**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident and staff interview, and policy review the facility failed to protect residents from abuse for 1 of 2 residents reviewed for abuse (Residents #69). The facility reported a census of 81 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had diagnoses of cancer, Alzheimer's Disease, dementia, and diabetes. The MDS recorded the resident had impaired short-term and long-term memory, severely impaired decision-making skills, and inattention. The MDS revealed the resident had a wanderguard alarm, and had independence with transfers. The MDS assessment dated [DATE] revealed Resident #50 had diagnoses of sexual dysfunction not due to a substance or known physiological condition, dementia, and malignant neoplasm of the pancreatic duct. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 6, indicating severely impaired cognition. The MDS recorded the resident had no behaviors, and did not have an alarm or wanderguard. The MDS indicated the resident independent for transfers and had the ability to ambulate at least 150 feet independently. The Care Plan initiated 11/7/24 and revised on 2/28/25 revealed the resident had impaired cognition and thought processes related to dementia. The resident ambulated and transferred independently with and without a cane. The Care Plan revealed the resident displayed inappropriate sexual advances towards another resident related to fondling, grabbing and touching the resident (initiated 11/7/24). The Care Plan directed staff to monitor the involved residents and know the resident's whereabouts, specifically while the resident was in the hallway (added on 11/7/24). A motion detector sensor was placed on the resident's door (added on 2/27/25), and 15-minute checks utilizing a monitor at the nurse's station and 1:1 whenever the resident was outside of his room (added to the care plan on 4/16/25). The Order Summary revealed the following orders: 11/7/24 - Medroxyprogesterone Acetate (a hormone) 20 milligrams (mg) daily for hypersexual behavior 2/24/25 - send Resident #50 to the Emergency Department (ED) for complaints of chest pain, shortness of breath (SOB), and elevated blood pressure. 2/24/25 - Sertraline (an antidepressant) increased to 75 mg by mouth (PO) daily 2/25/25 - obtain a UA (urinalysis) for increased behaviors for 2 days. 2/26/25 - Doxycycline (antibiotic) 100 mg BID (twice a day) for 10 days and Prednisone 20 mg daily for 7 days for pneumonia. 4/24/25 - increase Medroxyprogesterone to 40 mg PO daily for hypersexual behavior Incident reports revealed the following: a. On 11/5/24 at 4:42 PM, Staff H, certified nursing assistant (CNA), heard a female resident state no, no, no and turned to see Resident #50 cupping the female resident's vagina through her clothing while the resident stood in the hallway. Resident #50 was told to stop. Resident #50 stopped and walked away from the female resident. Resident #50 was placed on medication for sexual behavior. Resident #50 ambulatory without assistance and oriented to person. Resident #50 snickered when staff asked him what happened. Resident #50 said no when staff asked him if he touched the lady. Resident #50 educated is was inappropriate to touch other residents. A medication review was completed. b. On 2/23/25 at 11:00 AM, Registered Nurse (RN) paged to a resident's room STAT (immediately). CNA notified the nurse a male resident was in a female resident's room touching the resident inappropriately. CNA immediately told male resident to stop, do not touch her, get out, that is not ok. Male resident was directed back to his room. A full assessment was completed. Female resident was lying in bed sleeping with her brief pulled down. She stated not remembering what happened. Female resident notified of what occurred and became tearful. Resident #69 said she did not say Resident #50 could do that. Male resident placed on 1:1 observations. Resident #50 stated I know what I was doing, I needed to please her and that is what I was going to do. Resident #50 notified he could not to go into (resident) rooms that aren't his. The Director of Nursing (DON), Nurse Practitioner (NP), Assistant Director of Nursing (ADON), Administrator, and family were notified. The Quarterly MDS dated [DATE] documented Resident#69 had diagnoses including, Stroke, difficulty swallowing, left sided weakness, slurred speech, and muscle weakness. The MDS revealed the resident required total assistance of staff for transfers, and dressing. The MDS did not reveal any mood or behavior concerns. The Annual Assessment MDS dated [DATE] documented Resident#69 had the following symptoms present nearly every day over the last two weeks; trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy. The MDS revealed the resident had the following symptoms present 2-6 days in a 14 day look-back period, trouble concentrating on things, such as reading the newspaper or watching TV, moving or speaking so slowly that other people could have noticed, to the opposite- being so fidgety or restless that you have been moving around a lot more than usual. The Facility's Investigation File revealed a summary of the incident that occurred on 2/23/25: Staff G, RN, paged to Resident #69's room STAT. Staff F, Certified Medication Aide (CMA), notified Staff G she walked in on Resident #50 in Resident #69's room and found him touching Resident #69 inappropriately. The residents were separated immediately. Staff F stated to the Administrator she saw Resident #50 within the last 5 minutes and at that time he was not in Resident #69's room. Resident #50 had not had previous inappropriate sexual behaviors with Resident #69. The staff noted Resident #50 was not at baseline on this day. He spoke non-stop and something just seemed off. It was noted later that he had an infection (pneumonia). A UA was obtained on 2/28/25. Resident #69 had a BIMS of 13, indicating intact cognition. Resident #69 stated to Staff G she was confused about what was going on and she was alarmed by all of the yelling by staff as she had been relaxing in her bed half asleep when Resident #50 came into the room. She told the nurse she was not traumatized by the event. A full body assessment revealed no concerns. Social Services (SS) followed up with both residents for 3 days. Resident #50 had a BIMS of 3. He was unable to sign a statement due to his cognition and functional conditions. Resident #50 had expressed his preference to spend most of the time in his room but he came out of his room at times. Resident #50 moved to a different room away from Resident #69, by all male residents and nearby the nurse's station in order to keep an eye on him. Staff stated they felt the root cause of the resident's behavior may have been related to an infection. The police were contacted. A Psychiatry (Psych) visit occurred on 2/27/25. The physician reviewed the resident's medication and increased Sertraline to 75 mg for sexual behavior on 2/23/25 at 4:04 PM. An order for Prednisone 20 mg daily for pneumonia started on 2/26/25. The Ombudsman visited the facility on 2/27/25. Resident #69 had no concerns regarding the event and felt the facility addressed everything accordingly. A room change was offered to her but she declined. A motion detector monitor and baby monitor placed to ensure staff got alerted if Resident #50 was awake and to monitor if he came out of his room. Other female residents in the facility that had the potential to be impacted stated they felt safe and had no issues with the male resident. A typed statement dated 2/23/25 revealed Staff F, CMA, went to get a blood sugar on Resident #50's roommate. Resident #50 was not in the room. Staff F went to look for Resident #50 throughout the building where he normally went. Staff F started opening doors and checked other residents' rooms and found Resident #50 in Resident #69's room. Staff F saw Resident #50 sitting at the foot of Resident #69's bed with her brief all the way undone and his hand between her legs. Staff F was unsure if Resident #50 penetrated Resident #69. Staff F told Resident #50 to stop, don't touch Resident #69, that is not ok, this is not his room. Resident #69 woke up and looked like what is going on? Resident #50 got out of Resident #69's room. Staff F called for Staff G to get there STAT. Staff then met up at the nurse's station to call the people that needed notified. Resident #50 came out of his room looking for Resident #69 again. The police came ten minutes later. Staff F showed the police officer what happened and what she walked into. Resident #50 was placed on 1:1 watch while staff figured out what to do. An undated typed statement from the Administrator revealed the Administrator spoke with Staff F again on 2/28/25. Staff F witnessed the female resident's brief located to the side and the male resident by the bed next to her in a wheelchair with his hand by her legs. Staff F had just seen Resident #50 less than five minutes before. Staff F went to administer medications to Resident #50's roommate, then Staff F went to administer Resident #50's medications and found Resident #50 in Resident #69's room. Staff F screamed at Resident #50 because she assumed he was touching Resident #69 because her brief had been pulled to the side. Staff F said that startled Resident #69. She again told the Administrator she immediately separated the two residents and got the nurse. A written statement by Staff G, RN, revealed: RN was paged to Resident #69's room STAT. The CNA notified the nurse that the male resident was in the female resident's room touching the resident inappropriately. The CNA told the male resident to stop, do not touch her, get out, that is not ok. The male resident was directed back to his room. A full assessment was completed. The female resident was lying in bed with her brief pulled down. Resident #69 stated not remembering what happened. Resident #69 was notified about the incident and she was tearful. Resident #69 stated she did not say he could do that. Resident #69 stated she is ok at that time. Resident #50 in his room on 1:1 observation. Resident #50 stated he knew what he was doing. He needed to please her and that is what he was going to do. Resident #50 was notified he could not go into rooms that are not his. The DON, NP, ADON, Administrator and families of both residents notified. A typed statement signed by Resident #69 on 2/23/25 revealed the resident stated she did not remember what happened. Resident #69 said she did not say that Resident #50 could do that. Police Reports revealed: a. On 11/04/2024 at approximately 3:35 PM, an officer responded to the facility for a report of sexual abuse between residents. The officer met with the staff who witnessed to event. Staff O stated that at approximately 5:00 PM, Resident #50 and Resident #37 walked down opposite sides of the hallway. Staff O stated she saw Resident #50 grab Resident #37 vagina over her clothing and stated there it is. Staff O escorted Resident #50 back to his room and he was giggly but that is his normal demeanor. Staff O stated that Resident #50 had dementia and did not understand what he had done due to his mental status. Staff O also stated that Resident #37 was autistic and unable to comprehend what had happened. Staff at the facility stated they contacted the family members of both individuals regarding plans moving forward. It was reported that Resident #50 would have another psych evaluation and medication review to help treat his condition and for the safety of others in the facility. Staff reported they would make sure Resident #50 kept separate from Resident #37 in the future. b. On 2/23/2025 around 10:56 AM, a police officer was dispatched to the facility for a report of sexually inappropriate activity. Staff G stated that earlier that AM, a nurse walked into a female resident's room and observed her diaper around her ankles while a male was performing a sex act on her. The female victim, Resident #69, was sleeping during the assault. Resident #69 suffers heavily from dementia. She stated that she did not remember anything that happened. Resident #69 stated that she was told a man was in her room that AM. Resident #69 stated that she did not remember anything about the incident. She stated that her legs were in some pain, but that she had leg pain daily. Resident #69 stated that she had no knowledge of who the male was. The Officer then spoke with Resident #50. Resident #50 stated that he went into Resident #69's room and asked her if he could try what I wanted to try and she agreed. Resident #50 then began rambling incoherently about sexual things that happened in his past. Resident #50 stated that he knew what he was doing and also acknowledged that it was wrong. Resident #50 began rambling incoherently about people unrelated to the incident. The police officer asked Resident #50 if he knew he was supposed to stay in his room and not visit Resident #69 anymore and Resident #50 acknowledged. The officer then spoke with staff who witnessed the incident. Staff F stated that when she walked into Resident #69's room, Resident #50 was sitting at the foot of Resident #69's bed. Resident #69's undergarments were around her knees/ankles and Resident #50 appeared to be touching Resident #69's vagina. Staff F then confronted Resident #50 and he exited the room. Resident #50's Progress Notes revealed the following: a. On 10/24/24 at 5:17 PM, resident inappropriately touched a CNA while she gave him medication. Resident educated and hand removed (from the area). b. On 11/4/24 at 5:44 PM, resident touched another resident in the private area as he passed by her in the hallway. CNA present at this time and separated the residents. Resident #50 snickered when he was asked what happened. Resident #50 asked if he touched the lady resident. He said no. Resident educated not to touch other residents. Medications reviewed. c. On 11/6/24 at 1:15 PM (late entry), around 7:45 AM, Resident #50 asked the housekeeper to get into bed with him. He then stated, your pants are baggy. Your ass would look better if your pants were off. d. On 11/6/24 at 1:49 PM, attempted to call the resident's representative to inform of the resident's behaviors. New orders received from the NP to start hormone and antidepressant medications for hypersexual behaviors. NP declined to refer the resident to psych because the resident had declined to see psych in the past. e. On 11/8/24 at 3:10 PM, information added to the Care Plan to include monitoring the resident in the hallways because he most frequently exhibited behaviors with other residents in this area, and to monitor the resident during meal times when he was outside of his room as well as in the dining room. f. On 11/21/24 at 8:32 AM, CMA tried to administer Medroxyprogesterone medication for hypersexual behavior but the resident refused the medication three times. g. On 1/29/25 at 5:35 PM, resident came up behind dietary aide and tried to get handsy with her. Resident was asked to leave the dining room. h. On 2/23/25 at 11:00 AM, RN paged to Resident #69's room STAT. The CNA notified the RN that Resident #50 found in Resident #69's room touching a female resident inappropriately. CNA immediately told Resident #50 to Stop, do not touch her, get out, and that his actions were not okay. Resident #50 was directed back to his room and placed on 1:1 observations. Resident #50 stated I know what I was doing, I needed to please her and that is what I was going to do. Resident #50 notified he was not to go into any rooms that are not his. i. On 2/23/25 at 12:58 PM, Resident #50 moved to another room away from the female resident, closer to the nurse's station, and by other male residents. A motion sensor was placed on the door. j. On 2/23/25 at 4:04 PM, order obtained to increase Sertraline to 75 mg PO once a day for hypersexual behaviors. k. On 2/24/25 at 12:01 AM, resident on 1:1 for sexual behaviors. At 12:15 AM, resident sent to the ED for complaints of chest pain and shortness of breath. At 5:55 AM, the ED nurse advised the facility that the resident would be returning to the facility. l. On 2/24/25 at 3:35 PM, psych referral for sexual aggression and medication management. Hope Harbor was called to look for a locked male unit. m. On 2/25/25 at 2:39, resident talked to the aide in his room and stated he and his buddy used to go looking for 5-year olds and used to molest/please the little girls. n. On 2/25/25 at 5:42 PM, order for UA collected due to resident increased behaviors. o. On 2/26/25 at 2:58 PM, visual monitor in resident's room and at the nurses station to monitor Resident #50's activity. Resident room is insight of the nurse's station. p. On 2/27/25 at 1:16 AM, resident noted to be playing with his penis upon check and change. Resident advised to stop but not easily redirected. q. On 2/27/25 at 7:31 AM, SS Coordinator attempted to talk to Resident #50 over the past two days about the incident but he was sleeping. r. On 3/13/25 at 12:56 AM, resident yelling at staff for not letting him go to his old room. s. On 3/26/25 at 2:11 AM, resident not been sleeping at night. He requested all night long to go to the dining room. He was not easily redirected because within a few minutes he was back up and tried to go to the dining room again. A message was sent to the physician. t. On 4/9/25 at 1:45 AM, resident asked staff about people being up and down the hall having sex. Resident talked about his penis and how big or small his penis was and he talked about having sex. Resident not easily redirected. u. On 4/16/25 at 9:48 PM, per the Administrator on 4/16/25 at 9:41 PM, the resident is supposed to be on routine 15-minute checks for being outside of his room without supervision due to an allegation incident that was unwitnessed earlier in the day. v. On 4/24/25 at 9:04 AM, SS Coordinator left a message for Hope Harbor to see if the resident would qualify for placement. A NP Visit Note dated 2/24/25 revealed Resident #50 had increased sexual aggressive behaviors and a fall over the weekend. The resident was evaluated in ED but had no new diagnosis or change in the plan of care. He is on Sertraline and Medroxyprogesterone for hypersexual behavior. The NP recommended a psych consult for sexual aggression and medication management. Resident #50 was moved closer to the nurse's station and the plan of care was reviewed. Medications reviewed with no changes. The Plan of Care included to observe for change in condition and notify the provider with any questions or concerns. Continue prevention, and practice proactive medical treatment to allow the resident to remain in the home. The Physician's Encounter Note dated 3/3/25 revealed Resident #50 was evaluated in the ED for an atypical infection. Resident #50 started on doxycycline and Prednisone. A UA was negative. Pulse oximetry 96% on RA (room air). A previous visit on 2/26/25, it was reported Resident #50 had an inappropriate altercation with a fellow resident as he had entered the resident's room and grabbed the genital area. The action was unprovoked. He was with recall and stated he was talked to and he had told the staff he would not do again. He was placed in another room and required 1:1. Resident #50 sustained a fall and was transported to the ED. The CT findings revealed suspected pneumonia. Resident #50 had decreased appetite and slept more than fifteen hours a day. Reported the resident had increased sexual behaviors and inappropriate verbalization and physical contact. Sertraline and Medroxyprogesterone was initiated. The resident also had diagnosis of progressive dementia and pancreatic cancer. A Psychiatric assessment dated [DATE] revealed Resident #50 referred for sexually inappropriate behavior. The resident had diagnoses of adjustment disorder with mixed disturbance of emotions, Alzheimer's Disease, and dementia with behavioral disturbance. No new orders. A Fax communication dated 3/26/25 revealed the resident antsy, not sleeping at night, and came out of his room at night. Observations revealed the following: a. On 4/22/25 at 9:58 AM, Resident #50 smiled and laughed as he spoke to the surveyor. An alarm sounded while the resident was lying in bed. Staff A, RN, responded to the resident's room. Staff A adjusted the alarm pad under the resident and reset the alarm but the alarm continued to sound. Staff A stated he thought maybe the batteries needed to be replaced. b. On 4/23/25 at 7:43 AM, Resident #50 sat in bed looking toward the doorway of the room and smiled. The door to the DON's office was closed and locked. Staff A, RN, stood by the nurse's desk. c. On 4/23/25 at 11:10 AM, Resident #50 sat on the bed in his room. The DON's office door was open but no staff observed in the office. A staff person walked with another resident down the 200 hall. d. On 4/23/25 at 12:14 PM, Resident #69 sat in a wheelchair by the nurse's station (2 doors from Resident #50). e. On 4/23/25 at 2:54 PM, Resident #69 propelled her wheelchair down the 200 hall until Staff A offered to push the resident in the wheelchair to her room. f. On 4/23/25 at 3:00 PM, Resident #50 sat in a chair in his room approximately 5 feet from the doorway of his room. The resident smiled and talked to himself. 2. The MDS assessment dated [DATE] revealed Resident #69 had diagnoses of cerebrovascular accident (CVA)(stroke), hemiplegia, and muscle weakness. The MDS documented the resident had a BIMS of 13, indicating intact cognition. The MDS recorded the resident had impaired range of motion on one side of her body. She required partial to moderate assistance for bed mobility, and had dependence on staff for lower body dressing and transfers. The MDS documented the resident had no behaviors. The Care Plan revised on 6/11/24 revealed Resident #69 had limited physical mobility related to a stroke and hemiplegia that affected the left side of her body. The resident was non-ambulatory and required assistance with activities of daily living (ADL's) such as dressing and bed mobility. The Care Plan lacked information about a resident-to-resident incident. An Incident Report completed on Resident #69 revealed a staff statement entered on 2/23/25. Staff F found Resident #50 wandering the halls going in and out of female resident rooms. Staff redirected Resident #50 to his room. Staff F took him back to his room where he told Staff F he was going to pleasure her, she needed to be pleasured. Resident #50 then went into his room and went into the bathroom. Staff F then went and did blood sugars on the [NAME] Hall. Staff D and Staff E shut all of the female doors. When Staff F went to get a blood sugar on Resident #50's roommate, Resident #50 was not in the room. Staff F then looked for Resident #50. Staff F checked the building on where Resident #50 normally went. Staff F began to open the doors to the female rooms and found Resident #50 and Resident #69. Staff F saw Resident #50 sitting at the foot of Resident #69's bed with her brief all the way undone and Resident #50's hand between Resident #69's legs. Resident #50 was touching Resident #69. Staff F told Resident #50 to stop, don't touch her, that is not ok, this is not your room. That is when Resident #69 woke up and looked at Staff F like what is going on? Resident #50 got out of the room and Staff F called for the RN STAT. When staff met at the nurse's station to call people, Resident #50 came out of his room looking for Resident #69's room again. The police arrived 10 minutes later. Staff F told the police what happened and what she walked into. Resident #50 placed on 1:1 while staff figured out what to do next. The physician, Administrator, police, and family were notified. The Weekly Skin Observation dated 2/21/25 at 9:27 PM revealed no skin conditions observed. On 2/28/25 at 4:14 PM, no skin concerns noted. Barrier cream continued to her groin. A Progress Note dated 2/23/25 at 11:45 AM but created on 2/27/25 at 12:57 PM revealed a complete RN assessment completed on Resident #69. No signs of physical trauma noted to the resident's body. The resident denied pain. Staff stayed with the resident and assisted with cares and ADL's, then assisted the resident into the wheelchair per her request. Staff continued to monitor the resident. Progress Notes revealed the following: a. On 2/23/25 at 12:46 PM, Staff G stated to the Administrator that she had spoken with Resident #69 right after the incident with the male resident. At first Resident #69 was tearful because she was not sure what was going on initially but stated that it was not traumatic to her. Social Services to follow up for 3 days. b. On 2/24/25 at 12:16 AM, Resident #69 spoke with the nurse about the incident this morning and resident very sad that it happened. Encouraged her to seek out staff if she needs to talk. c. On 2/24/25 at 3:49 PM, SS Coordinator asked Resident #69 what happened over the weekend. Resident #69 advised she was awakened by screaming and it scared her as she thought she was hurt. A male resident was removed from her room. She later stated she noticed hand marks where the male resident apparently held her down. She was upset and stated she had reached out to have her therapist work with her. She was more upset from the commotion rather than the actual situation. d. On 2/25/25 at 3:04 AM, resident does not remember any of the incident that happened. Resident states she only knew what people had told her what happened. She stated she knew he was not supposed to be around her. She stated she didn't even know what he looked like. e. On 2/25/25 at 12:10 PM, SS Coordinator spoke to resident regarding the incident over the weekend. She stated she was not traumatized by the issue. She just wanted to know why it happened. She thought she did something. Resident was reassured it was not her. In an interview on 4/22/25 at 9:45 AM, Resident #69 reported a male resident lived down the hall from her. He came into her room and raped her a month or so ago. She was lying in bed. He took her brief off. She doesn't think he penetrated her but she doesn't know for sure. Staff yelled at him and asked him what he was doing, and got him away from her. Resident #69 stated the male resident had come and stood at her door but staff had caught him in time. Resident #69 reported she had a stroke and unable to move her left arm or leg. Resident #50 got moved to another room down the hall from her. The facility staff put a motion detector on him to keep track of him. Resident #69 stated she was concerned if he would come into her room at night. Resident #69 was tearful as she spoke with the surveyor about the incident. During confidential interviews with three other interviewable residents on 4/24/25, the female residents reported they had not had any staff or residents touch them inappropriately. The female residents reported they would yell if that happened to them. One female resident reported the staff don't like it when she spoke up about something that was not right. Staff told her to mind her own business and worry about herself. Resident #69 told one female resident what happened. One female resident didn't think the facility did enough to keep the male resident from going into other people's rooms. The female resident had asked the facility staff to move her bed to face the door so she could see if someone was coming into her room but they never moved her bed to face the door. One female resident recalled Resident #69's bed faced the window at the time of the incident but now her head of the bed faced the door. The female residents voiced concern the facility could retaliate for talking with the surveyor. Another female resident reported a male resident came into her room uninvited one time looking for his wife. When asked if she would feel uncomfortable with a male resident coming into her room, she said it would depend if the resident was with it. Some people had dementia or another diagnoses and that made people sometimes do things. Another female resident reported Resident #50, a male resident, walked into her room uninvited but she yelled at him and scared him off. She was fortunate. Resident #50 is wacko. The female resident reported an alarm goes off now if Resident #50 went out of his room. She had worked with therapy and built up her strength. She thought she would be able to flatten him if he tried to do anything to her. On the day Resident #50 came into her room she turned on her call light. Staff were busy with other residents at the time. When the CNA came in, she told the CNA she saw Resident #50 going in and out of the resident rooms. Staff got him to his room. The next thing she heard was a big commotion going on next door to her and he was found in Resident #69's room. The resident stated staff can't always come right away but she wanted to feel safe in her home. She is able to stand up for herself and she could talk or yell but not all residents could. In an interview 4/24/25 at 9:00 AM, Resident #69 reported she talked with another female resident about the incident that occurred with a male resident. A staff member came up to her and the resident and told her not to say anything about the incident. In an interview 4/22/25 at 2:45 PM, Staff A, RN, reported Resident #50 tended to be a lot more mobile at night and he slept during the day. He shared a bathroom with another male resident. Resident #50 had some behaviors. The resident's door had a motion sensor and the bathroom door had a doorbell chime. The chime was plugged into an outlet and sounded at the nurse's station. The alarms had distinct sounds. Staff A reported he kept Resident #50 in his line of site and listened for the doorbells. An alarm also went off if Resident #50 tried to get up without assistance. The resident mainly came out of his room for a shower and some meals. Resident #50 was 1:1 after the incident with Resident #69, but he had been on 15-minute checks for the past week due to him being more mobile. His room was located right across from the DON's office. Staff A reported Resident #50 came out of his room at night, walked to the nurse's station to get a snack or talked to staff, then went back to his room. He was not a group social person but he would talk 1:1 and had a conversation with people. Staff A reported he was not aware of other incidents when Resident #50 had been inappropriate with other residents. Staff A reported Resident #69 was alert and oriented x 4. She could be dramatic and get things blown out of proportion. She had nightmares or vivid dreams and said things happened but in reality things had not happened. In an interview 4/22/25 at 2:55 PM, Staff G, RN/Clinical Care Coordinator reported on the day of the incident with Resident #50 and Resident #69, Staff G got called to Resident #69's room. Resident #69 was in her room sleeping. Resident #50 went into Resident #69's room. Staff F told Staff G she found Resident #69's brief undone. Staff F told Resident #50 he needed to leave. Resident #69 was ok. Social Services came and talked with her. Resident #50 was placed on 1:1. Staff G called activities in to sit with him and called the physician. The police came in. Resident #50 had made sexual remarks in the past. He randomly said things to staff that made them feel uncomfortable. There was a note in the computer for staff to be aware of him and monitor for any behaviors. Resident #50 had some medication changes as he had had a mental health diagnosis in the past. Staff G reported when she first started working at the facility she worked in another unit but she observed residents in the dining room. She saw Resident #50 and his interactions with staff and the residents. He was more reserved. He would get up and go out of the dining room or the area. He was not a big communicator. He walked independently. He would come out of his room and ask for snacks. Staff G reported she paid more attention to him after the incident. Staff G stated she had seen a decline

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff, interviews the facility failed to provide treatments as ordered for one of three residents reviewed for treatment. The lack of treatment for (R#33) may have lead to a hospitalization. The facility reported a census of 86. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 has Brief Interview for Mental Status (BIMS) of 00, which indicated severe cognitive impairment, and diagnosis of Non-Alzheimer's Dementia, Atrial Fibrillation (A-fib), Congestive Heart Failure (CHF), muscle weakness, lymphedema, and cognitive communication deficit. MDS documented admission to care facility began 11/15/2023. The Care Plan dated 4/17/24 revealed Resident #33 is non-verbal, shakes and nods head to respond. Resident #33 is non-ambulatory and totally dependent on staff for transfers and cares. Receives anticoagulant (blood thinners) medication, diuretics for A-fib and CHF. Hospital Discharge summary dated [DATE] documented as follows; Review of resident #33's records revealed he was admitted to the facility on [DATE] for long term care after a hospitalization for pubic fracture. Hospital discharge documents revealed resident #33 had chronic lymphedema (swelling caused by buildup of lymph fluid in the body between the skin and muscle) treated with Lasix (diuretic) and use of lymphedema pumps (a device that treats chronic edema and venous disease with the use of air and compression into a stocking), peripheral venous insufficiency (circulation disorder), A-fib, stage 3 chronic kidney disease, a history of blood clotting disorder with deep vein thrombosis (DVT, blood clots in the veins), intellectual disability. Hospital discharge orders included medication list and use of lymphedema pumps from home, one hour in the morning and one hour in the afternoon. Plan of Care Note from Hospital Social Worker dated 11/14/23 at 9:20 AM documented Group Home to bring Lymphedema pumps to bedside to go with the resident for the admission to the nursing home. Skilled Nursing Facility/Nursing Facility to Hospital Transfer Form dated 2/11/24 documented the following; Resident#33 was transferred to the hospital on 2/11/24 for shortness of breath and admitted to the ICU (intensive care unit) and diagnosed with urosepsis, septic shock, DVT in both legs with cellulitis in the right lower leg. Resident #33 was discharged from the hospital returning to the facility on 2/21/24 with continued medications including an anticoagulant medication and to restart lymphedema pumps the day of discharge. Hospital Progress Note dated 2/13/24 at 8:31 AM documented that the resident previously had one year ago DVT's and PE (pulmonary embolism (blood clot)). The resident's bilateral lower extremities are swollen, and his right leg is very painful. The lower extremity swelling and pain may be due to the DVT's, but can't rule out necrotizing fasciitis with the organism in his blood. Physicians Order dated 2/26/24 for the resident documented lymphedema pump to bilateral lower extremities once daily. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 11/1/23-6/1/24 failed to reveal order for lymphedema pump and documentation of administration. On 6/13/24 at 2:20 PM revealed the resident laid in bed with no lymphedema pump in the room. On 6/17/24 at 12:17 PM Staff C, Registered Nurse (RN) reported the resident did not have a lymphedema pump in his room, and had not received this treatment. Staff C recalled this being discussed after hospital discharge on [DATE] but could not recall why this had not been initiated. On 6/17/24 at 2:21 PM the Director of Nursing (DON) stated the lymphedema pump order had not been sent with the original admission in November, and should have been clarified by the nurse at that time. An order was received from a physician on 3/3/24, that was not processed accurately to TAR, and had not been administered as ordered. The DON did confirm the lymphedema pump is in the facility, and the TAR had been corrected and treatments will be started. On 6/17/24 at 4:30 PM the DON was presented with the orders for the lymphedema pump that were received on initial admission documentation on 11/15/23. DON acknowledged the orders and identified the facility failed to accurately review, process and implement the orders for the lymphedema pump. Physician Orders Policy dated 4/1/24 directed staff as follows, Purpose to provide care to each resident by obtaining appropriate, accurate and timely physician/practitioner orders. Following hospitalization when a resident returns from the hospital, physician/practitioner orders must be updated to reflect the resident's current needs. admission orders and orders received throughout the resident's stay are processed and transcribed into PCC-Clinical-orders (electronic health record), immediately upon receipt of the order. The orders must be noted by the licensed nurse who has processed the order and filed in the central supervised location for scanning/indexing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #3 had diagnoses including of Multiple Sclerosis (MS), Malnutrition, Stage 4 pressure ulcers, anxiety, depression, and diabetes. The MDS documented that the resident received scheduled pain medication.The MDS documented the residents pain as follows; pain experienced almost constatly, pain frequently made it difficult for the resident to sleep, pain frequently limited the residents day-to-day activities. The MDS documented the resident described her pain as a 7 on a scale of 0 to 10. The Care Plan dated 3/11/24 revealed Resident #3 had unclear speech, slurred or mumbled words, receives pain medication due to chronic pain, is immobile and needs total assistance for all transfers and cares. Review of resident #3's physicians orders revealed the following orders: 3/21/24 Fentanyl Patch 72 hour 25 MCG/HR, Apply one patch transdermally every 72 hours for pain and remove per schedule. Discontinued on 3/25/24 3/25/24 Fentanyl Patch 72 hour 50 MCG/HR, Apply one patch transdermally every 72 hours and remove per schedule. Review of resident #3's Medication Administration Records (MAR) for 3/1/24-6/12/24, revealed on 4/9/24 no nurse's signature was noted, indicating no Fentanyl patch had been administered. Review of Controlled Drug Receipt/Record/Disposition Form (form used to document dispensed and inventoried controlled medications) revealed the following: On 4/10/24 at 1600, two 25 MCG/HR Fentanyl patches were signed out. Indicating these patches were administered late. (scheduled to be administered on 4/9/24) On 5/18/24 at 7:45 PM, one 25 MCG/HR Fentanyl patch was signed out, indicating the wrong dose was administered. 5/21/24 at 7:45 PM, one 25 MCG/HR Fentanyl patch was signed out, indicating the wrong dose was administered. 5/24/24 at 7:45 PM, one 25 MCG/HR Fentanyl patch was signed out, indicating the wrong dose was administered. 5/27/24 at 7:45 PM, one 25 MCG/HR Fentanyl patch was signed out, indicating the wrong dose was administered. 5/30/24 at 7:45 PM, one 25 MCG/HR Fentanyl patch was signed out, indicating the wrong dose was administered. 6/8/24 at 7:45 PM, one 25 MCG/HR Fentanyl patch was signed out, indicating the wrong dose was administered. Review of resident #3 ' s nurses progress notes revealed, on 4/9/24 the nursing staff failed to document the scheduled Fentanyl 50 MCG/HR patch had not been administered, reason for not being administered, and notification to family and physician. On 4/10/24 nursing staff failed to document two 25 MCG/HR Fentanyl patches had been administered late and notification to family and physician was made. Review of the controlled medication receipts, provided by the pharmacy, verified the quantity of Fentanyl patches, date, time and signature of staff who received the delivery from the pharmacy. Interview on 6/12/24 at 9:27 AM, A Pharmacy Technician with the Facility ' s contracted pharmacy revealed the process of receiving new and discontinued orders. The order is faxed from the facility to the pharmacy. When it is a controlled substance, the pharmacy will contact the writing physician for signature of ordered medication. When a controlled substance is discontinued by the physician, the pharmacy is to be notified by a faxed discontinuation order from the facility. The facility is responsible for disposing of the discontinued controlled medications by destroying them in a pharmacy provided, DEA approved, Rx destroyer. This is a container that contains a formula that neutralizes the substances placed inside. The Pharmacy Technician confirmed the facility has been provided a Rx destroyer. During an interview on 6/17/24 at 3:35 PM, the facility Administrator acknowledged administering the 25 MCG/HR Fentanyl patch was not following physicians orders, indicated a significant medication error. Review of Medication Administration policy dated 5/21/24 revealed: 1. Medications are administered to the resident according to the Six Rights. (Right medication, right dose, right resident, right route, right time and right documentation). 2. Perform three checks: Read the label on the medication container and compare with the MAR when removing the container from the supply drawer, when placing the medication in an administration cup/syringe and just before administering the medication. Document that the medication was given as soon as possible after administration. 3. Do not leave medications at the bedside or at the table unless there is a specific physician order to do so, and the resident has been evaluated for self-administration. If the resident has not been assessed for safety of self-administration and there is not a physician order to leave the medication with the resident, stay with the resident until the medication is taken and you observe the resident swallow. 4. An incident report will be completed for all medication errors. If a medication is not available for 24 hours, the provider must be notified. Review of Maintenance of Active Medical Records dated 5/11/23 revealed, the location will maintain medical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible and systematically organized. Based on observation, clinical record review, interviews, and policy review, the facility failed to administer medications to the correct resident (Resident#87) and, administer the correct dose of a pain medication to (Resident#3). Resident#87 was taken to the emergency room, and treated for the overdose of medications as a result of the incident when the resident experienced low blood pressure, and low pulse rate. The facility staff also left medication unattended. Seven residents were reviewed for medications. The facility reported a census of 86 residents. Findings include: 1. The Minimum Data Set (MDS) admission assessment for Resident #87 dated 4/23/24 documented a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicated intact cognition for decision making. The MDS revealed he had diagnoses of cerebral infarction referring to a recent stroke, renal disease, urinary tract infection, diabetes, depression and age-related cognitive decline. The Care Plan initiated 4/19/23 documented Resident #87 resident will be free from discomfort of preventable adverse reactions related to medication. A Progress Note dated 4/29/24 12:51 PM by Staff A, Registered Nurse (RN), late entry documented Resident#87 spouse medications sitting on bedside, waiting for blood pressure to be obtained, Resident #87 reached and took spouses medication. Provider, Nurse Practitioner (NP) at the facility notified, family aware, monitored per order and sent to ER for evaluations. A Progress Note 4/29/24 9:35 AM documented by Staff B, revealed provider, NP in facility notified took own medication as well as spouses who takes several blood pressure medications. Received new order to monitor blood pressure and pulse every two hours for 8 hours. A Progress Note dated 4/29/24 by Staff B, effective time 11:50 AM documented family notified took spouses medication this morning and blood pressure 82/46 at 11:30 AM. Resident # 87 on way to hospital. A Progress Note dated 4/29/24 by Staff B, created 12:18 PM documented, called and informed the hospital, resident took the wrong medications and has allergies to Atrovastatin and Simvastatin and the resident did take Pravastatin. Informed the Emergency Department (ED) that the medications and recent blood pressures were provided to the paramedics for the ED to review. A statement signed by the Director of Nursing (DON) on 4/29/24 documented on the morning of 4/29/24 at 9:20 AM received a message, Resident #87 received incorrect medications. An investigation revealed, the Registered Nurse (RN), Staff A placed the medication cup of Resident #188 on the bedside table of spouse, Resident #87. The RN left to obtain a forgotten alcohol wipe, when RN Staff A returned the medication cup was empty. Resident #188 and RN Staff A realized Resident #87 had taken the pills. The provider, Nurse Practitioner (NP) was in the facility, was notified along with family. Resident #87 was sent to ER for evaluation, was treated with calcium gluconate and fluids and returned to the NF, no other new orders. Nurse interviewed revealed no other residents affected, no other residents were left with medication unsupervised. A Facility Incident Report dated 4/29/24 documented, Resident #87 reached over and took Resident #188 medications, not remembering he had already taken his medication. Noted medication error, wrong medication and indicated Resident #87 blood pressure was monitored, resulted in hospital, ED visit. Hospital ED Physician Notes dated 4/29/24 documented inadvertent overdose on medication, diagnosis of beta blocker overdose (refers to mediations to lower blood pressure. Documented inability of Resident #87 to provide clear information, some confusion, undetermined if is baseline. Resident #87 blood pressure dropped to 80/40 after the incident, resident was bradycardic (low pulse rate) and hypotensive (low blood pressure) was treated with intravenous (IV) fluids and IV calcium, observed for seven hours post ingestion until blood pressure and heart rate improved. Coded complexity of problem, high an illness or injury that posed life threat or bodily function threat. The Medication Administration Record (MAR) April 2024 for Resident #87 documented took as directed on 4/29/24. a. Calcium-Vitamin D3 600-10, 1 capsule by mouth in the morning b. Apixaban oral tablet 5 MG, two times a day for anticoagulant c. Atenolol oral tablet 25 MG two times a day for hypertension d. Cetirizine HCl oral tablet 10 MG 1 tablet daily for allergies e. Docusate Sodium oral tablet 100 MG 2 tablet daily, constipation f. Escitalopram oral tablet 10 MG 1 tablet daily for depression g. Ferrous sulfate oral tablet 325 (65 Fe) MG two times a day h. Fish Oil, one oral capsule in the morning i. Magnesium Ox oral tablet 400 MG supplement, two times a day j. Metformin HCl oral tablet 500 MG two times a day for diabetes k. Multivitamin Men 50+ tab daily, ensure no Vitamin K additive l. Oxybutynin oral tablet 5 MG, two times a day for urinary spasms m. Pantoprazole Sodium oral delay release 40 MG daily, heart burn n. Theophylline ER oral extended release, 400 MG daily for asthma o. Macrobid oral capsule 100 MG two times a day for urinary tract infection (UTI) for 7 days beginning 4/27/24 The MAR, April 2024 for Resident #188 documented the following morning medications, reported was taken by Resident #87 accidentally. a. Calcium, Vitamin D Oral Tablet 600-3.125, supplement, daily b. Cholecalciferol Oral Capsule 50 MCG (2000 UT) supplement, daily c. Docusate Sodium Oral Tablet 100 MG daily for colon health d. Famotidine oral Tablet 20 MG daily for stomach upset/acid reflux e. Ferrous Sulfate Oral Tablet 325 supplement one, Monday & Friday f. Levothyroxine Sodium Oral Tablet 75 MCG one daily for thyroid g. Methylcobalamin Oral Lozenge 1000 MCG supplement daily h. Multivitamin Oral Tablet one time a day for supplement i. Pravastatin Sodium Oral Tablet 20 MG one daily for hyperlipidemia j. Valacyclovir Oral Tablet 500 MG daily for preventative k. Vitamin B12 Oral Tablet 500 MCG one supplement daily in AM l. Amlodipine Besylate Oral Tab 5 MG twice daily for hypertension m. Buspirone HCl Oral Tablet 10 MG twice daily for anxiety n. Labetalol HCl Oral Tablet 200 MG twice a day for hypertension o. Verapamil HCl Oral Tablet 120 MG three times a day for hypertension In an Interview on 06/13/24 at 09:34 AM, RN Staff A reported she did prepare medications for Resident #188 set them on the table per resident requested, went out of the room and came back, Resident #188 said you didn't set my pills there. Was determined Resident #87 took the pills, was evident as blood pressure assessed and it continued to go down, Resident #87 sent out to the hospital In an interview on 6/13/24 01:44 PM, RN Staff B recapped events of 4/29/24 relayed was the charge nurse, other RN, Staff A was working to administer medications relayed, can't believe what happened, relayed had put Resident #188 pills on the table left to get an alcohol wipe and came back the pills were gone. Staff A asked where are pills went, Resident #188 replied, Resident #87 took them. Staff B also relayed she alerted the ED what medications were taken by printing off both resident MAR's and highlighting the AM medications taken, from Resident MAR's # 188 and 188. Staff B recalled hospital report of treatment included calcium gluconate and fluids and thought a Beta blocker reversal was indicated medications to reverse the low blood pressure in regards to the extra medications taken. In an interview on 06/13/24 at 07:57 AM the DON relayed medication should not be left unattended. Facility Electronic file dated 4/29/24 revealed hospital visit summary dated 4/29/24, diagnosis noted, Poisoning by beta-adrenoreceptor antagonists, accidental (unintentional toxicology problem). Medication Policy with revised date 5/21/24 directed staff as follows; *To administer medications correctly and in a timely manner *Once medication pass has begun, interruptions should be avoided. Unless emergent, no one should interrupt the nurse/medication aid during the medication pass. *Medications are administered to the resident according to the Six Rights. -Right resident -Right medication -Right dose -Right time -Right route -Right documentation *Do not leave medications at the bedside or at the table unless there is a specific physician order to do so, and the resident has been evaluated for self-administration. 2. Observation on 6/11/24 from 7:20 AM to 8:25 AM of medication administration by Registered Nurse (RN) Staff C, prepared med's and went to residents' room to give medication, cart unattended, prepared med's for another resident, left cart to go to resident room and repeated leaving cart unattended while entering rooms of five (5) residents to administer medications. On top of the medication cart a plastic container with individual boxes labeled for residents, translucently viewed various insulin medication pens in the individual boxes, the container also contained diabetic supplies a glucometer, cotton, cleansing wipes, a cup of insulin pen needles was also observed on the top of the cart. On 6/11/24 at 8:25 AM, Staff B, RN queried regarding diabetic supplies and insulin left on the cart unattended. Staff B relayed in the morning took diabetic medications and supplies from the med room and is usual to leave it on the cart, generally they sit out when actively used in the mornings. Staff C, RN reported, she felt the pens need a needle added to inject so felt it was not a concern. A separate cup of insulin needles observed remained accessible on the top of the cart. Staff C in addition relayed, was not told not to do this. In an interview on 06/13/24 at 7:57 AM with the Director of Nursing (DON) acknowledged medication should not have been left unattended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff interview, and policy review the facility failed to ensure staff used a gait belt to safely transfer a resident for 1 of 4 residents reviewed for transfers who fell resulting in significant pain and swelling (Resident #4). The facility also failed to ensure a resident's bed was placed in a low position for resident's safety while the resident was lying in bed (Resident #5), and failed to utilize a fall mat and body pillow as care planned for 1 of 7 residents reviewed in the sample who fell from their bed resulting in an eye laceration that required sutures and caused significant facial pain and bruising (Resident #5). The facility reported a census of 55 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 4 had a brief interview for mental status (BIMS) score of 10, indicating cognition moderately impaired. The MDS revealed the resident had diagnoses including dementia and heart failure. The MDS revealed the resident required extensive assistance of one for bed mobility and limited assistance of one for transfers, toilet use, and ambulation in the room. The MDS dated [DATE] revealed Resident # 4 had a BIMS score of 10, indicating cognition moderately impaired. The MDS revealed the resident required extensive assistance of one person for bed mobility, toilet use, and ambulation in her room, and extensive assistance of two staff for transfers. The Care Plan revised on 8/24/22, revealed Resident #4 had a risk for falls related to medication side effects, weakness, cognition, and a left lower extremity (LLE) fracture. The Care Plan directed staff to ensure the resident wore appropriate non-slip footwear when ambulated, use a gait belt, walker, and assistance of one staff for ambulation and transfers (added 8/24/22). The care plan intervention added 2/10/23 for physical therapy evaluation upon return from the hospital. A fall tool assessment completed on 8/19/22 due to a fall revealed the resident had a medium risk for falls. A fall tool assessment completed 8/23/22 and 2/10/23 after the resident returned from the hospital revealed the resident at high risk for falls and referred to therapy. An E-interact transfer form revealed the following: a. On 8/19/22, resident transferred to the hospital at 10:50 PM after the resident had a fall. b. On 2/10/23, resident transferred to the hospital at 3:29 PM after trauma related to a fall. An x-ray completed revealed an obvious fracture to the left fibula (long bone in the lower leg). The left ankle/foot swollen and the inner left foot had bruising. The Progress Notes revealed the following: a. On 8/19/22 at 10:50 PM, CNA (certified nursing assistant) called a nurse to the resident's room. The Resident was lying supine in the bathroom doorway. CNA reported she ambulated the resident to the bathroom using a walker when the resident stated I'm falling. The CNA stated she assisted the resident to the floor and then heard a popping sound. Resident very tearful during assessment and complained of feeling dizzy. The resident had removed oxygen after she changed into a gown and prior to ambulating. Gripper socks were on. Vital signs revealed oxygen saturation 80% without oxygen. Oxygen replaced and oxygen saturation then 92%. The resident complained of left hip and leg pain. Slight external rotation noted to the left leg. Physician notified of fall. Order received to send resident to the emergency department (ED) for evaluation and treatment. b. On 8/20/22 at 5:06 AM, ED nurse reported the resident broke her ankle in two places, they planned to admit the resident (to the hospital), and awaited a surgical consult. c. On 8/22/22 at 10:06 AM, social service documented a follow up fall note for therapy to evaluate the resident upon return from the hospital. d. On 8/23/22 at 11:15 AM, an admission/readmission note revealed resident hospitalized post fall and had a left ankle fracture and contusion to her left hip. Resident treated with pain medications and wore a boot due to the fracture. Physical therapy, occupational therapy, and nursing to provide services due to a fall with fracture. e. On 8/29/2022 at 12:43 PM, MDS note revealed the resident had a recent hospitalization after resident lower to the ground during a transfer. Resident diagnosed with a left tibia/fibula fracture and UTI. No surgical intervention for the fracture. Ortho boot worn to the left lower extremity at all times except during hygiene and clothing changes, and Ortho boot worn for stability and for comfort. The resident took Gabapentin and Tramadol routinely, and used Tylenol for breakthrough pain. Required assistance of one staff for all ADL's. Currently receiving skilled services with PT/OT for balance, gait, strengthening, and ADL re-training with a goal of resuming prior functional ability. Plan of Care updated to reflect acute injury and pain. f. On 2/10/23 at 8:00 AM in a communication to the physician revealed a CNA reported to the nurse resident yelled out when she attempted to lift the resident's left leg up while getting resident ready to get up. Upon assessment, the resident's left outer ankle/foot noted as extremely swollen and very tender to touch. The resident had some light purple bruising to her inner left foot. Scheduled pain medication administered for the pain, then wrapped left ankle/foot up to her left knee per an existing order. Physician notified. Order received for a left ankle and foot x-ray. g. On 2/10/23 at 1:36 PM, portable x-ray done. Awaiting results. h. On 2/10/23 at 2:46 PM, physician notified of probable fracture to the resident's left fibula. Order obtained to send the resident to the ED for evaluation and treatment. i. On 2/10/23 at 3:54 PM ambulance service refusing to take resident to the hospital at this time due to not in critical condition. DON (director of nursing) aware. j. On 2/10/23 at 4:17 PM, the nurse practitioner ordered to change Tramadol (an anti-inflammatory pain medication) to every 6 hours PRN (as needed), start hydrocodone 7.5/325 milligrams (mg) every 6 hours for 7 days, Tylenol three times a day, and a cam boot to left leg. k. On 2/10/23 at 4:27 PM, EMS services and non-emergent transports unable to transport resident to hospital Ambulance transport arranged for 2/11/23. l. An incident Progress Note on 2/10/23 at 6:12 PM revealed resident ambulated with assistance using walker from bathroom when her knees became weak and CNA lowered the resident gently to the floor. Resident sat on her bottom when the nurse entered the room. No injuries observed and resident able to move all extremities without pain or discomfort m. On 2/10/23 at 6:37 PM, a new intervention put into place for physical therapy evaluation. n. On 2/11/23 1:41 PM, resident seen in the ED during 7 AM - 7 PM shift. X-ray confirmed the resident had a fracture to the left lower extremity distal fibula. Orders include a CAM boot at all times except for skin and circulation checks each shift, and non-weight bearing status to LLE. o. On 2/16/23 at 4:06 PM, hospital called facility with pre-op instructions. Nothing to eat or drink after midnight and arrive at the hospital ED entrance on 2/17/23 at 5:30 AM. Surgery for an ORIF (open reduction and internal fixation) on the left ankle with plates and screws scheduled. A facility investigation file revealed the following: a. On 2/9/23 at approximately 10:58 PM, Staff A, Registered Nurse, was summoned to the resident's room by Staff B, certified nursing assistant. Resident sat on her buttocks in the bathroom doorway. Staff B stated she attempted to ambulate from the bathroom to her bed when the resident's knees became weak, and bilateral lower extremities criss-crossed. Staff B gently lowered the resident to the floor. Staff A reported she assessed the resident while on the floor. The resident denied pain. Range of motion (ROM) within normal limits and vital signs stable. Two staff assisted the resident back to bed. On 2/10/23 at approximately 8:00 AM, the day shift CNA notified the nurse the resident complained of pain and tenderness to her LLE. The nurse assessed the area and observed area swollen and had discoloration. Physician notified and order received for x-ray. Portable x-ray obtained at 1:36 PM. X-ray results received at 3:30 PM and revealed a probable fracture to the left distal fibula. Nurse practitioner notified of results and ordered to send the resident to the hospital. EMS contacted but upon arrival EMS refused to transport the resident because resident's condition not an emergency and resident in stable condition. Non-emergent transportation services contacted but not able to transport the resident, but agreed to transport the resident to the ED the following AM (on 2/11/23). ARNP and family aware. An addendum added on 2/11/23 revealed the resident sent to the ED by ambulance. At approximately 12:00 PM, call received from the hospital nurse that the resident had a nondisplaced fibula ankle fracture. Resident had a previous fracture to the LLE on 8/19/22 resulting in two fractures to the left ankle. New orders to follow up with orthopedic physician, wear a CAM boot to LLE at all times, and non-weight bearing status to LLE. DIA report submitted on-line. b. An undated written statement by Staff A revealed Staff B called Staff A into the residents bathroom. Staff B stated she transferred the resident from the bathroom. The resident became weak and began to fall. Staff B stated she gently lowered the resident to the floor onto her bottom. Resident assessed for injuries. The resident had no non-verbal signs or symptoms of pain or discomfort and moved all extremities. Resident assisted from the floor by Staff A and Staff B without difficulty, and the resident ambulated with a walker and assistance of one to bed. c. An Incident Report dated 2/9/23 revealed a CNA called the nurse into the residents room. The CNA reported she transferred the resident from the bathroom. The resident became weak and she gently lowered her to the floor. Resident assessed for injuries, and able to move all extremities. Resident assisted from the floor without difficulty, then used a walker and assistance of one back to bed. No injuries observed and no apparent unsafe condition observed. d. In a learning opportunity for employees provided to Staff A on 2/10/23 by the DON revealed on 2/9/23 resident fell in the bathroom. Nurse assessed the resident and then two staff assisted the resident up and ambulated the resident to bed without a gaitbelt. Facility policy after all falls, include resident assisted up with a mechanical lift and assistance of two staff. Staff A aware of policy but policy not followed. Staff A reported the bathroom very small, resident sat up and easily assisted to her feet. Staff education on 2/10/23 revealed: a. Anytime a resident had a fall, a mechanical lift used for assisting resident off the floor. It doesn't matter if the resident was independent, used a stand aid, EZ stand. Do not manually lift a resident off the floor. b. A gait belt must be used at all times whenever a resident ambulated or transferred. All residents had a gait belt in their room. Let the DON know if no gait belt in the resident's room. c. Always check the resident's Care Plan if not sure of their plan of care, or ask another staff member. Never transfer a resident without confirmation on transfer status. The education document was signed by Staff A and Staff B on 2/13/23. A Major Injury Determination Form dated 2/15/23 signed by the ARNP revealed incident causing injury of probable fracture to the resident's left distal fibula was confirmed by x-ray on 2/11/23. The x-ray showed a nondisplaced fibula ankle fracture. The resident required assistance of one staff and front wheeled walker for ambulation prior to the fall. The injury deemed as a major injury pursuant to IA Code. During observation on 5/1/23 at 9:40 AM, Staff G, CNA, and Staff H, CNA, used a mechanical hoyer lift and transferred the resident from a wheelchair to her bed. At 1:50 PM resident lying in bed on her back with bed in high position. At 2:50 PM resident lying in bed on her back. The resident's bed continued to be in a high position. In an interview 5/2/23 at 11:05 AM Staff A, RN, reported she worked at the facility until 2/2023. Staff A stated an assessment completed to determine if a resident had any injuries whenever a resident had a fall. An Incident Report filled out, and information pertaining to the fall documented the EHR. Staff A reported she looked at the resident's Care Plan to know how the resident transferred and the number of staff needed for transfers. The CNA's looked at the [NAME] in the EHR. The [NAME] is a shortened version of the Care Plan and showed how a resident transferred and the number of staff needed for transfers. Staff A reported Resident #4 had a fall in 2/2023, and fractured her ankle. Staff A stated she was called to the resident's room. The resident was lying in the bathroom doorway. CNA ambulated resident to the bathroom using a walker and said the resident's left leg buckled under her. The CNA told her she lowered the resident to the floor. During an interview 5/2/23 at 12:45 PM, Staff C, RN and former DON, reported she worked at the facility for 3 years but left on 3/9/23. Staff C reported a head to toe assessment completed whenever a resident had a fall, then resident moved off the floor. Staff C acknowledged it was the facility's policy and procedure for staff to utilize a hoyer lift and two staff to move a resident after a fall. Staff C reported an incident report filled out under the risk management section in the EHR and the note in the incident report linked to the nursing Progress Notes. Staff C reported Resident #4 required assistance of one staff and used a walker for transfers and ambulation. After the resident had a fall with a fracture, she was non-weight bearing to lower extremity and needed a hoyer lift for transfers. On the day of the incident (2/9/23), Staff B, CNA, ambulated the resident to the bathroom. Staff B told her the resident legs got weak and criss-crossed, and the resident went down as she walked the resident with a walker back into her room. Staff B didn't use a gait belt when she ambulated the resident to the bathroom or on the way back to the room. Staff C reported a gait belt should be used for any resident that was ambulatory and required staff assistance. Staff C stated the nurse assessed Resident #4 after the fall but neither staff used a hoyer lift when they transferred the resident from the floor. Staff just got the resident up off the floor. The facility's policy required staff use a hoyer and two staff to transfer a resident after a fall. During an interview 5/2/23 at 2:55 PM, Staff D, CNA, reported she looked at the resident's Care Plan to know what cares were needed and how each resident transferred. Staff D reported a hoyer lift used to transfer a resident after the resident had a fall. During an interview 5/3/23 at 10:00 AM, Staff E, LPN, reported she worked at the facility 1/2023 - mid-2/2023. Staff E reported a resident assessment performed and neuro checks completed whenever a resident had a fall. Staff E stated she completed an assessment whenever a resident had a fall, then resident moved with a hoyer and two staff if the resident was able to be moved. Staff E reported during the time she worked at the facility, she spoke with staff who knew about the residents and winged it to know how to transfer a resident and the number of staff required. The facility had no papers to show if a resident required 1 or 2 staff assistance. The DON told her the resident status changed all of the time and she didn't have time to update a pocket care plan or similar type of cheat sheet. Staff E reported the facility was short staffed and several residents required assistance of at least two staff for transfers. During an interview 5/3/23 at 10:50 AM Staff I, LPN, reported she worked the 6 AM - 6 PM shift the day after Resident #4 had fallen in the night. During shift report it was reported the CNA had to lower the resident to the floor during the night but the resident had no injuries. Around 6:30 AM, after report, the resident complained of her foot hurting. The foot/ankle was purple and really swollen, so she requested an x-ray. She called an ambulance but when the ambulance showed up, emergency medical services (EMS) staff said it wasn't an emergency, and since they were short-staffed, EMS wouldn't transport the resident to the hospital. She called a non-emergency transport but they couldn't transport the resident either so they sent the resident to the hospital the next day. Resident able to tell you want she wanted or needed, but not fully cognitive. The resident could stand /pivot / transfer or use EZ stand prior to fall. It depended on the day and her strength. She used an EZ stand and 2 staff for transfers, then had to use hoyer after she had a fracture. When she fell, she doesn't think the CNA used the EZ stand because she was told the resident was lowered to the floor. Staff L stated the [NAME] would state how a resident transferred and the number of staff needed for transfers and cares. During an interview 5/3/23 at 6:05 PM, Staff B, CNA, reported she worked at the facility 2 months from 2/6/23 to 4/3/23 on the 2-10 PM shift. Staff B reported her orientation at the facility entailed being shown around facility and how to use a hoyer and [NAME]-lift. The facility didn't explain when to use a gait belt or where gait belts kept. She asked other staff for a gait belt and someone would get a gait belt for her to use on a resident but nobody told her where to get a gait belt if she needed one. The gait belts weren't kept in every resident room until after an incident occurred with a resident falling. Staff B stated staffing at the facility was horrible. Staff B stated the facility often had 3 CNA's working in 2 halls when she worked. Lilac and [NAME] halls were the busiest and most of the residents needed two staff assistance for transfers and cares. There were a couple of times she had to use one person because it was so busy and nobody was able to assist her. Staff B stated on the day Resident #4 fell it was the first time she had worked on the hall where the resident resided, and she worked with a brand new agency nurse and another agency CNA. It was the first time the other agency CNA had worked at the facility. Staff B reported the day shift CNA told her the resident used a walker and didn't have to wear oxygen when she took the resident to the bathroom because the oxygen tubing was a tripping hazard. On the day the resident fell, she assisted the resident to the bathroom. The resident ambulated well to the bathroom. After she changed the resident into pajamas and cleaned the resident up, the resident seemed shaky so she asked the resident if she needed to sit down. The resident ambulated fine but then her leg buckled and her legs criss-crossed. It took 5-10 minutes to get someone to come help her after the resident fell. She believed the resident's oxygen level dropped and the resident went down. The cheat sheet provided by the day CNA showed this resident as a stand by assist and used a walker. Staff B reported she placed the cheat sheet into a shred box at the end of her shift. She didn't use a gait belt because she couldn't find one. She looked in the resident's drawer but no gait belt found. She asked the nurse but the nurse was new and didn't know if Resident #4 needed a gait belt. She didn't put a gait belt on the resident when she transferred or ambulated with the resident to or from the bathroom. During an interview 5/4/23 at 10:30 AM Staff J, CNA, reported gait belt use required if resident required staff assistance during transfers and/or ambulation. Gait belts hung behind the door in the resident rooms. The staff use to carry a gait belt but after COVID-19, gait belts kept in each resident room due to infection control reasons. Staff J reported she looked at the [NAME] or asked staff that know how a resident transferred. Staff J reported Resident #4 ambulated by evening shift CNA from the bed to the bathroom and broke her ankle. The resident used a gait belt and walker for ambulation. After the resident fell and fractured her ankle, staff used a hoyer lift. A gait belt Policy revised 4/26/23 revealed gait belts used during an assisted ambulation unless medically contraindicated to safely stabilize a transfer and aid residents in maintaining balance. A fall prevention and management policy revised 3/29/23 revealed the facility had an obligation to provide the safest environment possible for residents trusted in their care. The purpose of a fall prevention program included to identify risk factors and implement interventions before a fall occurred. The proactive approach included communication about fall risks and interventions during 24 hour report, information placed on the Care Plan and [NAME], and discussion during a daily stand-up meeting. If a resident had a fall, the nurse must observe the resident and a full body exam completed to determine if any suspected injury, then direct the staff on whether to move the resident. A total lift used to transfer the resident off the floor when the resident had no suspected serious injury. 2. The MDS assessment dated [DATE] revealed Resident # 5 had impaired short-term and long-term memory. The MDS revealed the resident had diagnoses of Alzheimer's Disease, dementia, and anxiety disorder. The MDS revealed the resident required extensive assistance of two for bed mobility, and had total dependence on two staff for transfers and toilet use. The Care Plan revised on 2/24/23 revealed the resident had a risk for falls related to weakness and a recent history of falls. The resident also had an ADL self-care deficit related to unsteady gait and weakness. The staff directives included the following: a. Use a hoyer and assistance of two staff for transfers. b. Refer to physical therapy and occupational therapy as needed for weakness, c. Keep bed in low position (added 3/4/19) d. Place body pillow to outside edge of bed as boundary identifier (added 12/16/22) e. Instruct staff on proper usage of full mechanical lift (added 2/14/22) f. Body pillow to side of resident that is not against the wall (added 2/27/23) g. Fall mat in place next to the bed (added 2/27/23) An order summary revealed an order to transfer the resident to the hospital 2/24/23 and an order to cleanse the right eyebrow laceration and apply bacitracin twice a day for wound care. The Progress Notes revealed the following: a. On 12/7/22 at 4:03 PM, MDS review for resident with comorbidities of Alzheimer's dementia and anxiety. Dependent for hoyer lift transfers. b. On 12/16/22 at 1:13 PM, at approximately 6:05 AM, the CNA alerted nurse that resident lying on the floor. Resident observed lying on her back on the floor on top of her bed covers. Resident assessed but no injuries observed. Resident assisted back to bed using a mechanical lift and assistance of four staff. Neuro checks initiated. c. On 12/28/22 at 10:29 AM, IDT (interdisciplinary team) note indicated resident found on floor. Pillow to be placed for boundary identification. d. On 2/24/23 at 2:01 PM, Staff E, LPN, called to resident's room by the laundry aide. Resident's roommate stood at the doorway and reported she heard her roommate (Resident #5) fall out of bed. Upon entering the room, resident lying on her stomach parallel to her bed with her hands tucked up under her abdomen and her head turned to the left. A large pool of blood under the resident's head. Resident assisted onto her back by two staff ensuring resident's joints and neck protected due to concern for resident aspirating on her blood. The resident had a laceration above her right eyebrow, and right orbital bruised and swollen. ROM WNLs to all extremities. ROM was not attempted to neck due to facial injury. Physician contacted and ordered to send resident to the ED. e. On 2/24/23 at 6:16 PM, resident returned to facility via EMS. f. On 2/24/23 at 6:59 PM, staff educated on proper placement of body pillow. g. On 2/28/23 at 10:01 AM, IDT note, fall mat to be placed once available. h. On 3/1/23 at 2:31 PM, new wound care orders received for right brow laceration. Cleanse area with cleanser of choice and apply bacitracin twice a day. Incident Reports revealed the following: a. On 12/16/22 at 6:05 AM, resident found lying on the floor in her room. Resident lying on back on the floor on top of her bed covers. Resident assessed for injury. Full ROM ascertained and skin intact. Resident unable to verbalize what happened. Resident assisted back to bed using a mechanical lift and four assist. Neuro checks initiated. b. On 2/24/23 at 2:00 PM, nurse called to the resident's room by the laundry aide. The resident's roommate stood at the doorway and reported she heard her roommate (Resident #5) fall out of bed. Resident lying on her stomach parallel to the bed with her hands tucked up under her abdomen and her head turned to her left side. A large pool of blood observed under the resident's face. Resident assisted onto her back by two staff making sure to protect her joints and neck due to a concern the resident would aspirate on blood. The right eyebrow had a laceration and right orbital area bruised and swollen. Physician notified and ordered to send the resident to the ED. 911 called to transport the resident. Resident confused and incontinent at the time of the incident. During observations on 5/2/23 at 1:22 PM, resident observed lying in bed slightly on her left side. The resident's bed was in high position, no mat on floor by the bed, and no body pillow in place by the resident. At 1:23 PM, Staff D, CNA, denied putting Resident #5 in bed after lunch. Staff D entered the resident's room with the surveyor and reported concerns with the resident's bed left in high position, no mat on the floor by the bed, and no body pillow placed by edge of bed while the resident in bed. At 1:25 PM, Staff F, RN, entered Resident # 5s room with the surveyor. Staff D remained in the room with the resident. At the time, the surveyor advised Staff F of concerns related to Resident #5's bed left in high position, no mat on the floor by the bed, and no body pillow placed by the resident as directed in the resident's care plan. During an interview 4/27/23 at 6:50 PM, a family member reported the resident had a fall in 12/2022 without injury, and another fall in 2/2023. The resident was sent to the ED to get checked out because staff thought she had a concussion or a skull fracture. The resident's roommate told them the resident had slid out of bed. The resident had slid out of bed twice since 12/2022. The facility staff placed a mat by her bed, and got her a body pillow. During an interview 5/2/23 at 12:45 PM, Staff C, RN and former DON, reported she worked at the facility for 3 years but left on 3/9/23. Staff C reported she filled out a report to the DIA when the resident had bruising, and noticed the resident had fallen out of bed before but unsure what intervention put in place. The resident had a recent fall out of bed in 2/2023, so a fall mat placed and a body pillow implemented. During an interview on 5/2/23 at 1:27 PM, Staff K, CNA, reported she helped Staff L, CNA, put Resident #5 into bed after lunch on 5/2/23 but then she left the resident's room to go do something else. During an interview 5/2/23 at 1:30 PM, Staff F, RN, reported she expected staff lower the resident's bed into a low position whenever a resident lying in bed. Staff F reported even when staff had to leave Resident #5's room, they should've lowered the bed toward the floor, placed a fall mat on the floor by the bed, and put the body pillow in place, then return and change the resident when able. Staff F reported she expected staff follow the Care Plan and ensure interventions into place. During an interview 5/3/23 at 10:00 AM, Staff E, LPN, reported she worked at the facility 1/2023 - mid-2/2023. Staff E reported a housekeeper called her to Resident #5's room because the resident was on the floor. The resident's roommate yelled out Resident #5 had slid out of bed. She assessed the resident, then staff helped roll the resident onto her back while she supported her neck, and got her face out of the blood on the floor. The resident had two black eyes. She called the ambulance and sent the resident to the ED. Staff E reported she found out later the body pillow was not in place when the resident slid out of bed. At that time, a CNA trained a brand new CNA. The CNA had left the room and left the brand new CNA with the resident. The brand new CNA tucked the resident into bed but didn't know she needed to place the bed in low position or ensure a body pillow placed. Staff E reported the facility was short staffed. Staff E reported a resident assessment performed and neuro checks completed whenever a resident had a fall. Resident moved with a hoyer and two staff assistance if resident can be moved. Staff E reported during the time she worked at the facility, she spoke with other staff who knew about the residents and winged it to know how many staff required and how to transfer a resident. The facility had no papers to show if a resident required 1 or 2 staff assistance. During an interview, 5/3/23 at 6:05 PM, Staff B, CNA, reported she worked at the facility 2 months for 2/6 - 4/3/23 on the 2-10 PM shift. Staff B stated it's common sense to lower the bed whenever a resident lying in bed. If resident non-verbal and total care, the bed should be lowered after care provided. Staff B reported Resident #5 had a fall from her bed. Staff B reported she was aware a facility CNA trained a new CNA and didn't tell the new CNA she needed to place a mat on the floor and place a body pillow by the resident's side. During an interview 5/4/23 at 10:30 AM Staff J, CNA, reported a resident is a fall risk if the resident tried to climb out of bed or seemed really anxious. Staff J reported bed lowered to the ground after resident placed in bed, and a mat placed on the floor by the bed if care planned for a mat by the bed. Staff J reported resident # 5 had a fall recently when she fell out of bed. Staff J reported she wasn't working on the day the resident fell. But the resident would not be one to move around in bed on her own. During an interview 5/4/23 at 12:45 PM, Staff F, RN, reported a fall tool assessment filled out in the EHR to determine a resident's risk for falls and if the resident attempted to self transfer. Staff F reported fall interventions are individualized for residents.