 entered Resident #67's room and Resident #67 alleged a physical altercation occurred when he/she asked Resident #184 to leave the room. Resident #67 alleged he/she was hit in the mouth by Resident #184, which caused Resident #67 to fall, with no injuries noted. Although staff witnessed the altercation, the staff were unable to view if physical contact was made when Resident #184 swung his/her arm at Resident #67 but staff witnessed Resident #67 fall. Resident #184 was placed on 1:1 enhanced supervision and an investigation was initiated. An Investigation Statement dated 2/13/2021 at 10:30 PM from NA #1 indicated that while sitting at the nurse station she heard a loud voice and went to Resident #67's room. She observed Resident #184 in Resident #67's room and heard Resident #67 say Get out of my room. While approaching the room, NA #1 was unable to see Resident #67 but saw the back of Resident #184 and observed him/her swing his arm. When NA #1 reached the room, Resident #67 was sitting on the floor, and Resident #184 was redirected out of the room. Nursing Note dated 2/14/2021 at 1:18 AM identified Resident #67 was observed sitting on the floor in his/her room and stated another resident had entered his/her room. Resident #67 reported when he/she asked the other resident to leave the room, the other resident hit Resident #67 in the mouth. There was no bleeding, swelling, redness noted, and no complaint of pain to the area. The APRN was notified of the alleged physical contact. Neurological checks were initiated, and police notified. A Reportable Event Summary dated 2/17/2021 identified Resident #184 was interviewed and could not recall the incident but was observed standing partially in the doorway and his/her arm swung, however the view was obstructed as to see if contact had been made with Resident #67. Although Resident #67 stated he/she fell from being hit by Resident #184, the facility was unable to substantiate if physical contact was made, or if the fall was caused from physical contact or from losing his/her balance from the unexpected encounter since staff were not able to witness the alleged contact. During an interview on 9/01/2021 at 3:01 PM with Resident # 67, Resident #67 identified he/she was sleeping when Resident #84 came into his/her room, walked to the window and then stood at his/her bed. Resident #67 asked Resident #184 to leave, then got out of bed and closed the door after Resident #184 left. A short time later, Resident #184 returned and stood in the doorway. Resident #67 indicated he/she got up, stood near the door and asked Resident #184 what he/she wanted and asked him/her to leave the room. Resident #67 indicated that Resident #184 then punched him/her in the face, knocking him/her over. Resident #67 indicated no injuries was sustained and staff entered the room to intervene. An interview and facility documentation review on 9/02/2021 at 9:15 AM with NA #1 identified on 2/13/2021 she went to Resident #67's room after hearing yelling. NA #1 indicated although she observed Resident #184 standing in the doorway of Resident #67's room, she could not recall she observed Resident #184 swing his/her arm at Resident #67 or if she recalled finding Resident #67 on the floor when she entered the room. NA #1 indicated she did recall Resident #67 was upset that Resident #184 was in his/her room, and she notified the nurse of the incident. An interview on 9/2/2021 at 9:59 AM with the DNS identified although Resident #67 alleged he/she was hit by Resident #184; she was unable to substantiate abuse as the alleged physical contact was not witnessed by staff. The facility failed to ensure a resident was free from mistreatment. The facility policy entitled Abuse dated 1/23/2018, directed in part, that each resident had the right to be free from mistreatment including physical abuse such as hitting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and staff interviews for one of five residents (Resident #71) reviewed for unnecessary meds, the facility failed to ensure an order was obtained timely in accordance with a pharmacy recommendation approved by the APRN. The findings include: Resident #71 was admitted to the facility with diagnoses that included osteoarthritis and mild spondylosis. The quarterly MDS dated [DATE] identified Resident #71 had moderately impaired cognition, had occasional pain, and received a scheduled and a PRN pain medication. The Resident Care Plan (RCP) dated 4/1/2021 identified a problem with pain. Interventions directed to monitor for non-verbal cues of pain and discomfort and report to my charge nurse. The Physician's order dated 4/1/2021 directed to administer Acetaminophen 1000 milligrams (mg) by mouth at 9 AM and 9 PM. Additional order directed to administer Acetaminophen 650 mg by mouth every four hours as needed for general discomfort or temperature over 101 degrees, not to exceed three (3) grams in 24-hours. A physician's order dated 4/7/2021 directed to increase the Acetaminophen to 1000 mg three times a day. Review of monthly pharmacy medication review dated 4/14/2021 identified the pharmacist identified Resident #71 had physician's orders for standing (1000 mg three times a day) and PRN Acetaminophen with the potential to exceed the maximum daily dose of three (3) grams. The pharmacist further recommended to evaluate and discontinue the PRN Acetaminophen order or to taper the standing order to 650 mg three times a day if appropriate. Further review identified APRN #1 checked the box agree; will do and signed the form and entered the dated 4/20/2021. Review of the clinical record from April 2021, through September 2, 2021 failed to identify a physician's order to reduce the Acetaminophen daily dose; no order directed to discontinue the PRN Acetaminophen order or to taper the standing order to 650 mg three times a day in accordance with the pharmacy medication review signed by APRN #1. Interview and clinical record review with Assistant Director of Nurses (ADNS) on 9/2/2021 at 11:34 AM, identified that although APRN #1 signed the pharmacy medication review to indicate he agreed with the pharmacist's recommendation to discontinue the PRN Acetaminophen order or to taper the standing order to 650 mg three times a day, a physician/APRN's order was not entered in the clinical record to change either the standing or the PRN Acetaminophen order. The ADNS was unable to provide documentation to reflect that the pharmacy recommendations were acted upon timely after APRN #1 signed the recommendation. The ADNS indicated that she is notified when the pharmacist makes any recommendations, and she then gives the recommendations to the APRN to address. If the APRN agrees with the recommendation, they sign the form and give it to the charge nurse to write the order in the clinical record. The ADNS indicated that although she was unable to explain why the charge nurse did not enter an order after APRN #1 signed the medication review form, an order should have been entered in the clinical record in accordance with the signed form to indicate if the standing order was to be reduced, or if the PRN order was to be discontinued. Interview with Director of Nurses (DON) on 9/2/2021 at 11:50 AM identified her expectation was that the recommendations from pharmacist be followed up on as indicated by medical doctor or the APRN, and the ADNS was responsible to follow up on the recommendations to ensure they were addressed timely. The DON indicated that the order should have been entered into the clinical record on 4/20/2021 after it was signed and was unable to explain why the recommendation was not acted upon timely. Subsequent to surveyor inquiry, an order was obtained, dated 9/2/2021 (4 ½ months after the pharmacy recommendation was made on 4/14/2021) that directed to give Acetaminophen 650 mgs by mouth daily as needed for general discomfort or temperature greater than 101 not, to exceed four (4) grams in 24 hours, and to check the daily scheduled dose Review of the facility undated Drug Regimen Review-Monthly Policy directed in part, that the prescriber or licensed designee shall act upon the Drug Regimen Review findings/recommendations in a timely manner of 7 to14 days or less.