**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number MI00124713. Based on observation, interview and record review, the facility failed to prevent sexual abuse from occurring to Resident #3 when Resident #9 touched the breast area of Resident #3 for one resident (Resident #3) of four residents reviewed for abuse, resulting in sexual abuse occurring to Resident #3 with psychosocial distress using the reasonable person concept. Findings include: Resident #3: A review of Resident #3's medical record revealed the Resident was admitted into the facility on 4/10/2020 with diagnoses that included repeated falls, femur fracture, heart failure, developmental delay and disorders of psychological development. The Resident had a guardian and co-guardian responsible for health care decisions. Review of the Minimum Data Set (MDS) assessment, dated 1/27/23, revealed the Resident had a Brief Interview for Mental Status (BIMS) of 6/15 revealed severely impaired cognition and was independent with no assistance or set up help to walk in corridor and locomotion on unit and needed extensive assistance with dressing, toilet use and personal hygiene. On 3/16/23 at 10:31 AM, Resident #3 was observed to be dressed and sitting on her bed that was bare without linen on it. The Resident was able to answer simple questions but unable to hold a meaningful conversation. The Resident indicated she felt safe in the facility and that no one had hurt her but that she had hurt her hand and indicated her right hand. Resident #9: A review of Resident #9's medical record revealed the Resident was admitted into the facility on [DATE] with diagnoses that included sepsis, depression, traumatic brain injury, muscle weakness, developmental disorder of scholastic skills (learning disability) and encephalopathy. The Resident had a legal guardian. Review of the MDS, date of assessment 5/7/21 revealed a BIMS score of 15 which indicated the Resident was cognitively intact. A review of the incident report for Resident #9 revealed the following: -Dated of incident 10/22/21 at 11:10 AM. -Description of incident: Resident was in the hallway outside of his room [ROOM NUMBER] and was observed rubbing resident (#3) breasts with both hands rubbing in a up and down motion. -Witnesses: Staff name: (CNA -) Statement: I was transferring the resident in room [ROOM NUMBER]-1 into her wheelchair when I heard (Resident #3) laugh and (Resident #9) saying something in the hallway outside of (Resident #9) room, room [ROOM NUMBER]. I opened the door of 237 to see what was going on. I was (saw) (Resident #9) rubbing (Resident #3) breasts. He was using both hands, one on each breast, rubbing up and down. I immediately stopped it by saying (Resident #9's name) get your hands off of her now. You don't touch her like that. the Residents were separated and the CNA reported the incident to the charge nurse and supervising nurse. The Director of Nursing (DON) and Social Worker - were notified. The Resident was interviewed and when asked if he inappropriately touched resident (#3). He states he was hugging her and was yelling that the CNA is a fucking bitch. Also states she is going to get kicked off this floor . Writer educated him that touching other residents is inappropriate and that he cannot do this. Writer then went in and interviewed resident (#3) asked if he touched her and she stated yes. Writer asked her where he touched her and she placed both hands on each of her breasts and motioned up and down. -Notifications: .guardian notified (name) . stated yes he does have a guardian but he is fully aware of what he is doing. -Actions: continue to observe. Resident placed on 15 minute checks and 1:1 supervision when out of his room. A review of Psychosocial Follow Up Assessment after suspected abuse/neglect for Resident #3 for the incident on 10/22/21 revealed the following: -Dated 10/22/21, What does the resident remember of the occurrence? This worker spoke to (Resident #3) about what happened with (Resident #9). This worker stated, Was (resident #9) trying to give you a hug. Res stated, Yes, while laughing and smiling. This worker asked what else he had done and (Resident#3) touched her breasts, in which res had a more serious look on her face. This worker asked (Resident #3) what the male resident did when he had touched them and she held out her hand and was rubbing the top of her hand. Res then touched her breast. This worker asked if she wanted (Resident #9) to touch her breasts like that and she shook her head no and stated, No. -Dated 10/26/21, What does the resident remember of the occurrence? This worker followed up with (Resident #3) this morning regarding the situation that occurred on Friday. This worker asked (Resident #3) if she remembered what the male resident, (Resident #9), had done on Friday. Res touched her breasts and began rubbing. This worker asked if she liked (Resident #9) and res stated, No. Does the Resident feel safe in his/her current environment? Res states she does feel safe and is happy he is no longer by her and bug me. A review of Resident #9's Behavior Record documentation included but not limited to the following: -Dated 8/24/21 at 8:26 PM, resident is getting very upset around dinner time about how he is not the first one to eat, rolls self to room and yells at staff because of it. Tonight he was extremely rude and when multiple staffed tried to talk to him about it and explain that we are short staffed and all are trying our best and would like him to try to be patient he got more upset. Resident stated no one was more important then him. He didn't care if people needed help eating and that if we don't get it together he was going to fire all of us or complain until we are fired. He also said that if residents were not able to feed themselves they should not be allowed in the dining room and they deserve to starve. CNA told him that was not kind and if he would like to start eating in his room he may. -Dated 9/3/21 at 12:43 PM, Resident refused lunch, complaining he is going to turn the kitchen in because they are taking to long to serve everyone. Telling staff to get rid of other residents so he can eat his lunch faster. -Dated 9/3/21 at 9:18 PM, Resident very rude with staff again. Whishing to fire activities, kitchen and nurse and aide. Wondering if someone from socials will talk to him? He is getting to be like this a lot more lately and it is getting out of hand. -Dated 9/7/21 at 9:28 PM, Resident was following (female Resident's name) around most of the afternoon. He would wait outside of her bedroom door and talk to her while she was in her bedroom. Resident was also making inappropriate sexual comments during care tonight. -Dated 9/10/21 at 9:06 PM, (Resident #9) was getting really close to (female Resident's name from 9/7/21) and when aide went down and brought (female Resident's name) back to her room (Resident #9) kept saying that that aide needs to go because she's nosey and always sticking her nose where it does not belong . -Dated 9/10/21 at 9:29 PM, .After dinner I was coming around to the circle hallway up to the dining room hallway and I saw (female Resident's name from 9/7/21) down at the activity door which was locked but she was trying to get in and I saw (Resident #9) following her to the door. When I got down to both of the residents I asked (female Resident) if she was tired and would like to take a walk with me to her room, but she was upset because she wanted to have a cigarette. I told her that none of us smoke and (Resident #9) then told myself that he was going to start and that everyone here is nosey, and were all going to be fired. I eventually got (female resident) away from the situation and walked her down to her room where she remained for a brief period of time. After that for about an hour or so resident was complaining about myself in the hallway and telling everyone that I was nosey but would not speak to me directly. -Dated 9/12/21 at 9:05 PM, resident following a confused resident (233) around and telling her how to use the elevator. Resident also telling her not to listen to any of the aides and nurses and just get on the elevator. When resident in (233) would say she was tired resident (#9) would tell her to sit on his lap or try to lead her to his room and lay in his bed. -Dated 9/14/21 at 9:10 PM, resident frequently making more and more sexually inappropriate comments about staff and other residents in front of them both res and staff, and about them to other people. Effect: Disrupted Living Environment. Interventions: notified nurse. Other asked res to stop multiple times by multiple people and told that it was not appropriate or allowed. Outcome: unchanged, worsened. -Dated 9/15/21 at 1:49 PM, Grabbing at other female residents and lowering them down onto his lap. -Dated 9/26/21 at 9:18 PM, right at the beginning of dinner I had to leave the dining room to assist another resident on my hallway, when I was leaving circle to go back down to the dining room I noticed (Resident #9) on his way to his bedroom visibly upset. When I got down to the dining room no one knew what had happened with him so I went back down to his room to see what was going on and when I entered his room he had broken one of the towel rods off of the wall in his bathroom and was going to head back down to the dining room to whoop some ass I told he was not going to be able to do so and that if he wanted to he could eat in his room and that I would personally bring him his dinner. After talking to him for a moment to get him to agree with this, he had told me that the reason that he was upset was because the hospitality aide had given him soup for his appetizer rather than the salad that he had asked for. When I brought him more food back to his room, he then blew up on me because his cheeseburger had been cut into pieces as per his diet and meal ticket states . Eventually myself and another CNA asked our nurse to intervene. -Dated 10/9/21 at 11:00 PM, tonight during dinner the dinning room aide gave him the drinks he usually orders as he was starting to verbalize that he was upset that he hadn't gotten a drink yet. We had not had time to pass menus at this point but we were working on it as other behaviors where happening and peoples alarms were going off. He was upset that he didn't get a milk like he had wanted and had gotten juices even though I heard him say and the aide heard him say he wanted a juice .(the Resident had left the dining area to go back to his room, became irate when he did not get an extra entrée, was told he would have to wait until they were done serving everyone else. The kitchen staff ran out of the second helping entrée that the Resident wanted, was offered alternatives which he refused and his anger escalated) . about 5 minutes after this he rang his bell and I got another aide to go in with me as he was getting increasingly agitated and I did not feel safe answering this alone . he went off, yelling about how he was going to rip the kitchen apart and take what he wanted. He was also yelling fuck those mother fuckers he then started rolling out of his room and we yelled for help as he started attacking the other aide in his doorway, he was hitting grabbing and ramming his wheelchair into her screaming he was done and it was time to fuck these people up and he was done putting up with it. I yelled for help and another aide came running down the hall and she started to get attacked as well as she was standing in front of another resident to protect them from (Resident #9). I ran and yelled to the nurses station that we needed help now and closed the doors to the dinning room and other hallway as he was very upset and violent at this point so no one else would get hurt. He busted through the doors and was charging to the other set of double doors that is an entrance to the dinning room by the stairwell still screaming he was going to get them and it was over and he was screaming to be let in to get them. It took 5 or 6 nurses to pull him off the door and get him back to try to calm him down and he was hitting and grabbing and swearing and rolling into people trying to knock them over so he could get into the dinning room to hurt people. -Dated 10/22/21 at 1:49 PM, Resident was in the hallway with another resident (Resident #3). I observed him using both of his hands to rub her breasts. I immediately stopped him, separated them and told my charge nurse and nurse supervisor. On 3/16/23 at 11:17 AM, an interview was conducted with Social Worker (SW) - regarding Resident #9 and the sexual abuse incident with Resident #3. The SW reported that Resident #3 walks around on the unit, unassisted. The SW reported that Resident #9 had gone up to her and had both hands touching her breast, the CNA saw it and separated the Residents immediately and reported the incident immediately. The SW reported she had follow-up visits with Resident #3 and indicated she does not recall the incident but had remembered it after it occurred. The SW reported doing follow up visits with the Resident and had talked to the Resident almost on a daily basis. Resident #9's Behavior Record documentation was reviewed with the SW. The Social Worker explained that many of the Resident's behaviors stemmed around meals, food and his insistence on being given his meals first. The SW reported that after his outburst he was apologetic and would say it would not happen again. The SW reviewed the cyclic pattern of behaviors then being apologetic/remorseful afterwards was ongoing and she would meet with the Resident to discuss his behaviors. The SW was questioned about Resident #9's sexual verbal comments to staff and residents, pulling residents onto his lap, and cornering a female resident. The SW indicated that towards the end he had a couple incidents with female residents. The SW indicated Resident #9 had cornered a female resident in the hallway and the female resident was on 15-minute checks. When asked if Resident #9 was placed on 1 to 1 staffing or 15-minute checks, the SW stated, He was not made one to one or 15-minute checks until after the incident with (Resident #3). When asked why, the SW reviewed the Residents chart and stated, I can't find the answer to that. It's not charted why we didn't. I don't know why we didn't, if it was brought up in IDT (interdisciplinary team) but just not charted. The SW reported they had other Residents on 15-minute checks and they didn't want too many 15 minute checks due to being too much for the CNAs work load. The SW indicated the Resident had been followed by psych services, had gene site testing done and medication changes and adjustments and that staff knew that he was in need to be left alone to calm down. On 3/16/23 at 2:38 PM, an interview was conducted with the Administrator (NHA) regarding the concerns of sexual abuse to Resident #3 by Resident #9 and recurrent behaviors of Resident #9 that included behaviors towards other female residents prior to the incident on 10/22/21 and lack of interventions to ensure abuse does not occur. The NHA reported that the Resident was moved to the rehab section of the facility after the incident with Resident #3 and that there were less Residents on that unit while another placement was investigated for a more suitable place for Resident #9. When asked about the subpoenas for court, the NHA reported that they had called the police after the incident and that the court case was still in process. Review of the facility policy titled, Abuse, reviewed/revised 10/25/22, revealed, .Our residents have the right to be free from instances of abuse, irrespective of any mental or physical condition; be caused any physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse . 6 . If alleged perpetrator is a resident, he/she will be placed on one on one care until reviewed by the interdisciplinary team .

This Citation pertains to Intake Number MI00132818. Past Non-Compliance (PNC) was presented by the facility during investigation of the allegation and was accepted by the survey team upon exit from the facility for this citation. Following discussion with the State Manager, Past Non-Compliance was accepted with a Compliance Date of 12/09/2022. Based on observation, interview and record review, the facility failed to report a fall and ensure that fall procedures and protocols were followed after a fall for one resident (Resident #4) of five residents reviewed for falls, resulting in Resident #4 sustaining a fall with a delay in reporting and the identification of an injury timely after the fall, sustaining bruising to bilateral upper extremities and a fracture of the femoral head of the femur bone, pain, a decline in condition, ability and overall health status. Findings include: Resident #4: A review of Resident #4's medical record revealed an admission into the facility on 7/7/18 with diagnoses that included altered mental status, Alzheimer's disease, metabolic encephalopathy, atrial fibrillation, osteoporosis, malnutrition, heart disease, muscle weakness, and stroke. A review of the Facility Reported Incident for Resident #4 revealed the following: -Incident Summary: On 11/6/2022 at approximately 12:30 am, resident (#4) had a fall while ambulating to the bathroom with CENA (Certified Nursing Assistant) (S). It was determined on 11/7/2022, that CENA (S) failed to inform any other personnel at the facility that the fall occurred. This CENA also assisted the resident from the floor to her chair without assistance of other staff or the use of a mechanical lift. It appears that in the course of receiving this assistance manually by the CENA'S that (Resident #4) sustained bilateral bruising to her arms. (Resident #4)denies psychosocial distress and does not complain of pain in the bruised arm areas . CENA (S) has been suspended from employment at the facility while the investigation takes place. -Investigation Summary/Actions Taken: On Monday, November 7, 2022 at 6 pm facility nursing manager (name) became aware that resident (#4) had fallen while being assisted to the bathroom by CENA (S) on Sunday November 6th at approximately 12:00 am. CENA (S) admitted at that time to not following facility procedures by not reporting the fall to other facility personnel and by manually assisting the resident back to her chair by herself rather than seeking help and using a mechanical lift. This action by (CENA S) appears to have resulted in bruising to (Resident #4's) bilateral upper extremities . A BIMS (Brief Interview of Mental Status) was performed on resident (#4) at approximately 6:30 PM November 7th with a resulting score of 0/15 indicating severe cognitive deficits which is consistent with prior BIMS. -Interview with CENA (S): .CENA (S) stated that approximately 11:30 pm-12:00 am on November 5th-November 6th, (CENA S) was walking resident (#4) to the bathroom with the appropriate care planned devices and techniques when (Resident #4) fell to the floor. (CENA S) reported that she used the gait belt in her attempt to assist the resident to a standing position from the floor and she also used her arms under the resident's arm pits to help her to a standing position . By the morning of November 6, 2022, Nurse (name) [who was assigned to (Resident #4)] observed bruising to (Resident #4's) left hand and left leg pain and impaired ability to bear weight . an x-ray was ordered to be performed the following day per the physician's order . On November 7, 2022, the X-ray of the left leg was performed as ordered by the physician on November 6, 2022. The results were obtained at approximately 4 pm on November 7, 2022 as an impact fracture of the left femoral head . Upon further investigation it was determined that the fracture occurred in conjunction with the fall that was not previously reported . -Conclusion: .However, after the fall occurred, CENA (S) did not report the fall to anyone and proceeded to assist the resident back into her chair by herself. This technique was in violation of the facility policy and procedures and appears to have resulted in bilateral bruising to the resident's upper extremities . A review of Resident #4's progress notes in the medical record revealed the following: -Dated 11/6/22 at 10:44 AM, Purpose for Note: 7:20 am new or sudden onset/change in condition: C/O (complaints of) left leg pain initially then both legs. Misc. (miscellaneous) Note: At above time, CNA reported resident was having a hard time transferring and not standing well on her feet due to pain. Sara lift was attempted but resident screaming and yelling get that thing off me: This nurse and CNA did 2 person with resident into wheelchair, which she tolerated ok . Skin Status: New Skin Impairment: Abrasion/Bruise: Light purple bruising present to left hand slightly raised in the center, bruising to left hand middle finger, and new scattered bruises to right forearm, new from yesterday. -Dated 11/6/22 at 11:01 AM, Purpose for Note: 9:40 am new or sudden onset/change in condition: fatigue, pain, weakness . Pain: both legs, left more than right . This nurse and CNA attempted to transfer resident onto toilet at time noted above. Resident was able to stand, but had significant pain and moaning out, unable to safely pivot transfer . -Dated 11/6/22 at 1:27 PM, Physician/Consult Visit: 11/6/2022 spoke to/with resident examined resident reviewed physician orders. Concern Notes: Resident is not wanting to bear any weight to her left leg. Upon assessment, it appears that the left upper thigh is causing discomfort. When the resident coughs, she grabs at her left upper thigh and yells that it hurts. No recent trauma reported. No physical observation of trauma to the leg noted . new orders received and noted, 11/6/2022 chest x-ray 1 view, Left femur 2 view. Ok for Mobil-X to do at facility. -Dated 11/6/22 at 6:37 PM, Purpose for Note: Resident sitting in recliner, leaning to Rt side, per her usual posture. She was very sleepy. Son, (name) and D-I-L (daughter in law), were in room. They had several questions about the bruising on bilat forearms & especially on Lt hand & Lt posterior forearm. This CN (Charge Nurse) apologized that I couldn't answer where the bruising came from. I did reiterate to family that she did not have them yesterday . She did say that her pain was on her Lt posterior arm when this CN ask her. She did not c/o pelvis or Lt leg pain to this time . -Dated 11/6/22 at 11:13 PM, .Musculoskeletal Status: Musculoskeletal complaint: resident crying out in pain and grabbing left medial thigh with any movement of the extremity. There is no rotation or obvious deformity of the extremity, pedal pulse +2, warm and normal skin tone, no bruising or other indication of injury. Precautions: Will have resident remain in bed pending results of mobile X-ray of left femur [not yet completed]. Reported from previous shift that resident did not tolerate pivot or stand up lift . -Dated 11/7/22 at 9:23 AM, .Resident continues to show declines in her health and functional status. Continues to have increased incontinence both bowel and bladder, weight loss, increased behaviors as well as functional declines in her mobility ADL's (activities of daily living) . Over the weekend noted to be placed on bed rest until X-rays are performed . -Dated 11/7/22 at 2:28 PM, (X-ray company name) arrived at (facility) to complete x-rays on resident. -Dated 11/7/22 at 7:53 PM, .X-ray shows Acute Impacted femoral neck fracture to left hip . family do not want resident to go to hospital. They would like her to be treated her (here) for the pain . -Dated 11/8/22 at 1:31 PM, .left leg drawn up with knee bent this early am. Color warm and pink. Pedal pulse +1, Bruising continues to left hand, fingers and bilateral forearms, left tri-cep area . -Dated 11/8/22 at 9:49 PM, . Skin Status: Bruising noted to Lt hand, Lt forearm, Lt upper arm, & Lt inner buttock. Bruising also on Rt upper posterior arm, several small bruises on Rt forearm, & Pt posterior calf. Resident having severe pain when moved with guarding Lt leg. On 3/8/23 at 10:05 AM, an interview was conducted with the Administrator (NHA) regarding the Facility Reported Incidents reported to the State Agency. The NHA indicated that Past Non-Compliance was completed for Resident #4 with the incident of the fall not reported by the CNA (Certified Nursing Assistant) S. On 3/16/23 at 2:15 PM, an observation was made of Resident #4 dressed and in bed. The Resident was sleeping and did not arouse when her name was verbalized. The Resident appeared to be resting quietly. A wheelchair was in the room and had a non-slip pad on the seat. The Resident had a call light within reach. On 3/16/23 at 2:38 PM, an interview was conducted with the Director of Nursing (DON) and the NHA that included a review of Resident #4's fall that was not reported and the Past Non-Compliance (PNC) that was completed. The DON and NHA was informed that the PNC had been reviewed with the State Agency Manager and accepted. The DON and NHA were informed that the other Residents that were reviewed for falls had been reported and no other concerns were found. The DON and NHA were informed that staff interviews indicated that staff were educated on the PNC and were aware of facility policies. The NHA and DON were questioned about the follow up on falls and audits completed and the ongoing oversight from the Quality Assurance Committee. The NHA reported CNA S had been suspended during the investigation and employment had been terminated. The NHA had presented a past non-compliance request regarding Resident #4's fall that had not been reported timely and presented the following corrective action plan to attain and maintain compliance with F-689. -Element 1: Resident #4 was immediately assessed upon notification of the policy violation. -Element 2: The facility completed the following evaluations for all facility residents: A complete review of every resident's skin was conducted by nursing management team members including skin assessments on every resident's skin in the facility; Pain assessments were conducted on every resident in the facility; Psychosocial assessments of each resident in the same unit were conducted by the social worker; Facility nursing managers conducted a 6-month look-back review of all facility incident reports and a 2 month look back report of all charting. -Element 3: The facility immediately educated every employee in the facility on the proper policy and procedures for reporting a fall, injury, abuse and injury of unknown origin; All staff mandatory training on Abuse, Neglect, Misappropriation and Injuries of Unknown Origin scheduled for December 6 and 8, 2022. -Element 4: The facility DON or her designee will conduct audits on 10 charts weekly x 12 weeks to evaluate compliance with proper fall/incident reporting; The facility DON or her designee will conduct audits of 10 employees weekly x 12 weeks to evaluate understanding of the proper procedures for fall/incident reporting including injuries of unknown origin, abuse and neglect; Both audits will become part of the QAPI team reporting plan. -Date of completion of the Plan of Correction: 12/09/2022. The State Surveyor verified the documentation provided by the facility and conducted interviews with facility staff. During the interviews with facility staff, staff stated that they had been educated on the facility policy for falls and abuse, that included reporting of falls and were knowledgeable about the facility policies.