**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident received adequate supervision to prevent incidents and accidents for 1 of 1 sampled resident (#230) reviewed for accidents. The deficient practice resulted in an actual harm situation for Resident # 230 that began on 10/31/2022 at 10:00 p.m., when Resident #230 was not provided 1:1 supervision on the 10:00 p.m. to 6:00 a.m. shift. Resident #230, who was on Fall Precautions, fell 4 times on the day shift on 10/31/2022, and was ordered 1:1 supervision on 10/31/2022 at 12:31 p.m. after the 3rd fall. The CNA who provided care to Resident #230 on the 10:00 p.m. to 6:00 a.m. shift on 10/31/2022, did not provide 1:1 supervision of Resident #230 as ordered, and Resident #230 was found at 11:45 p.m. on the floor in her room on her stomach. Resident #230 was transferred to the emergency room of a local hospital, and diagnosed with an Acute Compression Fracture of T12 and L2 vertebra, Contusions, and a Hematoma to her left eye. Findings: Review of the Facility's Policy titled Shift Report revealed the following in part . Policy: It is the policy of this facility to promote successful transfer of information between nursing staff at shift change in an effort to prevent adverse effects, medication errors and medical mishaps. Policy Explanation and Compliance Guidelines: 62. Nursing and CNA staff will report relevant information such as change in condition, incidents, etc. at the end of each shift to oncoming shift using a reporting form and/or verbally. Interview on 09/13/2023 at 2:19 p.m. with S2 DON revealed there was no 1:1 Supervision policy. Review of Resident #230's EHR revealed an admit date of 11/01/2021, and a discharge date of 11/06/2022. Resident #230 had the following diagnoses that included: Difficulty in Walking, not elsewhere classified; Alzheimer's disease; Unspecified Lack of Coordination; Unspecified Abnormalities of Gait and Mobility; Generalized Muscle Weakness; and Wasting & Atrophy, not elsewhere classified, unspecified site. Review of Resident #230's Quarterly MDS with an ARD of 09/30/2022 revealed a BIMS of 4 (indicating severe cognitive impairment). The MDS revealed Resident #230 was independent with bed mobility, transfers, walking in room, walking in corridor, locomotion on and off unit, dressing, eating, and toilet use. Resident #230 required supervision with personal hygiene and bathing. Resident #230's balance was not steady, but was able to stabilize without staff assistance. Resident #230 had no impairment to ROM to upper or lower extremities, and used a walker for mobility. Review of Resident #230's Care Plan with a start date of 11/01/2021, revealed in part .Resident #230 was at risk for falls r/t lack of coordination - actual fall x 5 on 10/31/2022. Review of Resident #230's Nursing Notes dated 10/31/2022 at 2:31 a.m., revealed Resident #230 tested positive for COVID 19 during facility outbreak testing, and was moved to a COVID isolation room. Review of an Incident Report dated 10/31/2022 for Resident #230 revealed the following in part . 10:26 a.m. - S7 LPN observed Resident #230 lean down and reach for a snack from the snack cart. Resident #230 then stumbled to floor sitting on butt. On assessment no injuries noted. Resident #230 recently tested positive for COVID with general weakness noted. 11:00 a.m. - CNA notified S7 LPN that Resident #230 continued with unsteadiness of gait. On observation, S7 LPN observed Resident #230 walking into doorway of room a. S7 LPN went to assist and observed Resident #230 stumble to floor sitting on right butt. On assessment, Resident #230 [NAME] without problems, and was assisted to w/c and into room. 12:40 p.m. - Staff observed Resident #230 ambulating from snack cart holding cup of water, with continued increased weakness. Resident #230 spilled water on floor, slipped and fell to floor, and began to stand without assistance. CNA assisted Resident #230 to w/c. 1:1 initiated. No injuries apparent. 1:16 p.m. - CNA reported Resident #230 stood up from w/c while sitting in room. CNA unable to reach Resident #230, and Resident #230 lost balance and slid to the floor, no injuries apparent. CNA assisted Resident #230 to bed after assessment complete. 1:1 continued. 11:45 p.m. - Called to room per S8 CNA. S6 LPN entered Resident #230's room, and observed her lying on her stomach on floor at foot of bed. Rolling walker in upright position at Resident #230's head. Resident #230 alert and verbal. Resident #230 c/o pain to left eyebrow and left side of neck. Resident #230 with marked increased confusion and weakness. Neuro checks WNL. Hematoma approximately 4 cm to left eyebrow. Hematoma approximately 7 cm along left jaw line. Bruising to left side of neck. Abrasion approximately 7 cm to right upper chest/clavicle. Resident #230 assessed. Neuro checks initiated. MD notified. Resident #230 out to ER via ambulance service at 12:15 a.m. on 11/01/2022. Review of Resident #230's undated Fall Time Line revealed the following: 1. Fall #1 - 10:25 a.m. - Happened during ambulation to isolation area, Resident #230 with weakness. Resident #230 was assisted up to and back to isolation room. Resident #230 noted ambulating up and down hallway with rolling walker. 2. Fall #2 - 11:00 a.m. - Resident #230 was ambulating back into room, stumbled and sat on floor. Resident #230 assessed, assisted up to w/c and propelled into isolation room and into bed. 3. Fall #3 - 12:40 p.m. - Resident #230 noted at Hall 1 snack cart, ambulating with cup of water, turned to walk back to her isolation room, she spilled water on the floor and then slipped in water. 1:1 initiated. 4. Fall #4 - Resident #230 1:1 in isolation room, Resident #230 attempted to stand up, 1:1 unable to reach her before she slid to the floor. Continue 1:1 CNA rounds at approximately 10:00 p.m. Resident #230 asleep in bed. 5. No 1:1 6. CNA rounds at 11:40 p.m., Resident #230 noted lying on her stomach at the foot of the bed. Review of Resident #230's 10/2022 Physician Orders included the following orders: 10/31/2022 - PT/OT/ST screen (per 10/31/2022 @ 10:26 a.m. Incident Report) Staff to assist Resident with getting snacks off of cart. 10/31/2022 - PT/OT/ST screen (per 10/31/2022 at 11:00 a.m. incident report). Frequent/Purposeful Staff Rounds. 10/31/2022 - 1:1 initiated (per 10/31/2022 at 12:40 p.m. incident report). PT/OT/ST screen. 10/31/2022 - Remind 1:1 to remain within arm's reach of resident. Review of Resident #230's Transfer/Referral Record dated 11/01/2022 at 12:08 a.m., revealed the resident was transferred to an ED from facility via ambulance. The reason for the transfer was documented as COVID positive, fall at 11:45 p.m. 10/31/2022, Hematoma left eyebrow, left jaw line, abrasion right clavicle/upper chest, marked increased confusion. Review of Resident #230's Hospital CT of Chest dated 11/01/2022, revealed the following in part .Impression: T-12 and L2 upper vertebral bodies with mild acute compression fracture deformities. Partially imaged left lower neck with findings concerning for hematoma, or other mass in the left sternocleidomastoid muscle. Telephone interview with S7 LPN was unsuccessful. Interview with HR on 09/13/2023 at 9:50 a.m. revealed S7 LPN no longer worked at the facility. Telephone interview with S6 LPN was attempted several times on 09/13/2023 by surveyor without success. Interview on 09/13/2023 at 10:32 a.m. with S8 CNA revealed she worked the 10:00 p.m. - 2:00 a.m. shift on October 31, 2022, and found Resident #230 on the floor in her room. S8 CNA stated she was assigned Hall W (hall Resident #230 resided on), and Hall X because 1 CNA worked 2 halls on the night shift. S8 CNA stated she started her shift on Hall X, and then went to Hall W after completion of Hall X. S8 CNA stated she received report from staff prior to starting work, but had not been told that Resident #230 had fallen 4 times earlier in the day, and was not told about Resident #230 being 1:1 supervision. S8 CNA stated she entered Resident #230's room when making rounds, and found Resident #230 on the floor on her stomach. Interview on 09/13/2023 at 11:28 a.m. with S2 DON revealed Resident #230 was ordered 1:1 supervision after falling several times on 10/31/2022. S2 DON confirmed Resident #230 was not on 1:1 supervision at the time of her fall on 10/31/2022 at 11:45 p.m. and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents' rights to be free from sexual abuse for 1 (Resident #3) of 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) sampled residents. The facility failed to protect Resident #3 from non-consensual, inappropriate sexual contact by Resident #1. This deficient practice resulted in an Actual Harm for Resident #3 that occurred on 02/15/2023, when Resident #3, a cognitively impaired resident, was sitting at the dining room table and Resident #1 was observed with his hand in Resident #3's blouse with her breast exposed. Resident #1 did not remove his hand until staff repeatedly told him to stop. Resident #1, (who had no prior history of inappropriate sexual behavior), was immediately removed from the area and immediately placed on 1:1 supervision, then on in-sight supervision. On 02/15/2023, an appointment was scheduled for Resident #3 to receive counseling as an intervention due to the sexual abuse on 02/15/2023. The facility implemented corrective actions which were completed prior to the State Agency's Investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of facility policy titled Abuse/Neglect Policy Statement revealed in part . it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Sexual Abuse is non-consensual sexual contact of any type with a resident. Resident #3 Review of Resident #3's clinical record revealed an admit date of 04/27/2022 with diagnoses that included in part .Cerebral Vascular Accident, Anxiety Disorder, Depressive Disorder and Multiple Sclerosis. Review of Resident #3's Quarterly MDS Assessment with an ARD of 03/01/2023 revealed a BIMS score of 9 (moderately cognitive impairment). Resident #3 required extensive assistance of 2 persons with toileting, bed mobility, transfers, and required to be fed by staff. Review of Resident #3's Comprehensive Plan of Care with a goal date of 05/31/2023 read as follows in part .Resident #3 was diagnosed with Anxiety Disorder on 04/27/2020. On 02/25/2023, Resident #3's plan of care was updated to include a problem of at risk for altered mood after Resident #3 was inappropriately touched by another resident. Approaches included: observe for mental status change and report to the Physician; Social Service to evaluate and visit resident quarterly; approach the resident warmly and positively. On 02/15/2023 an appointment for counseling was scheduled and staff are to monitor resident for changes in mood and allow resident to express self, an assure resident that she is safe. Review of a facility incident report documented by S2 DON revealed that on 02/15/2023 at 7:12 a.m., Resident #1 was observed by staff inappropriately touching Resident #3 without her consent. Both residents were in the dining room during meal service. As soon as the action was observed Resident #1 and Resident #3 were separated. Resident #1 was taken to his room and was placed on 1:1 supervision. Resident #3 was allowed to finish her meal in the dining room. The Medical Director, Family/RP and Police were contacted and a report was taken. Observation on 03/20/2023 at 10:29 a.m. revealed Resident #3 sitting up in her wheelchair in the dining room with her back turned to all residents at a table to be fed. Interview with Resident #3 on 03/20/2023 at that time revealed Resident #3's speech was slow with delayed thought process, a flat affect was noted to her facial expression. When asked how she was feeling, Resident #3 responded with jumbled wording. When asked yes or no questions Resident #3 responded with a yes or no nod of the head. Resident #3 responded with a yes nod when asked if she had been sexually inappropriately touched by Resident #1. When asked again if she had been sexually touched inappropriately by Resident #1, Resident #3 responded by shaking her head no. Resident #1 Review of Resident #1's medical record revealed an admission date of 08/26/2022, and diagnoses that included in part .Major Depressive Disorder, DM 2, and PVD. Resident #1's medical record revealed there was no history or warning signs of inappropriate sexual behavior. Review of Resident #1's Quarterly MDS with an ARD of 02/03/2023, revealed in part . BIMS Score of 9 (moderate cognitive impairment), and Functional Status that included in part . Transfers - limited one person physical assistance; Locomotion on and off the unit - independent with no physical assistance required; ROM impairment on one side for upper and lower extremities, and wheelchair use for mobility. Interview with Resident #1 on 03/20/2023 at 10:35 a.m. revealed he did remember the incident where he inappropriately touched Resident #3, but stated I'm cured, because they sent me out of here to a psych facility and they cured me. Resident #1 stated he should have never gone to that dining table where she was at. In a telephone interview with S7 LPN on 03/22/2023 at 10:34 a.m., she revealed she was the nurse responsible for lunch and dinner monitoring of the residents. S7 LPN revealed while in the dining room on 02/15/2023, S8 CNA alerted her that Resident #1 was being inappropriate with Resident #3. S7 LPN stated that she and S8 CNA immediately walked toward Resident #1, telling him to stop, but Resident #1 did not stop until they reached him and separated him from Resident #3. S7 LPN stated she stayed with Resident #3 while staff escorted Resident #1 to his room. S7 LPN revealed Resident #1 was not crying, but she could tell by her facial expressions she was upset. S7 LPN stated the staff tried to comfort Resident #3 and make sure she knew she was safe. In a telephone interview with S8 CNA on 03/22/2023 at 12:45 p.m., S8 CNA revealed she worked on 02/15/2023 when Resident #1 inappropriately touched Resident #3. S8 CNA revealed she was passing out trays in the dining room when she turned around from picking up a tray at the window and saw Resident #1 with his hand under Resident #3's blouse. S8 CNA stated she alerted S7 LPN as she (S8 CNA) was walking towards Resident #1 and Resident #3. S8 CNA stated Resident #1 would not respond to their verbal commands to stop, and she and S7 LPN had to back Resident #1 away (in his wheelchair) from Resident #3. S8 CNA stated they immediately separated them and S7 LPN told another CNA to take Resident #1 to his room. S8 CNA stated she and S7 LPN checked on Resident #3 to make sure she was okay. S8 CNA stated Resident #3 never showed any expression other that she closed her eyes when it occurred. S8 CNA stated Resident #1 was immediately placed 1:1. Interview with S2 DON on 03/20/203 at 10:45 a.m. revealed Resident #1 after returning from the behavioral hospital on [DATE], was placed on in line of sight supervision when in public. S2 DON revealed there had been no further issues with Resident #1 being inappropriate with another resident since his return. S2 DON revealed that they were in the process of decreasing Resident #1's supervision since he had not had any further issues after his behavioral hospital stay. S2 DON revealed that when Resident #1 was not in his room, it was the entire staff's responsibility to ensure Resident #1 was not inappropriate with any other resident. S2 DON stated Resident #1's floor nurse and CNA were responsible for documenting Resident #1's supervision. Interview with S4 CNA on 03/20/2023 at 11:10 a.m. revealed she documented in Resident #1's medical record multiple times a day her observations that Resident #1 was within line of sight. S4 CNA revealed she observed Resident #1 on 02/24/2023 attempting to go into another female resident's room, while the female resident was on the toilet. S4 CNA revealed she blocked his attempt and immediately told him to get down the hall. S4 CNA revealed she then reported it to the nurse. Interview with S5 LPN on 03/20/2023 at 11:20 a.m. revealed Resident #1 was her resident, and she was responsible for making sure he was in line of sight at all times, encourage him to stay in his room, and remind the CNAs to keep an eye on him. S5 LPN revealed she was responsible for documenting in Resident #1's medical record that he was observed being in line of sight when out of his room. Interview with S6 Restorative CNA on 03/20/2023 at 11:50 a.m. revealed she had received an in-service on abuse after the incident with Resident #1 and Resident #3 on 02/15/2023). S6 Restorative CNA revealed she was aware she was to monitor to ensure that Resident #1 did not go around other female residents. Interview with the Psych NP on 03/20/2023 at 11:57 a.m. revealed he was scheduled to see Resident #1 on 02/16/2023 about the incident that occurred on 02/15/2023. The Psych NP stated he evaluated Resident #1 and did not make any recommendations other than what the facility staff were already doing by having him 1:1 supervision. The Psych NP stated he was scheduled to see Resident #1 the following week after the incident when he came as scheduled. The Psych NP revealed Resident #1 was out of the facility at an appointment last week when he came to see him. Review of the Discharge Transition orders from the behavioral facility dated 03/07/2023 revealed medication changes had been made, and Resident #1 was in stable condition. There were no supervision orders noted on the Discharge orders. Review of the verbal written discharge orders dated 03/07/2023 by S3 ADON revealed a verbal order had been written for Resident #1 to remain in line of sight when in public after Resident #1's return to the facility from the behavioral hospital. Interview with S3 ADON on 03/20/2023 at 1:40 p.m. revealed some of the orders she transcribed were written on the hospital discharge sheet, but she had contacted the behavioral hospital and spoke with a staff person, who was not the Physician, and resumed all previous orders as directed by the staff person. S3 ADON revealed she should have not written the order to continue line of sight supervision when in public, because she had not received the order from the Physician. Interview with the Behavioral Hospital's Psychiatrist on 03/21/2023 at 11:13 a.m. revealed he was the Psychiatrist who treated Resident #1 during his hospital stay on 02/15/2023 - 03/07/2023. The Psychiatrist stated he had made some medication changes for Resident #1. The Psychiatrist stated upon Resident #1's discharge, Resident #1 was in stable condition and able to return to his home. The Psychiatrist was asked if he discharged Resident #1 back to the nursing home on 1:1 supervision or in line of sight supervision, and he stated absolutely not. If Resident #1 had required that much supervision he would have kept him at the hospital until he was more stable. The Psychiatrist stated Resident #1 did not require 1:1 supervision, or in line of sight supervision when he (Resident #1) was discharged back to the nursing facility. The facility implemented the following actions to correct the deficient practice: Resident #1 was immediately put on 1:1, in-services were done and staff were educated on abuse. Multiple attempts to admit Resident #1 to a behavioral hospital were unsuccessful due to the resident having a wound. A list of facilities were included. In-services initiated immediately after the incident on 02/15/2023 and continued until all staff were educated. Education was continued with the Attorney General's office on abuse presenting an in-service on 03/07/2023 on abuse. The facility will continue to educate/in-service all staff on abuse and neglect. The next in-service on abuse/neglect will be held in April. 2023. Training and retraining of all staff included: Objective: to ensure the safety of all resident are free from abuse. Initial training session was done 02/15/2023 at 12:00 noon and lasted approximately 30 minutes. Other staff were in-serviced individually, per department head nurse/administration/DON as needed. Abuse policy and procedure were reviewed, no changes were made at the time of the review. Resident #1 was sent to a behavioral hospital on [DATE] and returned on 03/07/2023, with new order for Risperidone 0.5mg p.o. QHS. No other orders for were made for 1:1 or in line of sight from behavioral hospital at discharge. No inappropriate behavior has been noted from Resident #1 since his return from the behavioral hospital. QAA Evaluation of abuse, neglect, exploitation or misappropriation reports: For all reports of abuse, neglect, exploitation or misappropriation, the QAA committee will complete the following: Was a thorough investigation conducted? Yes. All interviewable residents were interviewed to see if they had seen or had any appropriate behaviors done to them. Body assessments were performed on resident that were not cognitively aware, for signs and symptoms of abuse. Were other resident's protected? How? Yes. Resident #1 was placed 1:1 immediately after the incident on 02/15/2023 and monitoring was continued as ordered. All residents were immediately protect after this incident. Was an analysis conducted as to why the situation occurred? Explain: Yes, this was an isolated incident for Resident #1, who had no known history or warning signs of inappropriate behavior. Risk factor that contributed to the abuse: No known history of inappropriate sexual behavior had been exhibited by Resident #1 since his admission on [DATE]. Isolated incident - addressed immediately Overall Goal: no inappropriate sexual behavior/abuse Identified Factor/Issue: Male resident inappropriately touched a female resident's breast Project Team Members: All Staff Plan: types of monitoring done - in-serviced staff on abuse policy, routine monitoring inappropriate behavior. Resident #1 was placed 1:1, then line of sight, daily smart chart review (supervision) of monitoring per DON/ADON, daily hall rounds per department head nurse, monitoring of daily rounds/round sheets per ADM/AIT. Plan for Monitoring/Completion Date: Monitor for any inappropriate behaviors and ensure that staff were following the plan of care on daily rounds. If any concerns, implement new interventions. Monitoring was initiated immediately after the incident on (02/15/2023) and continued until D/C order was received from the MD. No issues were found in the monitoring process. Will continue to re-educate staff on abuse. Line of sight was discontinued on 03/20/2023 related to clarification received from MD that the line of sight should not have continued upon re-admit to the NH on 03/07/2023. Today (03/21/2023), we began Q shift monitoring by LPN and Q2H monitoring per CNA and any sign or symptoms of inappropriate behavior, the DON/ADON will daily check smart chart review (supervision) for monitoring. QA team will meet in 2 weeks to review/change current plan. The Behavioral Hospital representative stated if line of sight or 1:1 was recommended, it would have been listed on the transition record. There were none of these recommendations made upon discharge. The line of sight order from 03/07/2023 was transcribed in error, clarification with the physician supports this was not ordered or needed after behavioral hospital stay. Expected Behaviors: No more sexually inappropriate behaviors have been displayed from Resident #1. QA committee will meet in April of 2023 to review/evaluate the plan of action related to this incident. Facility correction date 03/07/2023.