**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff, Legal Guardian, and former facility Executive Director interviews, the facility failed to exercise the rights of the Resident's Representative when Resident #115 had unsupervised visits with her son despite restricted visitation instructions from the Legal Guardian. The Legal Guardian stated, on Friday 1/24/2025, she informed the Admission's Director and the Resident Concierge Resident #115 was not to have visits from her son without supervision. Resident #115 was cognitively impaired, was adjudicated incompetent, and had history of sexual interactions with her son that included sexual intercourse, open mouth kissing, and inappropriate touching as witnessed by the previous facility's Executive Director. The Admission's Director left the Social Worker (SW) a note on Friday evening after the SW left for the day telling her to call Resident #115's Legal Guardian regarding visitation and concerns with Resident #115's son. The SW did not learn of the restricted visitation until 1/27/2025 at approximately 5:30 PM when the SW spoke to the Legal Guardian by phone. Resident #115's son had unsupervised and unrestricted visitation from 1/24/2025 through 1/27/2025 until he was asked to leave the room by the SW after the phone call with the Legal Guardian. This deficient practice affected 1 of 1 resident (Resident #115) reviewed for guardian directives. Immediate jeopardy began on 1/24/2025 when the Legal Guardian informed the Admission's Director and the Resident Concierge that Resident #115 was to have supervised visitation with Resident #115's son and this was not implemented until 1/27/2025. Immediate jeopardy was removed on 2/1/2025 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with potential for minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: The discharge summary from the hospital dated 1/22/2025 did not include Resident #115's Legal Guardian's wishes. Resident #115 was admitted to the facility on [DATE] with a history of dementia, anxiety, and major depressive disorder. A baseline care plan dated 1/22/2025 did not contain any problems or interventions regarding supervised visitation for Resident #115. An admission minimum data set (MDS) dated [DATE] revealed Resident #115 was moderately cognitively impaired, with no behaviors, wandering, or rejections of care. Resident #115 was coded as dependent on staff for eating, oral hygiene, toileting, bathing, upper body dessing, lower body dressing, and personal hygiene. Resident #115 had clear speech and was understood. Review of a document scanned into the Electronic Medical Record (EMR) on 1/31/2025 contained a Letters of Appointment Guardian of the Person State of North Carolina document, dated 5/19/2022. The documentation revealed Resident #115 was adjudicated as incompetent and was appointed a Legal Guardian. Review of a document scanned into the EMR on 1/31/2025 contained a Guardianship Notification document from the Department of Social Services (DSS), that was undated. The documentation revealed Resident #115's son was to have restricted visits, 2 days a week, with supervision. A telephone interview was conducted on 1/30/2025 at 3:20 pm with Resident #115's Legal Guardian. The Legal Guardian stated she believes DSS took guardianship over Resident #115 in approximately 2015 due to a sexual relationship with her son. The Legal Guardian stated she had been responsible for Resident #115 since September of 2024. The Legal Guardian stated when Resident #115 was at a previous facility, Resident #115's son had tried to have sex with Resident #115, which led to supervised and limited visitation. The Legal Guardian stated she had spoken to the hospital when Resident #115 was admitted and informed them of the need for supervision and limitation with Resident #115's son. The Legal Guardian stated she had told the Admission's Director and the Resident Concierge on 1/24/2025 when she visited the facility. The Legal Guardian stated she had given the guardianship paperwork to the Admission's Director and the Resident Concierge when she visited in person on 1/24/2025. An interview was conducted on 1/30/2025 at 10:18 am with the Admission's Director. The Admission's Director stated that he had been in contact with the Legal Guardian via email regarding admission paperwork prior to Resident #115 being admitted to the facility. The Admission's Director stated the first time that he had spoken with Resident #115's Legal Guardian in person was on 1/24/2025 at which time the Legal Guardian reported Resident #115 had to have limited and witnessed visitations because of a previous sexual relationship between Resident #115 and Resident #115's son. The Admission's Director stated this sexual relationship had been perceived as okay by Resident #115 and Resident #115's son. The Admission's Director stated that he had let the SW know and stated he had not received any guardianship paperwork as of 1/30/2025. The Admission's Director stated he did not have the guardianship paperwork or paperwork regarding restricted visitation. The Admission's Director stated he had requested the documentation, but it had not been sent. The Admission's Director stated he had sent the admission's paperwork electronically and had not visited with Resident #115's Legal Guardian in person until 1/24/2025. The Admission's Director stated this was the first time he had admitted a resident with a Legal Guardian. A follow-up interview was conducted on 1/30/2025 at 3:51 pm with the Admission's Director. The Admission's Director stated he left a note for the SW to call Resident #115's Legal Guardian on 1/24/2025 and knew that she would not be back at work until 1/27/2025. The Admission's Director stated he had not told the DON, Administrator, or contacted the SW the evening of 1/24/2025 because he thought the Legal Guardian had just made a request for supervised visitation, not that it was required, based on a history of a sexual relationship between Resident #115 and Resident #115's son. An interview was conducted on 1/30/2025 at 10:38 am with the Resident Concierge (assistant/advocate). The Resident Concierge stated Resident #115's Legal Guardian had stopped by the Admission's Director's office on 1/24/2025 and voiced concerns about family relations and had stated Resident #115's son had sex with Resident #115, which was perceived as being okay by the family. The Resident Concierge explained that he was present in the office at the time of the visit and stated Resident #115's Legal Guardian had requested restricted and supervised visits to ensure that Resident #115 was okay. The Resident Concierge was unable to explain why he didn't tell anyone about the information obtained from the Legal Guardian. An interview was conducted on 1/30/2025 at 9:59 am with the Social Worker (SW). The SW stated Resident #115 was admitted to the facility last week (1/22/2025) and stated she had a Legal Guardian. The SW stated the Legal Guardian had not contacted the facility prior to Resident #115 being admitted . The SW stated last Friday (1/24/2025) the Legal Guardian had come by the facility after she had left for the day and stopped to talk to the Admission's Director and the Resident Concierge regarding concerns about Resident #115's son visiting and left a message for the SW to call her back. The SW stated she made multiple attempts on 1/27/2025 to contact the Legal Guardian and received a call back at approximately 5:30 pm. The SW stated she was told by the Legal Guardian that Resident #115's son was to have supervised visitation due to Resident #115's son attempting to perform sexual acts with Resident #115. The SW stated she had been told by the Admission's Director that the type of relationship Resident #115 and Resident #115's son had been consensual. The SW stated the Legal Guardian informed her at Resident #115's previous facility, Resident #115's son had to have scheduled supervised visitation due to Resident #115's son attempting to perform sexual acts, which she did specify. The SW stated Resident #115's son had been present at the facility every day from 1/22/2025 until 1/27/2025 and no staff members had observed any inappropriate behavior. The SW acknowledged that Resident #115's son had not had any supervised or restricted visitation since admission to the facility. The SW stated Resident #115's roommate was alert and oriented and had not mentioned any inappropriate behavior to staff. The SW stated after her conversation with the Legal Guardian on 1/27/2025 she went to Resident #115's room, where she observed three other men at the bedside in addition to Resident #115's son. The SW stated she asked the visitors to leave and advised Resident #115's son he would have to contact her to schedule supervised visitation and was not to visit Resident #115 unsupervised. A follow-up interview was conducted on 1/30/2025 at 3:48 pm with the SW. The SW stated she was notified by the Admission's Director on the morning of 1/27/2025 that she needed to contact Resident #115's Legal Guardian regarding scheduled visits with Resident #115's son. The SW stated she did not remember notifying the Director of Nursing (DON) or the Administrator on 1/27/2025 prior to speaking with the Legal Guardian around 5:30 pm. The SW was not sure why she had not alerted administrative staff about the concerns voiced by the Legal Guardian. The SW stated she did not have a copy of the guardianship papers and stated the facility had requested those documents. An interview was conducted on 1/30/2025 at 11:55 am with Nurse Aide (NA) #1. NA #1 stated she frequently cared for Resident #115 since she was admitted to the facility. NA #1 stated she worked day shift (7:00 am to 7:00 pm). NA #1 stated she had seen Resident #115's son arrived at the facility as early as 7:00 am and stated he stayed throughout the day. NA #1 stated Resident #115's son kept the curtain pulled in Resident #115's room. NA #1 stated Resident #115's son acted odd but did not specify. NA #1 stated she had not witnessed any inappropriate behavior between Resident #115 and Resident #115's son. Resident #115's son was unavailable for interview. An interview was conducted on 1/30/2025 at 11:25 am with Resident #72. Resident #72 was alert and oriented to person, place, time, and event. Resident # 72 acknowledged that she had been Resident #115's roommate since she was admitted to the facility. Resident #72 stated Resident #115's son visited Resident #115 every day, including the weekend 1/25/2025 and 1/26/2025, since she had been admitted to the facility until Monday (1/27/2025) when the SW came and told him he needed to leave. Resident #72 stated Resident #115's son would arrive around 8:00 am and stay all day until dinner trays were served between 4:00 pm and 5:00 pm. Resident #72 stated staff would bring Resident #115's son a guest tray at lunch. Resident #72 stated when Resident #115's son arrived each day, he would pull the curtain and keep the curtain closed the remainder of the day. Resident #72 stated Resident #115's son made her uncomfortable because he would stand at the door and look at her. Resident #72 stated she left the room on occasion to go to the common area at which time Resident #115 and Resident #115's son were alone in the room. An observation was conducted on 1/27/2025 at 12:47 pm of Resident #115. Resident #115 was not visible from the door due to the curtain being pulled. After entering the room, Resident #115 was observed lying in bed and Resident #115's son was sitting in a chair by the window next to her bed. Both were fully clothed. An observation was conducted on 1/30/2025 at 11:24 am of Resident #115. Resident #115 was lying in bed and did not respond when she was asked questions and did not make eye contact. An interview was conducted on 1/30/2025 at 1:52 pm with the Director of Nursing (DON). The DON stated Resident #115 had recently been admitted to the facility on [DATE] and reported Resident #115 was placed on supervised visitation after DSS notified facility staff of an inappropriate relationship between Resident #115 and Resident #115's son on 1/27/2025. The DON stated she was not made aware that the request for supervised visitation was made on 1/24/2025. The DON stated the Legal Guardian should have made the facility aware of the need for supervision prior to admission to the facility and stated that the Admission's Director and/or Resident Concierge should have notified her or the Administrator on 1/24/2025. The DON stated she would have honored the Legal Guardian's request starting 1/24/2025 if she had been made aware. An interview was conducted on 1/30/2025 at 3:55 pm with the Administrator. The Administrator stated Resident #115 was placed on supervised visitation on 1/27/2025. The Administrator stated she was not made aware the Legal Guardian had requested Resident #115 to have supervised visitation with Resident #115's son on 1/24/2025. The Administrator stated if she would have known on 1/24/2025 she would have implemented the supervised visits immediately. The Administrator was not able to recall what time, or who brought to her attention the concern regarding Resident #115 and her son. A telephone interview was conducted on 1/30/2025 at 12:07 pm with the Executive Director at Resident #115's former facility. The Executive Director stated he was very familiar with Resident #115 and stated that she resided at his facility from 1/29/2024 through 1/22/2025. The Executive Director stated Resident #115 was discharged from the facility to the hospital on 1/22/2025 due to requiring a higher level of skilled care. The Executive Director stated Resident #115 had a Legal Guardian after she was removed from the care of Resident #115's son. The Executive Director stated Resident #115 required supervised and limited visitation with Resident #115's son while at his facility due to inappropriate sexual behaviors such as open mouth kissing and inappropriate touching. The Executive Director stated Resident #115's son had stated Resident #115 was the only woman he had ever known. The Executive Director stated he had not reported the need for supervised visitation or limited visitation to the hospital when Resident #115 was transferred because he assumed Resident #115's Legal Guardian would be responsible for that. The Administrator was notified of Immediate Jeopardy on 1/30/2025 at 5:44 pm. The facility provided the following credible allegation of Immediate Jeopardy Removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 01/24/25, the Admissions Director and Resident Concierge were notified by Resident #115's guardian/resident representative that Resident #115 was to have supervised visitation due to a history of a sexual relationship between Resident #115 and Visitor #1 (Resident #115's son). The Admissions Director and Resident Concierge did not report this information to anyone until 01/27/25. The Social Worker was informed via note by the Admissions Director to contact Resident #115's guardian/resident representative regarding visitation on 1/27/25. The Social Worker attempted to reach Resident #115's guardian/resident representative multiple times throughout the day without success. At approximately 2:45pm on 01/27/25 a verbal discussion took place between the Admissions Director and Social Worker regarding the concerns voiced by Resident #115's guardian/resident representative regarding visitation. The Administrator was notified at this time and instructed the Social Worker to place Resident #115 on supervised visitation while waiting to obtain further information from Resident #115's guardian/resident representative. The Social Worker immediately went to Resident #115's room and asked Visitor #1 and two additional visitors to leave the room and meet with the Social Worker. During the meeting Visitor #1 was informed that all future visits would need to be scheduled with the Social Worker and supervised. Visitor #1 voiced understanding and exited the facility. Visitor #1 visited Saturday 1/25/2025 and Sunday 1/26/2025 and per the nurse working on the hall for approximately 6 hours each day. The nurse reported she observed Visitor #1 in Resident #115's room while standing out in the hall at the med cart outside of Resident #115's room. The supervised visits will be monitored by the Social Worker, if the Social Worker is not available at the time of the visit, the Administrator will be notified and will ensure that a staff member is assigned to monitor the visit for resident safety. At approximately 5:30pm on 01/27/25 the Social Worker was able to communicate with Resident #115's guardian/resident representative and was able to obtain specifics regarding the circumstances leading up to appointment of a guardian/resident representative with DSS and history with Visitor #1. On 1/30/25, all Residents with guardian/resident representatives were identified by the Social Worker. On 1/30/2025, all residents with visitor restrictions were confirmed. The care plan for Resident #115 was updated to reflect the visitation restrictions by the Care Plan Coordinator/Minimum Data Set Nurse on 1/30/2025. The Unit Supervisor completed a head-to-toe assessment on Resident #115 on 01/31/25. No signs of injury or distress were noted. Employees (nursing and housekeeping) that worked on Resident #115's unit from 1/24/25- 1/27/25 were interviewed in person or via phone by the Social Worker and Social Worker Assistant on 1/31/25 to determine if the staff witnessed any inappropriate sexual behaviors with Resident #115. No inappropriate sexual behaviors were identified. On 1/31/25 the resident's roommate was interviewed by the Social Worker to determine if any inappropriate sexual behaviors occurred from 1/24/25-1/27/25 during Visitor #1's unsupervised visits. 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: Education was performed by the Regional Admissions Director with the Admissions Director and Resident Concierge regarding proper notification to Administrator and/or Director of Nursing when admitting residents and the resident's guardian/resident representative made request including restricted/supervised visitation on 1/30/25. Regional Director of Admissions implemented a new form 1/31/2025, Guardian/resident representative or Power of Attorney Documentation Form, this form is to be completed for all new admissions prior to admission by the Admissions Director. This form will be used to identify if the Resident has a guardian/resident representative appointed or if any restrictions on visitation are in place, or other specific wishes requested by the appointed guardian/resident representative. This form will facilitate communication and ensure the notification of the Administrator and/or Director of Nursing. When a Resident is identified as requiring restricted or supervised visits or other wishes it will be added to the Resident's care plan by the appointed Administrative Nurse. Effective 1/31/25, Guardian/resident representative wishes will be reviewed quarterly or as needed by care plan coordinator and renewed. In addition to the care plan the information will be documented on the Resident's profile under special instructions by administrative nurse. Education was provided to the Care plan Coordinator and social worker on 1/31/2025 by Administrator and Director of Nursing that during baseline care plan and/ or quarterly care plan meetings the guardian/resident representative wishes are reviewed and ensured the wishes are reflected on the Resident's care plan which will add the information to the [NAME]. On 1/31/2025 the Social Worker was educated by the Administrator on the process for supervised visits and to ensure to respect and follow the guardian/resident representative wishes as though the resident is making the decision themselves. Supervised visits will be conducted as follows: Visitor will call the facility to schedule the visit with the Social Worker. Day of supervised visit visitor will come to the facility and ask for the social worker at the front reception desk. Social Worker will accompany the visitor to the Resident room or room decided on by Resident or visitor. Social Worker will remain present during the visit to monitor for Resident safety. When the visit is completed, the Social Worker will accompany the visitor to the front lobby and the visitor will exit the facility. If the Social Worker is not available, the Administrator will be notified and will ensure that a staff member is assigned to monitor the visit for Resident safety. If a visitor comes to the facility after hours that require supervised visits, the staff will ask the visitor to leave the facility and schedule the visit with the Social Worker. If the visitor refuses to leave, the facility staff will call law enforcement to have the visitor removed from the facility and notify the Administrator and Director of Nursing. On 1/31/2025 all certified nursing assistants were educated by the Staff development Nurse on supervised visitation process, where to identify on the [NAME] visitation restrictions, to notify administrative on call number if restrictions are not followed, and that facility is to adhere to any guardian/resident representative wishes. On 1/31/2025 all Nurses were educated by the Staff development Nurse on supervised visitation process, where to identify on the [NAME] visitation restrictions, where the visitation restriction will be located on the Resident profile chat under special instructions, and to ensure to respect and follow the guardian/resident representative wishes as though the resident is making the decision themselves. Nursing staff will understand this is information that is expected to be passed along in the report. On 1/31/2025 All Administrative Nurses were educated by the Director of Nursing on the process for supervised visitation, how to add to the [NAME] on visitation restrictions, where the visitation restriction will be added on the Resident profile chart under special instructions, and to ensure to respect and follow the guardian/resident representative wishes as though the resident is making the decision themselves. If a resident was identified as needing new restrictions the appointed administration nurse by the Administrator or Director of Nursing will notify the nurse on the hall and front desk, and will add restriction to [NAME], and resident chart under special instructions. IJ removal date: 2/1/2025 A validation of immediate jeopardy removal was conducted on 2/6/2025. An audit was conducted on 1/30/2025 to identify which residents had a guardian or representative and to ensure that any visitor restrictions were honored. Interviews with facility staff (housekeeping and nursing) revealed staff knew who required restricted/supervised visitation and what to do if a restricted visitor showed up at the facility unscheduled or refused to leave (which included notifying law enforcement). Interviews with the Admission's Director and Resident Concierge revealed they had received education regarding changes to the admissions process which included gathering guardianship information, restrictions with visitation, and information regarding limited visitation on a new form. The Admission's Director and Resident Concierge also verbalized guardianship papers would be received/reviewed prior to a resident being admitted and the Administrator and Director of Nursing would be notified immediately. Interviews with staff who participate in baseline care plan meetings and quarterly meetings revealed staff would review guardian/representative wishes at each meeting and their wishes would be reflected in the care plan. Interviews with the Social Worker and Receptionist revealed restricted/supervised visitors were to call to schedule a supervised visit with the SW, when the visitor arrived at the facility, the Receptionist should notify the SW, the SW should remain with the visitor for the duration of the visit and should walk them out following the visit. The immediate jeopardy date of 2/1/2025 was validated.