**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff and Nurse Practitioner interviews, the facility failed to protect residents' right to be free from sexual abuse (Resident #2) and intentional inappropriate touching (Resident #6) perpetrated by Resident #1. In the evening of 11/26/23 the facility was made aware Resident #1 entered another resident's room (Resident #6) uninvited and Resident #6 reported to Nurse #1 that a strange man (identified as Resident #1) woke her up and was holding her hand, telling her he was going to care for her and kissed her on the cheek. Resident #6 was upset and scared and was not sure what Resident #1 was doing in the room and told him he did not belong in her room. Resident #6 required Ativan (a medication to treat anxiety) 4 days later because she was still upset. On 11/27/23, the day following the incident with Resident #1 and Resident #6, Resident #1 was found by Nurse Aide #1 in Resident #2's room sitting at his bedside while Resident #2 lay in bed. Resident #1 had his hand down Resident #2's brief and was manually stimulating (moving hand in an up and down motion) Resident #2's penis. Due to the inappropriate act initiated by Resident #1 toward Resident #2, a reasonable person would have experienced intimidation and fear. This was for 2 of 3 residents reviewed for abuse. Immediate Jeopardy began on 11/27/23 at 4:15 PM when Resident #1 was found by Nurse Aide #1 in Resident #2's room sitting at his bedside while Resident #2 was lying in bed. Resident #1 had his hand down Resident #2's brief and was manually stimulating (moving hand in an up and down motion) Resident #2's penis. Immediate Jeopardy was removed on 12/08/23 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level D isolated with potential for more than minimal harm to correct the deficient practice and to ensure that the education and monitoring systems put in place to remove the Immediate Jeopardy were effective. Findings included: 1a. Resident #1 was admitted to the facility on [DATE]. Diagnoses included pervasive developmental disorder (delay in development of multiple basic functions including socialization and communication), dysarthria (speech disorder), and cognitive communication deficit. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and demonstrated no behaviors. He was independent with bed mobility, transfers, walking in his room and corridor and with all activities of daily living ADLs. He had no impairments and did not use a mobility device. There was no care plan for behaviors for Resident #1 and there was no documentation to support Resident #1 had any prior behaviors. Resident #6 was admitted to the facility on [DATE]. Diagnoses included, in part, anxiety, age related physical debility, tremors, difficulty in walking, and depression. The MDS admission assessment dated [DATE] revealed Resident #6 was cognitively intact and required extensive assistance with two person physical assistance with bed mobility and transfers. She had impairment to both sides of lower extremities and used a wheelchair. A nursing progress note written on 11/26/23 at 10:47 PM by Nurse #1 revealed Nurse #1 answered the phone around 7:00 PM and the caller identified herself as the responsible party for Resident #6, stating that the resident had called her and reported a strange man in her room. Went to resident's room and a male resident was sitting in a chair beside her bed. Informed male resident that he was in the wrong room and assisted him back to his room. Reported incident to the nurse and the nurse aide on the 400 hall about the male resident being in the room of Resident #6 and that the nurse should inform the Director of Nursing immediately of incident and to notify the responsible party that the male resident had been removed from room. A nursing progress note written on 11/26/23 at 11:26 PM by Nurse #3 revealed at 7:00 PM was told by a Nurse #1 that Resident #1 was sitting in Resident #6's room. Was also told that Resident #6 was upset and the responsible party called to report the incident. This nurse went to speak with Resident #6. Upon entering the room, the resident was tearful and speaking with her responsible party on a cell phone. Resident #6 stated, A man sat on the side of my bed and told me he loved me and said he will take care of me. He kissed me on the cheek. Resident #6 stated she was scared and made it clear that his advances were unwelcome so she pushed the call button and called her responsible party and the responsible party contacted the facility. A nursing progress note written by Nurse #3 on 11/27/23 at 3:04 AM revealed at 8:00 PM, Resident #6's responsible party came to the facility. Discussed incident with Resident #6 and her responsible party. Resident #6 was aware that she could move to another room. This nurse would be included in all care for this shift and provided Resident #6 with nurse's personal cell phone number. A Social Service Note written by the Social Worker on 11/27/23 at 1:21 PM revealed he met with Resident #6 in her room and discussed a room change. Resident #6 stated she did not wish to move rooms at this time. A physician's progress note written by the Nurse Practitioner on 11/27/23 at 6:00 PM revealed Resident #6 was requesting Ativan (a medication to relieve anxiety) to help with her anxiety caused by the man coming into her room. A nursing progress note written on 11/27/23 at 6:22 PM revealed Nurse #2 notified responsible party and left message on voicemail to make her aware Resident #6 had a new order for Ativan 0.5 milligrams every 8 hours as needed for anxiety for the next 14 days. Review of Resident #6's physician orders revealed there were no orders for any antianxiety medications prior to 11/27/23. A review of the medication administration record revealed Resident #6 received the ordered Ativan one time on 11/30/23. An interview was conducted with Nurse #1 on 12/07/23 at 11:15 AM via phone. Nurse #1 stated she responded to a phone call that the responsible party of Resident #6 put into the facility. She stated the responsible party reported to her that some strange man was in Resident #6's room. Nurse #1 stated after she spoke with the responsible party, she went to Resident #6's room and she saw Resident #1 sitting in a chair at the bedside talking with Resident #6. Nurse #1 reported she asked Resident #1 what he was doing in the room and he had replied that Resident #6 told him to get out and that was not his room. Nurse #1 stated she then took Resident #1 to his room. Nurse #1 stated Resident #6 appeared to be upset, but she was not crying. Nurse #1 stated Resident #1 was normally confused. She stated she reported to the Medication Aide and Nurse #3 on the hall what had happened to make sure Nurse #3 followed up with the responsible party and the Director of Nursing. An interview was conducted with Medication Aide (MA) #1 via phone on 12/06/23 at 4:22 PM. MA #1 reported she was assigned to the hall Resident #1 and Resident #6 resided on the night of 11/26/23 and she arrived on her hall at 7:00 PM. When she first arrived on the hall she noticed Resident #1 sitting across the hall from Resident #6 in Resident #'2's room. She stated she did not think much about him visiting with Resident #2 and when she observed them they were just talking. MA #1 stated after about 5 minutes or so, she noticed Resident #6's call light go off and saw Nurse #1 go into Resident #6's room and saw her bring Resident #1 out of Resident #6's room. MA #1 stated she went into the room to see Resident #6 and the resident shared with her that a strange man had come into her room and was holding her hand and telling her he loved her and he was going to take care of her and he kissed her on the cheek. MA #1 stated Resident #6 stated she was scared. MA #1 stated Resident #1 remained in his bed in his room for the remainder of the night. MA #1 stated she had never seen Resident #1 go into Resident #2's room or any other room until 11/26/23. An interview was conducted with Nurse #3 via phone on 12/06/23 at 2:38 PM. Nurse #3 reported Nurse #1 told him she received a call from the responsible party of Resident #6 with concerns that a strange man was in her room. Nurse #3 stated Nurse #1 went into Resident #6's room at the time of the phone call to investigate and had Resident #1 leave the room. Nurse #3 went and spoke with Resident #6 and she stated she was sleeping and she woke up to see this strange man who she did not know and she was upset and scared. Nurse #3 stated she said her responsible party was on the way to the facility. Nurse #3 stated he had asked Resident #6 if she wanted to move to a different hall but she said she was okay and she declined to move. Nurse #3 stated he had explained to Resident #6 that Resident #1 was confused and once he had explained that to her, she did not believe he was trying to hurt her or anything. Nurse #3 stated Resident #6 expressed she did not want him to come into her room again and he made sure to follow up with her through the remainder of the shift to be sure she felt safe. Nurse #3 stated he called the DON and reported what happened between Resident #1 and Resident #6. The DON instructed him to speak with both families regarding the incident and he (DON) would move the resident in the morning. Nurse #3 reported Resident #6 stated she was fine knowing that Resident #1 was not going to be moved until the next morning. Nurse #3 reported he checked on Resident #1 through the night and he seemed to have his normal baseline confusion and he was not presenting with any signs and symptoms of a urinary tract infection (UTI). Nurse #3 reported he spoke with Resident #1 after the incident and Resident #1 had no recollection at all of what happened. Nurse #3 stated he told him to say in his room and stay out of residents' rooms. He was very agreeable and he seemed very innocent. He added, shortly after the incident, Resident #1 went to bed and remained in his bed through the remainder of the night. Nurse #3 stated he had never known Resident #1 to wander into other resident's rooms. Nurse #3 reported he reviewed the nursing notes a few days later and saw that he had been sent to the hospital for a psychiatric evaluation and it was discovered in the emergency room he had UTI. Nurse #3 reported it made a little more sense that he would have this very out of character behavior if he had a UTI. An interview was conducted with Resident #6 on 12/06/23 at 2:45 PM. Resident #6 reported a strange man came into her room while she was sleeping on 11/26/23. She stated she had never seen him before and he woke her up when he sat on the bed and was holding her hand. He began to tell her he loved her and he was going to take care of her and she told him he did not belong in this room and needed to leave. She stated he remained in the room and continued to say he would take care of her and he kissed her on the cheek. Resident #6 stated she was scared and did not know what this man was going to do to her. She continued to tell him he had to leave. She stated he moved to the other side of the bed and sat on a chair beside the bed. Shortly after he moved, a nurse came in and she took him out of the room. She stated she called her responsible party because she as scared. She added, the staff asked her if she wanted to move to another room, but she declined. She stated she just did not want him to come back in her room again. She stated Nurse #3 checked on her frequently throughout the night and she felt safe. A follow up interview was conducted with Resident #6 on 12/07/23 at 10:35 AM. Resident #6 revealed she was told Resident #1 would be moved in the morning on 11/27/23 and she was glad to hear that he would be getting moved and that that made her feel safer. An interview with the Director of Nursing on 12/06/23 at 3:43 PM revealed he was made aware of Resident #1 entering Resident #6's room on 11/26/23. He stated during morning meeting on 11/27/23 it was decided since this was a new behavior for Resident #1 we would monitor him to be sure he did not enter Resident #6's room. He stated we did not feel the need to change his room at this time because Resident #6 said she felt safe. He stated we completed an incident report but we did not initiate an abuse investigation. He stated he should have implemented a measure to protect all the residents from Resident #1 after that incident occurred with Resident #6. An interview was conducted with the Nurse Practitioner (NP) on 12/07/2023 at 10:00 AM. The NP stated she was notified on 11/27/23 when she reviewed the physician's book which was located at the nurse's station. She stated she went to speak to Resident #6 and she reported Resident #1 was on her bed and he kissed her cheek. The NP stated Resident #6 told her it really scared her and she asked for something for anxiety because it was making her very anxious. The NP added, Resident #6 was not on any antianxiety medications in the past but had asked for something to see if it would help her. The NP could not definitively say his behavior was as a result of the urinary tract infection, but that it could have possibly caused the increased confusion. An interview with the Administrator on 12/06/23 at 4:00 PM revealed he was made aware of Resident #1 entering Resident #6's room on 11/26/23 and was told that Resident #1 kissed Resident #6 on the cheek and she told him not to do that and he left the room. The Administrator stated he was not aware Resident #6 was scared. He stated on Monday he interviewed her and since she stated she felt safe and did not want her room changed he did not investigate further. 1b. Resident #2 was admitted to the facility on [DATE]. Diagnoses included, in part, Alzheimer's Disease, cognitive communication deficit, and anxiety. The MDS quarterly assessment dated [DATE] revealed Resident #2 was severely cognitively impaired and demonstrated no behaviors. He required extensive assistance with 2 staff physical assistance with bed mobility and dressing and was totally dependent with 2 staff physical assistance with toileting and transfers. A review of Resident #2's care plan dated 09/06/23 revealed a plan of care for decision making related to difficulty making his own decisions. Interventions included, in part, validate thoughts/feelings when confused or anxious and provide an environment that respects privacy. A nursing progress note written by Nurse #2 on 11/27/23 at 7:09 PM revealed at approximately 4:15 PM, Resident #2 was noted by a staff member that Resident #1's hand was down the front of Resident #2's brief. Nurse #2 was notified by the staff member and observed Resident #1 was sitting in a chair beside Resident #2's bed and Resident #1 had his arms crossed and his hands tucked under his arms. Nurse #2 asked Resident #1 to, please go to assigned room. The Assistant Director of Nursing and Administrator were made aware. A skin assessment was performed on Resident #2 and there were no noted injuries or impairments. Every 15 minutes safety checks were ordered. Review of the initial allegation report submitted to the Health Care Personnel Registry on 11/27/23 at 5:38 PM per fax transaction report indicated Resident #1 was observed in another resident's room with his hands down another resident's brief. There was no apparent physical or mental harm. Review of a hand written statement dated 11/27/23 by Nurse Aide (NA) #1 revealed About 4:15 PM on 11/27/23, as I was walking to get ice, passing resident's [Resident #2] room, another resident [Resident #1] had his hand in resident's [Resident #2] brief manually stimulating him. When the other resident [Resident #1] saw me he quickly removed his hand. Notified nurse. Review of a hand written statement dated 11/27/23 by NA #2 revealed I am the aide on the 400 hall. I did not see anything out of the norm with the residents [Resident #1 or Resident #2]. [Resident #1] had been in his own room today until they had movie day on the 100 hall. Around 2:00 PM he was walking around. Review of a hand written statement dated 11/27/23 by Nurse #2 revealed At approximately 4:15 PM, [NA #1] notified of [Resident #1] with his hand down [Resident #2's] brief in the front of his brief. This nurse walked down and [Resident #1] was sitting in a chair at bedside of [Resident #2] with both hands crossed tightly under his arms. When this nurse went in the room and asked Hey, [Resident #1] what are you doing? Resident said nothing and [Resident #2] stated He's just talking junk [Resident #1] said No I'm not. This nurse asked [Resident #1] to please go to his assigned room until this nurse could come and speak with resident. [Resident #1] got up, closed his right hand to a fist, and went to his room. This nurse notified the Assistant Director of Nursing and Administrator and the Administrator implemented every 15 minute safety checks until further advisement. A nursing progress note written by ADON on 11/27/23 at 7:54 PM revealed at 5:00 PM notified Psychiatric provider on call regarding sexually inappropriate incident with resident this evening who stated they have 24 hours to do an evaluation and will notify the supervisor on call and contact our Nurse Practitioner to discuss plan of care for resident and will call facility back. A nursing progress note written by the Assistant Director of Nursing (ADON) written on 11/27/23 at 7:32 PM revealed she notified Resident #2's responsible person regarding a situation earlier this evening where a resident from another room was observed by the Nurse Aide inappropriately touching Resident #2 by reaching under his brief. The ADON informed the responsible party no injuries were noted and the other resident was moved to another hall. The ADON explained to the responsible party she had attempted to process this incident with Resident #2 but was unable due to his confusion. A nursing progress note written by the ADON on 11/27/23 at 7:48 PM revealed at 6:20 PM notified Resident #1's responsible party regarding an incident that happened this evening where resident was observed by a nurse aide in another resident's room with his hand under the other resident's brief. Explained that this resident will be moved to another room closer to the nurse's station with no roommate and be placed on every 15 minute safety checks as well as be evaluated by Psych Services on call in the next 24 hrs. A nursing note written by Nurse #4 on 11/28/23 at 1:49 AM revealed Resident #1 continued on 15 minute safety checks; resident moved to room on the 200 hall per management without any issue. Oriented resident to new room location, bathroom, call light, and remote. Resident had been in room all shift with no behaviors noted. A nursing note written by Nurse #5 on 11/28/23 at 5:18 PM revealed a physician order was received to send resident to hospital for psychiatric evaluation. Emergency Medical Services (EMS) called at 3:30 PM. EMS arrived at 3:41 and exited facility with resident via stretcher at 3:49 PM. The emergency room (ER) progress note dated 11/29/23 revealed Resident #1 was seen and evaluated by psychiatry. He was cleared for disposition (dismissed) back to the facility at this time. Resident was started on antibiotics due to moderate leukocytes (elevate white blood cells indicative of infection) on urinalysis. Will continue with antibiotics at facility. A nursing progress note written by Nurse #4 on 11/29/23 at 7:51 PM revealed Resident #1 returned from hospital at 3:30 PM on 11/29/23 with orders for an antibiotic to treat a urinary tract infection. A physician's order written on 11/29/23 revealed an order for Cephalexin (antibiotic to treat urinary tract infections) 500 milligrams 3 times daily for 7 days. A review of the medication administration record revealed Resident #1 received the ordered antibiotic three times daily starting on 11/29/23 and finished on 12/06/23. Review of the 5 Day investigation report submitted on 12/01/23 at 2:27 PM per fax transaction report to Health Care Personnel Registry indicated Resident #1 was observed in another resident's (Resident #2) room with his hands down his brief. Resident #1 was cognitively impaired and had a diagnosis of pervasive developmental disorder. Resident #1 was observed inappropriately touching Resident #2. Resident #1 was sent for psychiatric evaluation. Findings negative. Medical evaluation revealed presence of urinary tract infection (UTI). Resident #2 who was recipient of touching showed no physical harm or mental anguish related to incident. Resident #1's room moved to different unit and resident was placed on every 15 minute safety checks. No further inappropriate behaviors have been observed at this time. Resident #1 placed on antibiotics for UTI. An interview was conducted with Nurse Aide (NA) #1 via phone on 12/06/23 at 1:02 PM. NA #1 reported as she was walking by to get ice on the 400 hall she noticed Resident #1 sitting in a chair beside Resident #2's bed and noticed Resident #1 had his hand under the brief of Resident #2 and was manually stimulating (moving hand in an up and down motion) on Resident #2's penis. NA #1 stated Resident #1 noticed that she saw him and he quickly pulled his hand out of the brief. NA #1 stated she went into the room and asked what Resident #1 what he was doing in the room and replied nothing. She added, she went straight to Nurse #2. NA #1 stated Resident #2 had a surprised look on his face when she entered the room and was calm. She stated Resident #2 was not observed being upset or showing signs of refusing to have Resident #1 touch him. She added he was just laying back in his bed. NA #1 stated she had never seen this behavior before from Resident #1 and that their rooms have always been near each other. NA #1 reported when he was asked to leave the room he kept his hand balled up and tucked in. An interview was conducted with Nurse #2 on 12/06/23 at 1:33 PM. Nurse #2 reported NA #1 quickly had approached her and told her Resident #1 was in Resident #2's room and Resident #1 had his hand down Resident #'2s brief and was stimulating him. Nurse #2 stated she went straight to Resident #2's room and Resident #2 was lying down on his back in his bed and Resident #1 was sitting in a chair right beside Resident #2's bed with his arms tucked under him. Nurse #2 stated she asked what he was doing and Resident #1 replied nothing, and Resident #2 replied He's just talking junk and Resident #1 said No I'm not. Nurse #2 stated she asked Resident #1 to go to his room and she would be in to speak with him. Nurse #2 stated she did a complete head to toe assessment on Resident #2. She added, Resident #2 did not speak about Resident #1 having his hand down his brief and acted as though it did not happen. Nurse #2 stated she did not see any erection or semen or any signs of stimulation at the time of the assessment. Nurse #2 stated once the residents were separated, she initiated every 15 minute safety checks until Resident #1 could be further evaluated and every 15 minutes safety checks continued after Resident #1's return from the hospital until he finished his antibiotic treatment. She stated his room was moved to the 200 hall as well. Nurse #2 added Resident #2 remained in his room as he usually would not come out of his room and he was monitored as well with every 15 minute safety checks. An interview was conducted with the ADON on 12/06/23 1:41 PM. The ADON reported that after she was made aware of the incident between Resident #1 and Resident #2 by Nurse #2 she went into Resident #2's room to assess his mental state. The ADON reported that his confusion was at his baseline and it was difficult to process the incident with him because he did not seem to understand what was going on. The ADON reported Resident #2 was not upset or recalling any of the incident. The ADON reported she then went to see Resident #1 who was in his bathroom at the time. She stated it seemed he knew he had done something wrong but that he did not understand; he seemed embarrassed. The ADON spoke to him and told him that that behavior was not acceptable and he needed to stay out of residents' rooms and to keep his hands to himself. An interview was conducted with Nurse Practitioner (NP) on 12/07/2023 at 10:00 AM. The NP reported she had seen Resident #1 on the morning of the 11/27/23 in his room. She stated he had no signs or symptoms of a urinary tract infection and his confusion seemed at baseline. The NP stated she received a call later on 11/27/23 as to what had happened with Resident #1 and Resident #2 and that the facility was waiting for a psychiatric evaluation. The NP stated a psychiatric provider was unable to come to the facility and it was decided to send Resident #1 to the ER for a psychiatric evaluation. The NP stated he was cleared after the psych evaluation but it was determined he had a urinary tract infection and was started on antibiotics and discharged back to the facility and continued with every 15 minutes safety checks until the antibiotic was completed. The NP stated she assessed Resident #2 and his assessment was benign and he did not share any information of the incident with her nor did he seem to have any recollection. An interview with the Director of Nursing on 12/06/23 at 3:45 PM revealed he was made aware of Resident #1 entering Resident #6's room on 11/26/23 by Nurse #3. He stated during morning meeting on 11/27/23 it was decided since this was a new behavior for Resident #1, the facility would monitor him to be sure he did not enter Resident #6's room. He stated he did not feel the need to change his room at this time because Resident #6 said she felt safe. He stated he completed an incident report, but that he should have implemented a measure to protect all the residents from Resident #1 after the first incident occurred with Resident #6 because if he had followed the abuse policy and procedure the sexual abuse with Resident #2 could have been prevented. An interview with the Administrator on 12/06/23 at 4:00 PM revealed he was made aware of Resident #1 entering Resident #6's room on 11/26/23 and was told that Resident #1 kissed Resident #6 on the cheek and she told him not to do that and he left the room. The Administrator stated he was not aware Resident #6 was scared. He stated on Monday he interviewed her and since she stated she felt safe and did not want her room changed he did not investigate further. The Administrator stated if he had further investigated the incident with Resident #6, the incident that occurred with Resident #1 and Resident #2 could have been avoided. An observation of Resident #1 on 12/06/23 at 12:42 PM revealed Resident #1 was an alert resident who was sitting in his room on the 200 hall. He was pleasant and cheerful but confused. An observation of Resident #2 on 12/06/23 at 12:53 PM revealed Resident #2 was an alert resident lying on his bed in his room on the 400 hall. He was pleasant and cheerful but confused. The Administrator was notified of Immediate Jeopardy on 12/06/23 at 6:30 PM. F600 Identify those residents who suffered, or are likely to suffer a serious adverse outcome because of the non-compliance: The facility failed to protect Resident #6 from inappropriate touching on 11/26/23 and Resident #2 from sexual abuse on 11/27/23 perpetrated by Resident #1. Resident #1 was evaluated 11/29/23 at the hospital emergency room and was diagnosed with a urinary tract infection and was treated with antibiotics. The hospital completed a psychiatric evaluation and was cleared to return to the facility. He was relocated to be closer to the nurse's station to ensure closer observation on 11/29/23. No further complaints from other residents have been received to date. Resident #1 has been a resident at this facility since 03/31/21 and this was a newly identified behavior for this resident. The facility has scheduled a neurology consult for 12/07/23, to evaluate any current changes to the plan of care. A review of the updated care plan for Resident #1 revealed on 11/28/23 revealed a plan of care for wandering into other's residents' room with a goal that wandering would not contribute to injury through the next review with interventions to include move resident close to nurse's station, follow up with psychiatry, and implement every 15 minute safety checks. Resident #2 has a diagnosis of Alzheimer's Disease and a Brief Interview Mental Status (BIMS) score of 6. Upon interview by the Regional Clinical Consultant on 12/06/23, he had no recollection of the event and had demonstrated no new behaviors. Resident #6 was alert and oriented with a BIMS of 15. Upon interview by the Regional Nurse Consultant on 12/06/23, she recalled the event and was fearful at the time of the incident because she was asleep and was awakened by a man kissing her cheek. On 12/06/23, during the interview with the Regional Nurse, she affirmed that she felt safe in the facility and has had no further incidents of this type. A review of Resident #6's care plan dated 12/07/23 revealed Resident #6 had experienced a trauma in this facility related to another resident entering her room uninvited with a goal that Resident would feel safe through next review and interventions included, in part, resident to be assessed by Physician or Practitioner, offer to change room for resident, provide assurance that she was safe at this facility and monitor resident. On 12/06/23, the Regional Nurse Consultant completed a review of progress notes for the last 30 days to identify any incidents that could be interpreted as abuse. As a result of this review, two additional initial reports were filed to the state agency on 12/07/23 and investigations initiated at that time. One report was for the incident of inappropriate sexual touching with Resident #6 and Resident #1 on 11/26/23. The other report was filed as a precautionary measure for a resident-to-resident verbal yelling incident on the memory care unit. The facility Social Worker and the Admissions Coordinator completed trauma care assessments on current residents on 12/07/23 to identify any existing trauma affecting the psychosocial well-being of the resident. The facility Social Worker and the Admissions Coordinator interviewed current alert and oriented residents on 12/07/23 to determine if they felt safe in the facility. There were no other residents who were identified as feeling unsafe. For those residents who were unable to be interviewed, their responsible party would be contacted on 12/07/23 by the Social Worker and Admissions Coordinator to ensure they felt their resident was safe in the facility. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The facility Administrator and Director of Nursing received re-training from the Director of Operations and Regional Clinical Nurse on Abuse/Neglect policy and procedure, including identification of abuse, investigation, protection, reporting/respond, prevention, screening, and the possible psychosocial effects of sexually inappropriate behavior on a resident. This training was completed on 12/07/23. The DON and Regional Clinical Nurse began education with current facility staff, including contract Housekeeping/Laundry and Rehabilitation, on Abuse/Neglect policy and procedure, including identification of abuse, investigation, protection, reporting/respond, prevention and screening abuse, the reporting of abuse, types of abuse and the possible psychosocial effects of sexually inappropriate behavior on a resident. This training was completed as of 12/07/23. Any current employee who had not received this education as of 12/07/23 would not be allowed to

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews, the facility failed to protect Resident #2 from sexual abuse when the Administrator was made aware of Resident #1 entering Resident #6's room uninvited on 11/26/23. Resident #6 reported to Nurse #1 that Resident #1 woke her up and was holding her hand, telling her he was going to care for her and kissed her on the cheek. Resident #6 was upset and scared and was not sure what he was doing in the room and told him he did not belong in her room. The following day 11/27/23, Resident #1 was found by Nurse Aide #1 in Resident #2's room sitting at his bedside while Resident #2 lay in bed. Resident #1 had his hand down Resident #2's brief and was manually stimulating (moving hand in an up and down motion) his penis. Additionally, the facility failed to identify abuse, to report the allegation of abuse to the state agency and to conduct a thorough investigation for Resident #6. This was for 2 of 3 residents observed for abuse. Immediate Jeopardy began on 11/26/23 when the facility failed to implement measures to protect other residents from sexual abuse after Resident #1 entered Resident #6's room uninvited on the evening of 11/26/23 where it was reported to Nurse #1 by Resident #6 that Resident #1 woke her up and was holding her hand, telling her he was going to care for her and kissed her on the cheek. Immediate Jeopardy was removed on 12/08/23 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level D isolated with potential for more than minimal harm to correct the deficient practice and to ensure that the education and monitoring systems put in place to remove the Immediate Jeopardy were effective. Findings included: The facility's abuse policy dated February 2021 titled Abuse Prevention, intervention, reporting and investigation read, in part, as follows: #5 Identification: (a) It is our policy that all staff monitor residents and will know how to identify potential signs and symptoms of abuse and (d) identifying possible indicators of abuse in residents (injuries, fearfulness, behavioral or social changes). #6 Investigation: (a) It is our policy that reports of abuse are promptly and thoroughly investigated. #8 Protection: (a) It is our policy that the residents will be protected from the alleged offender. #9 Reporting: (a) It is our policy that abuse allegations are reported per Federal and State Law and all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse to the Executive Director of the facility and other officials including the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long term care facilities. 1. Resident #1 was admitted to the facility on [DATE]. Diagnoses included pervasive developmental disorder (delay in development of multiple basic functions including socialization and communication), dysarthria (speech disorder), and cognitive communication deficit. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and demonstrated no behaviors. a. Resident #6 was admitted to the facility on [DATE]. The MDS 5 day assessment dated [DATE] revealed Resident #6 was cognitively intact. A nursing progress note written on 11/26/23 at 11:26 PM by Nurse #3 revealed at 7:00 PM was told by a Nurse #1 that Resident #1 was sitting in Resident #6's room. Was also told that Resident #6 was upset and the responsible party called to report the incident. This nurse went to speak with Resident #6. Upon entering the room, the resident was tearful and speaking with her responsible party on a cell phone. Resident #6 stated, A man sat on the side of my bed and told me he loved me and said he will take care of me. He kissed me on the cheek. Resident #6 stated she was scared and made it clear that his advances were unwelcome so she pushed the call button and called her responsible party and the responsible party contacted the facility. An interview was conducted with Nurse #1 on 12/07/23 at 11:15 AM via phone. Nurse #1 stated she was assigned to another hall and she responded to a phone call that the responsible party of Resident #6 put into the facility. She stated the responsible party reported to her that some strange man was in Resident #6's room. Nurse #1 stated after she spoke with the responsible party, she went to Resident #6's room and she saw Resident #1 sitting in a chair at the bedside talking with Resident #6. Nurse #1 reported she asked Resident #1 what he was doing in the room and he had replied that Resident #6 told him to get out and that that was not his room. Nurse #1 stated she then took Resident #1 to his room. Nurse #1 stated Resident #6 appeared to be upset, but she was not crying. Nurse #1 stated Resident #1 was normally confused. She stated she reported to the Medication Aide and Nurse #3 on the hall what had happened to make sure Nurse #3 followed up with the responsible party and the Director of Nursing. Nurse #1 reported she recognized Resident #1's action as being abuse and that was why she told Nurse #3 to be sure to call the Director of Nursing immediately. Nurse #1 stated she has been in serviced on abuse annually through the facility's computer program. An interview was conducted with Nurse #3 via phone on 12/06/23 at 2:38 PM. Nurse #3 went and spoke with Resident #6 and she stated she was sleeping and she woke up to see this strange man who she did not know and she was upset and scared. Nurse #3 stated he had asked Resident #6 if she wanted to move to a different hall but she said she was okay and she declined to move. Nurse #3 stated Resident #6 expressed she did not want him to come into her room again and he made sure to follow up with her through the remainder of the shift to be sure she felt safe. Nurse #3 stated he called the DON right after Nurse #1 had informed him and he had spoken with Resident #6 on 11/26/23 and informed the DON of the abuse. Nurse #3 stated the DON instructed him to speak with both families regarding the incident and he (DON) would move the resident in the morning. Nurse #3 reported Resident #6 stated she was fine knowing that Resident #1 was not going to be moved until the next morning. Nurse #3 reported Resident #1 was brought to his room and remained in his room the remainder of the night and he and Medication Aide did frequent checks on both residents throughout the shift. Nurse #3 stated he also gave Resident #6 his personal cell phone number to call him if she needed him through the rest of the shift. Nurse #3 reported he called the DON because he felt what Resident #1 did to Resident #6 was abuse and it needed to be reported. Nurse #3 stated he got training annually regarding abuse. An interview with the Director of Nursing on 12/06/23 at 3:43 PM revealed he was made aware of Resident #1 entering Resident #6's room on 11/26/23. He stated during morning meeting on 11/27/23 it was decided since this was a new behavior for Resident #1 we would monitor him to be sure he did not enter Resident #6's room. He stated we did not feel the need to change his room at this time because Resident #6 said she felt safe. He stated we completed an incident report but we did not initiate an abuse investigation because it was a new behavior for Resident #1 and Resident #6 stated she felt safe. He stated he should have implemented a measure to protect all the residents from Resident #1 after that incident occurred with Resident #6. b. Resident #2 was admitted to the facility on [DATE]. The MDS quarterly assessment dated [DATE] revealed Resident #2 was severely cognitively impaired and demonstrated no behaviors. A nursing progress note written by Nurse #2 on 11/27/23 at 7:09 PM revealed at approximately 4:15 PM, Resident #2 was noted by a staff member that Resident #1's hand was down the front of Resident #2's brief. Nurse #2 was notified by the staff member and observed Resident #1 was sitting in a chair beside Resident #2's bed and Resident #1 had his arms crossed and his hands tucked under his arms. Nurse #2 asked Resident #1 to, please go to assigned room. The Assistant Director of Nursing and Administrator were made aware. A skin assessment was performed on Resident #2 and there were no noted injuries or impairments. Safety checks every 15 minutes were ordered. An interview was conducted with Nurse Aide (NA) #1 via phone on 12/06/23 at 1:02 PM. NA #1 reported as she was walking by to get ice on the 400 hall she noticed Resident #1 sitting in a chair beside Resident #2's bed and noticed Resident #1 had his hand under the brief of Resident #2 and was manually stimulating (moving hand in an up and down motion) his penis. NA #1 stated Resident #1 noticed that she saw him and he quickly pulled his hand out of the brief. NA #1 stated she went into the room and asked what Resident #1 was doing in the room and replied nothing. She added, she went straight to Nurse #2. NA #1 stated she received annual training on abuse and knew she needed to report this immediately to a supervisor. An interview was conducted with Nurse #2 on 12/06/23 at 1:33 PM. Nurse #2 reported NA #1 quickly had approached her and told her Resident #1 was in Resident #2's room and Resident #1 had his hand down Resident #'2s brief and was stimulating him. Nurse #2 stated she went straight to Resident #2's room and Resident #2 was lying down on his back in his bed and Nurse #2 stated she asked Resident #1 to go to his room and she would be in to speak with him. Nurse #2 stated she did a complete head to toe assessment on Resident #2. She added, Resident #2 did not speak about Resident #1 having his hand down his brief and acted as though it did not happen. Nurse #2 stated once the residents were separated, she initiated 15 minute safety checks until Resident #1 could be further evaluated and the safety checks continued after Resident #1's return from the hospital. She stated his room was moved to the 200 hall on 11/28/23. Nurse #2 added Resident #2 remained in his room as he usually would not come out of his room and he was monitored as well with every 15 minute safety checks. Nurse #2 stated she reported the sexual abuse to the Assistant Director of Nursing and the Administrator. Nurse #2 stated she received annual training regarding abuse. An interview was conducted with the ADON on 12/06/23 1:41 PM. The ADON reported that after she was made aware of the incident between Resident #1 and Resident #2 by Nurse #2 on 11/27/23 at about 4:15 PM she went into Resident #2's room to assess his mental state. The ADON reported that his confusion was at his baseline and it was difficult to process the incident with him because he did not seem to understand what was going on. The ADON reported Resident #2 was not upset or recalling any of the incident. The ADON reported she then went to see Resident #1 who was in his bathroom at the time. She stated it seemed he knew he had done something wrong but that he did not understand; he seemed embarrassed. The ADON spoke to him and told him that that behavior was not acceptable and he needed to stay out of residents' rooms and to keep his hands to himself. The ADON reported she received annual training regarding abuse through the facility's computer program. An interview with the Director of Nursing on 12/06/23 at 3:45 PM revealed he should have implemented a measure to protect all the residents from Resident #1 after the first incident (11/26/23) occurred with Resident #6 because if he had followed the abuse policy and procedure the sexual abuse with Resident #2 could have been prevented. An interview with the Administrator on 12/06/23 at 4:00 PM revealed he was made aware of Resident #1 entering Resident #6's room on 11/26/23 and was told that Resident #1 kissed Resident #6 on the cheek and she told him not to do that and he left the room. The Administrator stated he was not aware Resident #6 was scared. He stated on Monday he interviewed her and since she stated she felt safe and did not want her room changed he did not investigate further. The Administrator stated if he had further investigated the incident with Resident #6, the incident that occurred with Resident #1 and Resident #2 could have been avoided. The Administrator was notified of the Immediate Jeopardy on 12/06/23 at 6:30 PM. F607 FAILURE TO IMPLEMENT THE ABUSE POLICY Identify those residents who suffered, or are likely to suffer a serious adverse outcome because of the non-compliance: The facility failed to follow their abuse policy and procedure to investigate allegations of abuse and to protect other residents from abuse following an incident of inappropriate touching, kissing, and unwanted advancements by Resident #1 into the personal space of Resident #6 on 11/26/23. The Regional Clinical Nurse completed an interview 12/07/23 with Resident #6. Resident #6 stated Resident #1 did enter her room on 11/26/23 and gave her a kiss. She told him to go sit in the chair across the room until someone came for him. He did comply. She added that she felt safe in the facility and has had no further incidents. An initial report was completed and filed with the state agency on 12/07/23. Adult Protective Services (APS) and police were called on 12/07/23 by the Administrator. This investigation was opened and completed on 12/07/23 by Regional Clinical Nurse. Resident #1 was moved closer to the nurse's station on 11/27/23. He was transferred to the emergency department on 11/28/23 for medical and psychiatric evaluation where he was diagnosed with a urinary tract infection. Antibiotics were prescribed for 7 days. Resident #1 completed his course of antibiotics on 12/07/23. The Regional Clinical Nurse completed a review of current resident electronic medical records, including progress notes and incident reports for the last 30 days to determine if there were any other incidents that would require further investigation and reporting of abuse on 12/06/23. The results of the audit identified one incident that had occurred on 11/29/23. This investigation was opened and completed on 12/07/23 by the Regional Clinical Nurse. The facility Administrator completed an initial report on 12/07/23, including notification of law enforcement, APS, and report to the State Agency on 12/07/23. This was related to a yelling incident between two residents. The facility Social Worker and the Admissions Coordinator interviewed current alert and oriented residents on 12/07/23 to determine if they felt safe in the facility. There were no other residents who were identified as feeling unsafe. For those residents who are unable to be interviewed the responsible party will be contacted on 12/07/23 by the Social Worker and Admissions Coordinator to ensure they felt their resident was safe in the facility. Specify action the facility will take to alter the process or system failure to prevent a serious outcome from occurring or recurring and when the action will be completed: The facility Administrator and Director of Nursing received re-training from the Director of Operations and Regional Clinical Nurse on Abuse/Neglect policy and procedure, including identification of abuse, types of abuse, investigation, protection, reporting/respond, prevention, screening, and the possible psychosocial effects of sexually inappropriate behavior on a resident. The Administrator and DON were trained in the steps to follow in a facility investigation. This training was completed on 12/07/23. The 24-hour report will be reviewed by the oncoming nurse and shared with the nursing assistants at the beginning of the shift. The nursing assistants will sign the 24-hour report indicating that they have been informed of the previous day's events. The 24-hour report was a review of the last 24 hours any resident change in condition, behaviors, or other acuities. This will be a new process for the nursing assistants. The DON and /or Administrative Nurse will be completing education with current licensed nurses and nursing assistants on the use of the 24-hour report sheet. Any current licensed nurse and nursing assistant who does not receive this training by 12/07/23 will not be able to work without the training from the DON and/or Administrative Nurse. Newly hired licensed nurses and nursing assistants will receive this training at orientation by DON or ADON. The DON and Regional Clinical Nurse began education with current facility staff, including contract Housekeeping/Laundry and Rehabilitation on Abuse/Neglect policy and procedure, including identification of abuse, investigation, protection, reporting/respond, prevention and screening. abuse, the reporting of abuse and the possible psychosocial effects of sexually inappropriate behavior on a resident. Staff were also educated that the cognitive status of the resident does not rule out abuse. This training was completed as of 12/07/23. Any current employee who has not received this education as of 12/07/23 will not be allowed to work until education was completed by the facility DON. All newly hired employees will receive this education during orientation and prior to assignment. The DON will be responsible for the education. The DON is responsible for the tracking of the education to ensure completion. The facility does not utilize agency staff. The facility alleges the removal date of the Immediate Jeopardy was 12/08/23. The removal plan of the Immediate Jeopardy was validated on 12/08/23. A sample of staff including the Administrator, Director of Nursing, nurses, nurse aids, therapists, housekeeping staff, and dietary aides were interviewed regarding in services they received related to the deficient practice. All staff interviewed stated they had been in serviced regarding identifying, reporting, and investigating abuse. Additionally, nurses and nurse aides were interviewed regarding the in-services they received for the new process of the 24 hour report sheet which was a tool used to communicate daily events when reporting off or on shift. The removal date of 12/08/23 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff, Resident, Medical Director interviews, the facility failed to provide care in a safe manner for 1 of 3 residents (Resident #1) reviewed for accidents. On 5/8/23 the Nurse Aide raised the level of the bed to provide incontinence care and change bed linens for Resident #1. Resident #1 was positioned on her right side while the bed linens were being changed and fell out of bed landing face down on the floor. The resident was sent to the Emergency Department (ED) for evaluation and diagnosed with a subdural hematoma (blood collection between the skull and surface of the brain), scattered skin tears, skin lacerations to the left forearm and right knee that required sutures, forehead abrasion, closed fracture of the right orbit (eye) with right periorbital hematoma (black eye) and premaxillary hemorrhage (bleeding) and a minimally displaced right nasal bone fracture. Resident #1 was admitted to the trauma service step down unit for wound care, antibiotics, and post operative pain control. Findings included: Resident #1 was admitted on [DATE] with diagnoses that included vascular dementia without behaviors, atrial fibrillation, chronic obstructive pulmonary disease (COPD), debility, bowel and bladder incontinence and bed bound. Review of physician orders revealed Resident #1 was prescribed Xarelto 2.5 milligrams (mg) daily for atrial fibrillation on 4/21/22 and scheduled oxycodone IR (immediate release) 5 mg 1 tablet every 8 hours for generalized osteoarthritis pain and was also prescribed oxycodone IR 5 mg 1 tablet every 4 hours as needed for generalized osteoarthritis pain on 3/29/23. Resident #1 was admitted into hospice on 10/14/22 with diagnoses that included moderate vascular dementia without behaviors, atrial fibrillation, chronic obstructive pulmonary disease (COPD), debility, bowel and bladder incontinence, and bedbound. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed moderately impaired cognition and required 2-person assistance with bed mobility and transfers. Resident #1 was always incontinent of bowel and bladder. Resident #1 had bilateral lower extremity impairment in range of motion and was receiving opioid pain medication daily. The MDS indicated no falls since admission/reentry/prior assessment. Review of Care Plan dated 4/26/23 identified a focus of at risk for falls related to history of falls with impaired mobility contributing of vascular dementia, insomnia, and muscle spasm. The goal was for the resident to not sustain falls that will create injury over the next review period and the interventions were to refer to physical therapy for evaluation, monitor for changes in condition that may warrant increased supervision/assistance and notify the physician, and floor mat next to bed when resident was in bed. The Nurse Aide care guide ([NAME]) updated 10/06/22 revealed Resident #1 required extensive assistance of 2 with positioning and mobility. The care guide revealed that the resident required 1 assist with dressing, 2 assist with positioning, and 2 assist with mechanical lift. Interview with NA #1 on 5/24/23 at 8:30 am revealed incontinence care was being provided to Resident #1 on 5/8/23 when Resident #1 fell out of the bed. NA #1 stated he typically provided incontinence care and bed linen changes for this resident without assistance and the fall was not expected. NA #1 explained Resident #1 was heavily soiled requiring a full bed change and after incontinence care had been provided Resident #1 was rolled onto her right side while the dirty sheets were being removed. Resident #1 changed the position of her top leg by sticking it out and rolled off the side of the bed onto the floor. The interview further revealed NA #1 had raised the level of the bed to provide care and the fall mat was in place at the time of the fall, but the resident fell off the opposite side of the bed. NA #1 observed Resident #1 lying on the floor face down with her right arm underneath her body after the fall. NA #1 notified Nurse # 3 who came and assessed Resident #1. Phone interview with NA#1 on 6/2/23 at 9:42 am revealed when Resident #1 fell out of bed she yelled out Oh, oh and initially did not express pain but when she was being assessed by Nurse #3, she would say oh, that hurts when being moved. Skin tears were noted to both arms and legs, and she had bleeding on her face, but NA#1 did not know where the bleeding was coming from but stated there was a considerable amount of blood. Resident #1 was alert and oriented the entire time and seemed fully aware that she had fallen out of bed. Resident Incident Report dated 5/8/23 at 3:15 pm revealed that Resident #1 went over the side of the bed toward the window during incontinence care with a bed change. The fall resulted in injuries including right lip small laceration, bump to the left side of forehead, nose fracture with black right eye, large skin tear to left forearm, large skin tear to right lower leg, skin tear to left knee and right forearm. Resident #1 was transported to the Hospital by Emergency Medical Services (EMS). It further revealed that at the time of the incident the resident had received analgesics/narcotics in the past 8 hours. This report was documented by Nurse #3. A nurse's notes written by Nurse #3 dated 5/8/23 at 6:46 pm revealed that the Resident #1 fell from the bed during a full bed linen change and was face down next to the bed after the fall. Bleeding was noted from the head, leg, and nose. It further revealed that the resident reported pain everywhere. Resident was alert. Emergency Medical Services (EMS) was notified and due to resident injuries and being on blood thinners. Resident #1 was transported to hospital emergency department (ED) where she was admitted for subdural hematoma. A telephone interview with Nurse #3 on 5/23/23 at 2:50 pm revealed she was on duty on 5/08/23 when Resident #1 fell and was called to the room by Nurse Aide (NA) #1. Resident #1 was found on the floor next to her bed in the prone position. She indicated that NA #1 had been changing Resident #1 to include a full bed change and Resident #1 was a fairly big person for one aide to do but, only one aide would typically be assigned. Nurse #3 revealed that the resident was sent out with Emergency Medical Services. Nurse #3 stated that the resident could stabilize herself a little, but you had to always keep a hand on her. The interview further revealed the fall mat was in place at the time of the fall but was on the other side of the bed. A follow up phone interview with Nurse #3 on 6/2/23 at 9:55 am revealed she was on duty on 5/8/23 when Resident #1 had a fall from the bed and was called to the room by NA #1. She observed Resident #1 on the side of the bed closest to the window face down on the floor, she described seeing a large amount of blood in her mouth, and bleeding noted from the nose. She added that she had injuries to her head, face and that her nose looked broken, and she could observe that blood was going to the back her throat, so she kept her on her side while awaiting Emergency Medical Services (EMS) to arrive. Nurse #3 revealed there was a lot of blood mostly from the face and Resident #1 had 2 deep skin tears, one on the left forearm and one on the right knee, and an abrasion to the forehead. Nurse #3 added that Resident #1's left arm may have come into contact with hardware from the a nearby chest of drawers when she fell causing the deep skin tear. When asked about pain Resident #1 indicated she had pain everywhere. Nurse #3 revealed that she worked with the resident after she was readmitted from the hospital after the fall. On return to the facility Nurse #3 described Resident #1 as bruised on her face and was in more pain than before the fall and when staff moved her to change her, she was vocal about the discomfort and pain and would grimace. Resident #1 would tell them it hurt. Nurse #1 stated that Resident #1 returned to the facility with a PRN (as needed) pain medication ordered but the pain medicine was changed to scheduled after the first few days after admission because of the pain. She described Resident #1's pain prior to the fall as more general discomfort and after the fall as being more related to the injuries from the fall. She added Resident #1 would not give you a number on a pain scale but would just say real bad so that is how they knew she was in a lot of pain. On return Resident #1 was described as having more real bad pain, especially in the first few days after return, and more lethargic and tired and it took about 10 days to get back to her baseline. Nurse #3 indicated that Resident #1 had anxiety and after the fall had to be reassured when she was changed because she was afraid she would fall again, but that was getting better now. Resident Incident Report dated 5/8/23 at 3:45 pm revealed that Resident #1 fell out of bed while incontinence care was provided. The fall resulted in injuries including upper right lip laceration, raised bump to left forehead, possible nose fracture, bruise to right eye, multiple skin tears - left upper arm, left forearm, right upper arm, right forearm, and bilateral knees. Resident #1 was transported to the Hospital by Emergency Medical Services (EMS). It further revealed that at the time of the incident the resident had received analgesics/narcotics in the past 8 hours. This report was documented by Nurse # 2. Phone interview with Nurse #2 on 6/1/23 at 3:55 pm revealed that she was the wound nurse and had assessed Resident #1's skin tears, bruises, and lacerations that she received from the fall on 5/8/23 and provided wound care to the Resident #1 after her readmission from the hospital after the fall. She added that Resident #1 was like her normal self even though she was all cut up, happy and talking to staff and no different from before the fall, other than her injuries. Nurse # 2 reported that Resident #1 denied pain and did not have non-verbal expressions during wound care. The interview further revealed that Nurse #2 would at times assist the NAs with brief changes and Resident #1 would say ow, that hurts or don't touch me there when they were rolling her over and added that Resident #1 had bruises on the backs of her arms and if touched there would say ouch and that Resident #1 did not do that prior to the fall and didn't complain of pain prior to the fall during care. Nurse #2 described Resident #1's skin condition after the fall and stated that she had multiple skin tears on both upper and lower extremities on both sides and bruising on the face, arms and legs with sutures in her right knee. Review of hospital records dated 5/8/23 revealed Resident #1 presented to the emergency department (ED) after a fall from bed during a transfer that impacted her face. No report of loss of consciousness. The ED Provider's review of systems noted numerous skin avulsions, right periorbital ecchymosis and the resident reported a headache. The CT scan of the face noted closed fracture of the right orbit (eye) with right periorbital hematoma and premaxillary hemorrhage, a minimally displaced right nasal bone fracture. The CAT scan of the head noted a right frontal subdural hematoma. The history and physical completed by a Trauma Surgeon on 5/8/23 revealed the resident reported pain in her left shoulder, extremities and skin tears and rated the pain level as a 4 out of 10. History and physical further noted right periorbital ecchymosis and the lacerations to the left forearm and right knee were repaired with dissolvable sutures. The x-ray of the left shoulder was negative for fracture. Resident #1 was admitted to the trauma service step down unit for wound care, antibiotics and post operative pain control. It was determined that the subdural hematoma did not require surgical intervention. Resident #1 was discharged from the hospital back to the facility on 5/10/23 with orders that included Oxycodone 5 mg every six hours as needed for pain and to stop Xarelto 2.5 mg. Review of a progress note dated 5/11/23 written by the Family Nurse Practitioner revealed Resident #1 was readmitted to the facility with a diagnosis of fall resulting in nasal bone fracture, fracture of right orbital floor, subdural hematoma and multiple skin tears. The progress note review revealed Resident #1 was readmitted with orders for Oxycodone 5 mg every four hours as needed for pain and an order for alprazolam 0.5 mg 1 tablet every eight hours and 1 tablet every 4 hours as needed for anxiety for 4 months. The physical exam revealed Resident #1 had bruising to the forehead, nasal and orbital area, and neck and bruising and multiple skin tears to upper and lower extremities. Resident #1 was oriented to person, not place and time. The review further revealed that anticoagulants were being held. Review of nurses note dated 5/10/23 7:15 pm Nurse # 1 revealed that Resident #1 returned from the hospital to the facility alert and oriented and noted to have numerous facial bruises (eye area) color observed to be reddish purplish. Resident #1 was noted to have dressings to bilateral arms and bilateral lower extremities and returned with a prescription for a narcotic pain pill that was faxed to a pharmacy. On 6/1/23 at 4:06 pm phone interview with Nurse #1 revealed that she was the nurse on duty when the resident was readmitted from hospital on 5/10/23. Nurse #1 indicated that she worked with Resident #1 on a routine basis and was familiar with her. She did not recall complaints or signs of pain on readmission. Nurse #1 described her condition as being bruised, to include on her face with dressings on the injuries from the fall. She was described as happy to be back home and was laughing and smiling. Review of a progress note dated 5/11/23 written by the Family Nurse Practitioner revealed Resident #1 was readmitted to the facility with a diagnosis of fall resulting in nasal bone fracture, fracture of right orbital floor, subdural hematoma and multiple skin tears. The progress note review revealed Resident #1 was readmitted with orders for Oxycodone 5 mg every four hours as needed for pain and an order for alprazolam 0.5 mg 1 tablet every eight hours and 1 tablet every 4 hours as needed for anxiety for 4 months. The physical exam revealed Resident #1 had bruising to the forehead, nasal and orbital area, and neck and bruising and multiple skin tears to upper and lower extremities. Resident #1 was oriented to person, not place and time. The review further revealed that anticoagulants were being held. After the fall Resident #1 was initially prescribed oxycodone 5 mg 1 tablet every 6 hours as needed for pain. This regime was ordered on 5/10/23 and discontinued on 5/11/23. Review of nurse's notes dated 5/11/23 12:24 pm Nurse #5, unit manager, revealed that she received a new physician order for Resident #1 to discontinue oxycodone 5 mg as needed (PRN) every 6 hours and to start Oxycodone 5 mg every 4 hours as needed for pain. Review of the Medication Administration Record (MAR) on 5/11/23 oxycodone 5 mg 1 tablet every 4 hours as needed for pain was started. This order was discontinued on 5/12/23 after receiving 3 doses with a pain scale of 8 reported on a scale of 1 to 10 with 10 being the worst pain. Review of a progress note dated 5/12/23 written by Adult-Gerontology Nurse Practitioner revealed nursing staff reported Resident #1 moaned when repositioned and the family requested oxycodone 5 mg be scheduled. An order for oxycodone 5 mg every 4 hours written and an order for oxycodone 5 mg every 6 hours as needed for pain written. Review of nurses note dated 5/12/23 at 6:40 pm revealed that Nurse #4 received new pain medication orders for Resident #1. The new order was to discontinue Oxycodone 5 mg every 6 hours and to start Oxycodone 5 mg every 4 hours. A phone interview with Nurse #4 on 6/1/23 at 5:15 pm revealed that after Resident #1 was readmitted to the facility from the hospital that she was very bruised with skin tears on each extremity, bruising to her face and in a lot of pain. Nurse #4 further revealed that she did a pain assessment on Resident #1 the day after she returned (5/11/23) and she couldn't give a number on a pain scale but was moaning and grimacing. Resident #1's pain medication was prescribed as PRN (as needed) at that time and her son wanted it scheduled and the order was changed to scheduled every 4 hours since she was in pain but would not ask for anything. Nurse #4 further revealed that you could tell that she was hurting, and Resident #1 told her that her left arm was hurting but would not ask for pain medication. The interview further revealed that Resident #1's pain was worse after the fall, and she had non-verbal signs of pain. Nurse #4 described Resident #1 as more confused after the fall and that she could not insert a urinary catheter because Resident #1 was in too much pain and if you tried to open her legs it was too painful for her because of her injuries to her legs. On 5/12/23 a physician order for oxycodone 5 mg 1 tablet every 6 hours as needed for pain was started in addition to the scheduled every 4-hour dose. She received this as needed dose 3 times between 5/19/23 and 5/26/23. Review of the May MAR further revealed that Resident #1 reported pain (on a pain scale of 0-10) consistently as a 1-7 prior to the fall. After the fall Resident #1 reported pain (on a pain scale of 0-10) consistently as a 3-8. On 5/11/23 and 5/12/23 Resident #1 reported pain as an 8 (on a pain scale of 0-10). Review of Resident #1's MAR from 5/10/23 through 5/31/23 revealed that Resident #1 continued to receive scheduled oxycodone 5 mg every four hours and oxycodone 5 mg every 6 hours as needed for pain. MAR review further revealed that between the dates of 5/11/23 and 5/31/23 the resident had a total of 5 days where pain was documented as a 0 (on a pain scale of 0-10) all other dates had pain scale ratings ranging from a 3 to 8 (on a pain scale of 0-10). Interview with NA #2 on 5/23/23 at 12:30 pm revealed Resident #1 could communicate needs and was a 2 person assist. NA #2 stated she would always get help when providing incontinence care and linen changes for Resident #1. NA #2 indicated that she followed a care guide that was in a book on the unit and the care guide listed the resident as a 2 assist with positioning and mobility with a mechanical lift, and a 1 assist with dressing. Interview and observation of Resident #1 on 5/23/23 at 10:45 am revealed the resident did not report concerns of pain. Resident #1 was noted to have bandages to her left lower forearm and right upper arm and an abrasion to the left side of the forehead. Yellowing bruising was noted below the left eye and to the left side of the forehead. When asked Resident #1 describes her injuries and bruising as occurring from being in a wreck and did not respond when asked if she had pain. Review of Medical Director progress notes dates 5/16/23 revealed Resident #1 was diagnosed with a nasal bone fracture, fracture of the right orbital floor, subdural hematoma, multiple skin tears, laceration of the left forearm and laceration of the knee. She was evaluated by neurosurgery and after a follow-up CT it was determined that she did not require surgical intervention for the subdural hematoma. Once stable Resident #1 was discharged back to the facility to continue long-term care with the help of hospice. The review revealed that upon physical examination by the facility Medical Director that Resident #1 had decreased range of motion in both lower extremities, a decrease of range of motion of both hands, but she was able to feed herself, and Resident #1 had hematomas all over her face. The review indicated that Resident #1 was back to her baseline and required total care. The Medical Director noted a concern that since the subdural hematoma Resident #1 would most probably have more cognitive impairment and would not be able to do the inhaler prescribed for her chronic obstructive pulmonary disease. Additionally, the report revealed that after several skin tears and nasal-orbital floor fracture that Resident #1 would continue on Tylenol (acetaminophen) 650mg three times a day and oxycodone every 6 hours as needed for pain. The review further revealed that Resident #1 was at significant risk of worsening medical and neurobehavioral status. An interview on 5/24/23 at 9:55 am the Medical Director indicated she was aware of Resident #1's fall from the bed on 5/08/23 and participated in the post incident care plan review. She was aware of the injuries sustained by the resident from the fall. She indicated that the resident was large, and the amount of assistance required during care would be determined by the facility. The interview revealed that Resident #1 would easily bruise and always had skin issues related to blood thinners. The Medical Director stated that the resident had returned to her baseline. Interview with the Director of Nursing (DON) on 5/23/23 at 5:30 pm revealed that the DON was aware of the injuries of Resident #1 from the fall. He stated that on the [NAME] she was a 2 person assist with positioning, but based on her condition it was appropriate for a 1 person assist at the time of the fall. He further indicated that the fall was caused by the resident unexpectedly changing position. He stated the fall was unexpected for her. Interview with Administrator on 5/24/23 at 11:00 am revealed that a Plan of Correction (POC) had been done for the incident that involved Resident #1. 5/24/23 at 11:30 am interview with the DON and Administrator revealed both indicated that they would not expect a resident to fall from the bed during an occupied full bed linen change. The DON stated the fall and injuries obtained by Resident #1 were determined as caused by the resident changing position unexpectedly and the Administrator agreed. The Administrator was notified of Immediate Jeopardy on 5/31/23 at 5:27 pm. The Administrator provided the following corrective action plan with a compliance date of 5/11/23. Address how corrective action will be accomplished for resident(s) found to have been affected: Resident #1 is a [AGE] year-old female, who has been a resident at the facility since 7/25/2016 and admitted to Hospice services 10/14/2022. She was admitted to the facility with the following diagnosis: GERD, Dysphasia, COPD, Candidiasis (skin, nail, vulva, and vagina), Allergic Rhinitis, Insomnia, Hypertension, Heart Failure, A. Fibrillation, Anxiety D/O, Hypothyroidism, Diabetes Mellitus, Vascular Dementia w/o behaviors, Depression D/O, Obstructive Sleep Apnea, Dyspnea and Obesity. Resident #1 is currently on Eliquis twice a day for the diagnosis of Arial Fibrillation. Nurse Aide #1 was providing ADL/Incontinent care to the resident. While positioned on her side Resident #1 kicked out her leg from the bed causing her to roll off the bed onto the floor between the bed and the window. Nurse Aide #1 immediately notified the residents' assigned nurse. Licensed Nurse #3 came to the room and completed a head-to-toe evaluation of the resident. Licensed Nurse #3 identified injuries to the residents' upper lip, left side of her forehead, nose, bilateral arms/legs and her right eye. First aid was initiated immediately, the Director of Nursing was informed, who immediately came to assist, and 911 emergency services were contacted. Licensed Nurse #3 and the Director of Nursing provided first aid while awaiting 911 emergency services. Resident #1 was transported to New [NAME] Regional Medical Center where she was admitted with a diagnosed of subdural hematoma. Nurse Aide #1 received retraining on bed mobility to include appropriate positioning of resident during care and safe bed mobility practices with return demonstrations on 5/11/23 by the Asst. Director of Nursing. Resident #1 returned to the facility on 5/10/23 and has been changed to requiring 2 persons to assist her with bed mobility and positioning. A care plan meeting was held with resident #1 representatives, resident #1, Administrator, Director of Nursing, and hospice services on 5/12/23. Address how corrective action will be accomplished for resident(s) having potential to be affected by the same issue needing to be addressed: All residents in the facility have the potential to be affected. An audit was completed of all current resident's positioning/bed mobility status by the Director of Nursing, Asst. Director of Nursing and Director of Rehabilitation Services to determine their current functional status and care needs. Current residents care plans have been reviewed and updated with any changes in functional mobility status by the MDS coordinator. Completed 5/11/23. Address what measures will be put in place and systemic changes made to ensure that the identified issue does not occur in the future. Current licenses nurses and CNA's including agency nurses received retraining on appropriate positioning/bed mobility status with a return demonstration. This included reviewing the 24-hour report daily in the morning clinical meeting to identify changes in condition. All newly hired licensed nursing staff and CNA's will be educated on the functional mobility evaluation by the Director of Nursing or designee during orientation. Any nurse or CNA including agency personnel not in-serviced by 5/11/23 will not be able to work until completion of education. Resident #1 has been changed to requiring 2 persons to assist her with bed mobility and positioning. Indicate how the facility plan to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The Director of Nursing and Assistant Director of Nursing conduct a random observation audit of 5 residents per week for 12 weeks to ensure appropriate positioning/bed mobility status. Also, the Director of Nursing and Asst. Director of Nursing will review the 24-hour report daily in the morning clinical meeting to identify changes in condition, 5 days a week for 12 weeks. The results of all observations and audits will be reported to the Quality Assurance Performance Improvement Committee by the Director of Nursing for 3 months to determine the effectiveness of this plan. Negative findings will be addressed by the committee. Additional interventions will be developed, implemented, and monitored by the Committee to ensure sustained compliance. Date of Compliance 5/11/2023 *This QAPI Action Plan must be discussed at your next QAPI meeting and Medical Director should review and sign. The QAPI Action Plan was signed and dated 5/12/23 by the Administrator and Department Managers On 5/24/23 at 12 pm, the corrective action plan with a compliance date of 5/11/23 was validated. The survey team confirmed the facility addressed the resident involved and acted to mitigate the risk of the other residents. The facility re-educated all staff on safety transfers and repositioning. The facility implemented an audit to update all care guides. The facility initiated a process to review resident's transfer capabilities and updated the care guides of all residents including new admissions. The facility also implemented the monitoring process, and it was to be included in the Quality Assurance and Performance Improvement Committee meeting. The facility's compliance date of 5/11/23 was validated.