**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #4 was admitted into the facility 12/7/2020 with diagnoses of unspecified dementia, unspecified severity, with psychotic disturbance, generalized anxiety disorder, depressive episodes, and acquired absence of right leg above knee. A review of Resident #4's quarterly Minimum Data Set, dated [DATE] indicated that he was moderately cognitively impaired, had no behaviors, and no rejection of care. A review Resident #4's comprehensive care plan revealed a focus created on 2/9/21 of resident/patient exhibits or has the potential to exhibit physical and verbal behaviors related to: unspecified dementia, unspecified severity, with psychotic disturbance. Interventions included evaluating the nature and circumstances (i.e., triggers) of physical behavior with resident and/or resident representative. Discuss findings with resident and family members/caregivers and adjust care delivery appropriately. Encourage the resident to seek staff support for distressed mood. Observe for non-verbal signs of physical aggression, e.g., rigid body position, clenched fists, etc. Remove the resident from the environment, if needed. Gently guide the resident from the environment while speaking in a calm, reassuring voice. If the resident becomes combative or resistive, postpone care/activity and allow time for him to regain composure. Resident #2 was admitted into the facility on 3/2/22 with diagnoses of non-Alzheimer's dementia, anxiety and depression. A review of Resident #2's annual Minimum Data Set, dated [DATE] indicated that he was moderately cognitively impaired and had no behaviors or rejection of care. A review of Resident #2's comprehensive care plan revealed a focus on Resident/patient exhibits or is at risk for distressed/fluctuating mood symptoms related to: Sadness/depression with interventions of Provide resident/patient with opportunities for choice during care/activities to provide a sense of control and Social Service visits to provide support, as needed. On 2/20/24 the facility submitted an initial allegation report related to Resident #4 and Resident #2 having an altercation when Resident #2 ran over Resident #4's foot while leaving an activity. Resident #4 then punched Resident #2 on the right side of his face near his nose resulting in a bruise. The residents were separated, and Resident #2 was sent to the emergency room for evaluation and Resident #4 refused to go for evaluation. The facility notified the resident representatives, medical director, adult protective services, and police. A review of the hospital report dated 2/20/24 for Resident #2 indicated a computerized tomography revealed no intracranial or facial injuries or abnormalities and he returned with no new orders. The facility investigated, and a witness statement dated 2/20/24 was obtained from the Recreational Activity Assistant that stated Resident #2 had approached the Recreational Activity Assistant for a muffin. When he received his muffin, he proceeded to leave and accidentally bumped into Resident #4. Resident #4 then punched Resident #2, Resident #2 started to defend himself and the residents were separated. The Director of Nursing interviewed Resident #2 who stated that he had run into another resident and was going to apologize when Resident #4 hit him. The former Social Worker noted that Resident #2 was very apologetic. An interview was conducted with Nurse #5 (who is normally scheduled on Resident #4's hall) on 5/22/24 at 9:00 AM revealed that Resident #4 was moody and if he refused something Nurse #5 would leave him alone at that time and would go back and try him again. He further revealed that he could usually tell what mood Resident #4 was in and adjusted what he needed to do to ensure that he did not escalate the behavior or situation. An interview conducted on 5/22/24 at 11:00 AM with the Recreational Activity Assistant revealed that Resident #2 had attended a baking activity. When Resident #2 received his muffin, he attempted to turn his wheelchair to leave and bumped or ran over Resident #4's foot on accident. She stated that before she could get to the two residents Resident #4 had punched Resident #2 and Resident #2 had hit Resident #4 back. She stated that she called for help and separated the two residents. An interview was conducted on 5/22/24 at 11:30 AM with the Recreational Activity Director who sat with Resident #4 indicted that Resident #4 was normally a loner who did not like anyone in his personal space however once he felt his space was being invaded, he became hostile either verbally or physically towards the person. She further indicated that during the time she sat with him he was in his room watching television and she had no problems with him. She also indicated that if he had become aggressive that she would have given him space and talked calmly to him so she would not antagonize him more. An interview conducted on 5/22/24 at 1:00 PM with Resident #4 indicated that he remembered the incident and stated that that guy ran over my foot, and I hit him he further indicated that he only had one foot left and he was going to protect it any way that he could. He denied that he had received any injury related to the altercation. An interview conducted on 5/22/24 at 1:30 PM with Resident #2 revealed that he remembered the incident and that he had accidentally ran over another person's foot when he was turning his wheelchair to leave, and the other person hit him, so he hit him back. He further stated that he had not had any issues with the other person before or since that time. An interview with the Administrator on 5/22/24 at 2:00 PM indicated that she was made aware of the incident and that the residents had been separated. She stated that Resident #4 was immediately put on one to one until psychiatric services saw him, both residents had skin checks completed, and Resident #2 was sent to the emergency room for evaluation, but Resident #4 refused to go to the emergency room for the evaluation stating that he was fine. The Administrator stated that Resident #2 returned from the emergency room with no new orders and noted that he had sustained no fractures but did have a bruise located by his nose. She further indicated that Psychiatric services saw Resident #4 the next day and removed him from one on one after she spoke to him and readjusted his medication. The facility initiated a four-step plan of correction which included: On 2/20/24 Resident #4 and Resident #2 were both separated, and Resident #4 was placed on one-to-one supervision. As of 5/19/24 Resident #4 has been placed on one-to-one supervision indefinitely. The Abuse Prevention Coordinator was notified of the occurrence and a report was filed with the Department of Health and Human Services on 2/20/24. The administrator and or designee notified Adult Protective Services of the occurrence on 2/20/24. The Licensed Nurse assessed Resident #4 and Resident #2 on 2/20/24 and notified the Physician and responsible parties. The Social Service Director assessed Resident #4 on 2/20/24 and a referral for Psychiatric services was generated. Psychiatric Services evaluated Resident #4 on 2/21/24 and changed his medication. Psychiatric Services re-evaluated Resident #4 on 2/27/24 with no changes in orders. How the facility identified other residents having the potential to be affected by the same deficient practice. A licensed nurse and/or designee conducted a 30 day look back of incident/accidents and no further resident to resident altercations and/or changes in behavior were noted as of 3/20/24. The measures put into place or systemic changes made to ensure that the deficient practice will not occur was completed by: The Nurse Practice Educator and/or designee-initiated re-education with employees on the Abuse Prohibition policy with emphasis on strategies to reduce and/or prevent resident to resident altercations. This education was started on 2/20/24 and was completed on 2/22/24. Supervision by the Administrator and/or his designee during mealtimes to assist with the flow of traffic in and out of the dining area also started on 2/22/24. The Director of Nursing and or/designee will audit a sample of residents who exhibit identified behaviors of wandering, physical behaviors towards staff or others, and verbal behaviors towards staff or others, weekly for 30 days starting 2/20/24, then monthly for two months to ensure no other residents to resident altercations and ensure the plan of care was being followed to reduce behaviors. The Nursing Home Administrator and/or designee will review the results of the audit of any resident-to-resident altercation prior to 2/20/24 in the next Quality Assurance Performance Improvement meeting. The Administrator or Director of Nursing or Designee will review, and report results of the audits in the Quality Assurance Performance Committee meeting monthly for one quarter. If the audits reveal a potential or actual event related to resident to resident altercations subsequent plans of correction will be submitted as necessary. This will start with the next Quality Assurance Performance Committee meeting in March of 2024. The plan of correction was verified on 5/23/24 by reviewing the one-on-one documentation for 2/20/24-2/21/24 and one-on-one documentation from 5/19/24 to 5/23/24. The Psychiatric notes dated 2/21/24 noted that the Psychiatric Nurse Practitioner had removed Resident #4 from one-on-one and had increased Resident #4's Zyprexa. Her note dated 2/27/24 was also reviewed and reflected no additional changes in his medication and noted no further behaviors. A review of the in-service Abuse and Neglect and Resident Rights conducted on 2/20/24 through 2/24/22 was reviewed to ensure 100% of the staff had attended and interviews were conducted with random staff to ensure education had been received and understood. A review of the Quality Assurance Performance Committee meeting minutes included the audits of resident behaviors and of the 30 day look back period for any resident to resident altercations. Observations during mealtimes during the survey dates for flow of traffic in and out of the dining area were completed and a review of the monitoring of sampled residents who exhibited behaviors was completed. The validation verified the deficiency was corrected on 5/18/24. Based on observations, record review, and interviews with residents, staff, medical doctor, nurse practitioners, and law enforcement, the facility failed to protect a female (who was deemed an incompetent person by the North Carolina Clerk of Court) resident's (Resident #1), right to be free from sexual abuse by a cognitively impaired male resident (Resident #2). On 05/15/24 Resident #1 was naked from the waist down in her bed when Nursing Assistant (NA) #1 observed Resident #2 in Resident #1's bed with his face between Resident #1's legs. Resident #1 was incapable of giving consent for Resident #2 to touch her. A reasonable person expects to be protected from abuse in their home environment and sexual abuse would cause trauma. Additionally, the facility failed to protect Resident #2 from resident to resident physical abuse. Example #2 was cited at a scope and severity of D. This deficient practice affected 2 of 4 residents reviewed for abuse. The findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses which included, in part, dementia with other behavioral and psychotic disturbance, muscle weakness, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic pain syndrome, depression, anxiety disorder, muscular dystrophy, and bed confinement status. A review of the State of North Carolina Letters of Appointment Guardian of the Person document revealed Resident #1 was deemed an incompetent person before the Clerk of The General Court of Justice Superior Court Division on 07/27/23. A review of Resident #1's annual Minimum Data Set (MDS), dated [DATE], revealed that Resident #1 was severely cognitively impaired. A review of Resident #1's Care Plan, last updated 02/07/24, revealed she exhibits or has the potential to demonstrate verbal and physical behaviors related to cognitive loss/dementia and indicated she preferred to wear facility gowns versus her own clothing and had tendencies to expose herself while lying in her bed without privacy precautions. The Care Plan indicated she had a Brief Interview for Mental Status (BIMS) score of 3 and noted it fluctuated at times. The Care Plan specified Resident #1 had impaired/decline in cognitive function or impaired thought processes related to vascular dementia and acute encephalopathy and exhibits or is at risk for alterations in functional mobility related to cerebrovascular vascular accident (stroke) with left-sided flaccid hemiplegia. The Care Plan indicated Resident #1 met Preadmission Screening and Resident Review (PASRR) II Level of determination secondary to serious mental illness. A review of Resident #1's quarterly MDS, dated [DATE], revealed that Resident #1 was cognitively intact, had the ability to make herself understood, had the ability to understand others, and had no behaviors. The MDS indicated that Resident #1 was dependent on staff for oral hygiene, toileting hygiene, bathing, upper and lower body dressing and personal hygiene. Resident #2 was admitted to the facility on [DATE] with diagnoses which included dementia with other behavioral disturbances, cognitive communication deficit, mental disorder not otherwise specified, depression, anxiety disorder, and muscle weakness. A review of Resident #2's quarterly MDS, dated [DATE], indicated that Resident #2 was moderately cognitively impaired with clear speech and the ability to make himself understood and to understand others. The MDS indicated Resident #2 had no behaviors and required the extensive assistance of one staff for bed mobility and transfers, had no impairment with his upper and lower extremities, and used a wheelchair as a mobility device. A review of Resident #2's Care Plan, last updated on 03/15/24, revealed Resident #2 had the tendency to exhibit sexually inappropriate behaviors related to cognitive loss and dementia (initiated on 01/11/23), and had impaired and/or declined cognitive function or impaired thought processes related to dementia. An interview was conducted with Resident #3 on 05/23/24 at 8:15 a.m. Resident #3 was assessed as severely cognitively impaired on 02/27/24. Resident #3 asked if this interview was about the incident involving her roommate (Resident #1) and Resident #2 that had occurred a few nights ago or the one a while back. When asked to explain, she said one weekend not too long ago (referring to the 05/11/24 incident), she said she had left her room and when she returned, she saw Resident #2 trying to get in the bed with Resident #1. She said she immediately left the room to find the nurse (Nurse # 1) and report him to her. Resident #3 said the nurse came to the room and threatened to call the law if he would not leave the room. Resident #3 said Resident #2 was always in her & Resident #1's room, day or night, because Resident #1 always wanted him to bring her a soda. She said as far as she knew, the two of them never had a sexual relationship but they did have a friendship and he spent a lot of time in their room bringing her sodas and talking to her. A review of Resident #2's Progress Notes revealed he had been discovered by Nurse #1 on 05/11/24 entering a female resident's room and attempting to get in the bed with her. An interview was conducted with Nurse #1 on 05/22/24 at 1:15 p.m. Nurse #1 indicated on Saturday, 05/11/24, around 1:00 p.m. - 2:00 p.m., Resident #3 was observed standing in the doorway to her and Resident #1's room and called for the nurse. Nurse #1 stated she went to the room and observed Resident #2 attempting to get into Resident #1's bed. Nurse #1 stated she had never known Resident #2 to display any inappropriate sexual behaviors with Resident #1 or any other resident. She explained that Resident #1 and Resident #2 have always had a friendship and he often brought her sodas; however, on that day, she observed Resident #2 to have placed his wheelchair beside Resident #1's bed and had one of his knees on the side of her bed as if he was trying to climb into the bed with her. Nurse #1 stated Resident #1 told her, he's not doing anything and that Resident #2 did not say anything. Nurse #1 stated she then removed Resident #2 from the room, returned him to his room, and put him into his bed. Nurse #1 explained she called the Director of Nursing (DON) to get the telephone number of the new Assistant Director of Nursing (ADON) who was their on-call admin that day. She further explained she informed the DON of the incident who instructed her to call the ADON. She did so and was told by the ADON to document the incident and because she had already removed Resident #2 from Resident #1's room, there had been no further instructions. An interview was conducted with the ADON on 05/22/24 at 1:50 p.m. The ADON explained she had received a phone call from Nurse #1 on 05/11/24 about Resident #2 attempting to get in bed with Resident #1. The ADON further explained, stating that because Nurse #1 had already removed Resident #2 from Resident #1's room and had placed him in his bed, she said she instructed the nurse to continue to monitor. The ADON stated she failed herself in that she had not asked the nurse if Resident #1 was in her bed at the time Resident #2 was attempting to get in the bed as she assumed he was just trying to get into the bed. When asked if this incident had been discussed with the Interdisciplinary Team during their Monday morning meeting, she indicated it may have been since it had been a change in Resident #2's condition, however she did not have any notes from that particular meeting. Review of the facility's Initial Allegation Report, completed by Nurse #3 on 05/15/24, revealed an allegation of resident abuse on 05/15/24. The facility became aware of this allegation on 05/15/24 at 4:30 a.m. The allegation stated that a male resident (Resident #2) was found in a female resident's (Resident #1) room and that the male resident was noted to be performing oral sex on the female resident. The report indicated the facility reported the incident to law enforcement on 05/15/24 and to the State agency on 05/15/24. The witness statement from NA #1 was reviewed. It read, .Patient [Resident #2] was addressed several times from getting in and out of bed. Patient was then placed up front to desk. Patient stated he was ready to go to bed. Patient was placed in bed. Patient was watched for 20 minutes and I started my rounds. I heard bell ringing and step into hall. I went to answer call light and saw [Resident #2] with his face between [Resident #1's] legs with her diaper off. Nurse was notified ASAP [as soon as possible]. Nurse responded ASAP. [Resident #1] stated that nothing happened. I saw [Resident #2] with his mouth on [Resident #1's] private part. An interview was conducted with NA #1 on 05/21/24 at 12:13 p.m. NA#1 confirmed she worked the 11:00 p.m. to 7:00 a.m. shift that began on 05/14/24 and ended on 05/15/24 and had been assigned to care for both Resident #1 and Resident #2 during her shift. NA #1 explained Resident #1 was alert and able to make her needs known and required the extensive assistance of staff to being fully dependent on staff for her care needs. She explained that Resident #1 frequently removed her adult diaper and hospital gown so to find her in a stage of undress was not unusual for her. NA #1 explained Resident #2 had never displayed inappropriate sexual behaviors and admitted that he was known for frequent masturbation, however that act was always performed when he was in his own room. She stated that she had never known Resident #2 to make inappropriate sexual remarks or display inappropriate sexual behaviors towards other residents or staff. NA #1 stated that the rooms of each resident, on the morning of the incident, were located on opposite sides of the same hall however not quite directly across from each other. NA #1 explained that Resident #2 had been up and down all night and had required frequent redirection that night, which had been unusual for him as he typically stayed in his bed, in his room, at night. NA #1 stated she was not sure what had been going on with Resident #2 that particular night, but because he had been restless, she had given him a shower and placed him at the nurses' station in his wheelchair. She explained that he sat at the nurses' station for a couple of hours while she continued to make rounds on her other residents. She stated she had noticed Medication Aide (MA) #1 had taken him back to his room because he had wanted to lie down and stated she continued making rounds. Around 3:30 a.m. - 4:00 a.m. (05/15/24), she noticed the call light for Resident #1's room had come on and she went to the room to respond to it. Upon arriving to the room, the door to the room was shut and she had not been able to open it fully as Resident #2's wheelchair was blocking the door from opening all the way. NA #1 explained she was able to push open the door enough so as to allow her head into the room and stated when she looked in, she noticed Resident #2's wheelchair was positioned near the foot of Resident #1's bed (with the wheelchair facing the head of Resident #1's bed), between the wall and the left side of Resident #1's bed however it blocked the door to the room fully opening. She stated she observed Resident #2's right foot on the floor and his left leg and upper torso was in the bed with Resident #1, with his face between Resident #1's legs and his mouth on Resident #1's vagina. She noted that he was dressed in a t-shirt and pajama bottoms while Resident #1 was observed in a hospital gown which had been pulled off one of her shoulders and the bed covers were pulled up to her chest but pulled away from the lower half of Resident #1's body leaving her exposed from the waist down. She stated Resident #1's adult diaper had been taken off and was noticed on the floor beside the bed. NA #1 indicated Resident #1's breasts were not exposed. NA #1 explained she and Resident #1 made eye contact but Resident #1 did not say anything at that time. She stated Resident #2 seemed unaware he was being observed. NA #1 stated she asked them, what are y'all doing? at which time Resident #2 became aware of her presence and looked at her but did not say anything. NA #1 stated she then took a step back, away from the doorway but still in sight of the residents, and immediately called for Nurse #4 who had been standing in an area by the front of the nurses' station. NA #1 stated Nurse #4 immediately came to the room. NA #1 heard Resident #1 tell the nurse that nothing happened. The witness statement from Nurse #4 was reviewed. It read, [Resident #2] has made multiple attempts entering [Resident #2's] room. He was put to bed multiple times with himself transferring back the bed and attempting to enter her room again. He sat with us at the nurses' station for a while until he stated he was ready to lay down. After 20 minutes of no signs trying to get up again, me and the CNA [certified nursing assistant] [NA #1] was doing her rounds. She went into [Resident #2's] room to do care and found [Resident #1] with his head between her legs performing oral sex. She immediately informed me and resident [Resident #2] was removed from room. Unit Manager was called. DON [director of nursing] was called. Administrator was called with no answers. I then called [name of an Administrator from a sister facility who was assisting the facility while the facility's Administrator was out on leave] for further instructions. He directed me to call both resident's families and ask if they feel they are capable of making decisions. Placed [Resident #2] on 1:1 supervision, perform skin check on female resident. I got in contact with [Resident #2's] RP [responsible party], left a voicemail for [Resident #1's] RP to call the facility back at her earliest convenience. Got statements from all involved. Female stated nothing happened, male could not give coherent statement. An interview was conducted with Nurse #4 on 05/21/24 at 3:47 p.m. Nurse #4 confirmed she worked on 05/14/24 from 7:00 p.m. until 7:00 a.m. (05/15/24) and had been assigned to care for Resident #1 and Resident #2. She explained she had noticed Resident #2 was awake, in his wheelchair, and that he kept trying to enter Resident #1's room and that he had to be frequently redirected. She said this was abnormal behavior for him; around 12:30 a.m. - 1:00 a.m. (05/15/24), he had been brought to the nurses' station where he stayed for approximately an hour. She stated around 3:30 a.m., the resident started nodding off, so he was brought to his room, assisted back into his bed and that once he started to fall asleep, she left. The nurse said around 15 minutes later, NA #1 informed her that Resident #2 was in Resident #1's bed and stated she immediately went to the room but once there, she could not fully open the door as his wheelchair was blocking it from inside the room. Since he was already back in his wheelchair, she pushed open the door wide enough for her to shimmy her way in there and immediately removed him from the room. Because of what NA #1 had told her, she returned to Resident #1's room and performed a skin assessment which included her perineal area (the area between the anus and vulva in females) which did not reveal any signs of trauma. After that, Nurse #4 stated she began making phone calls to the administrative staff which included the Administrator, the DON and the Unit Manager. When she did not get an answer, Nurse #4 called the Administrator from a sister facility (who had been assisting their facility during the absence of the facility's Administrator) who instructed her on what the next steps would be to begin an investigation of the incident. She stated she called the Responsible Party (RP) for Resident #2 and spoke with her. She stated she then called the guardian of Resident #1 (as she is a ward of the State) and left a message for her to return the call. Nurse #4 stated the guardian returned her call while and explained that Resident #1 was not able to give consent for a sexual act. Nurse #4 stated after that, the Unit Manager (Nurse #2) had arrived and had been the one to call local law enforcement who came to the facility and interviewed the staff. Nurse #4 stated she provided the police officer a copy of the statements she had taken from Resident #1 and Resident #2. Nurse #4 stated Medication Aide (MA) #1 witnessed her conversations with the Resident #2's RP and with Resident #1's guardian. An interview was conducted with MA #1 on 05/22/24 at 8:49 a.m. MA #1 confirmed she worked on 05/14/24 from 7:00 p.m. until 7:00 a.m. She stated she had worked at the facility for as long as both residents had resided there and had never known Resident #2 to display any inappropriate sexual behaviors before. She also said it was the first time that she could recall seeing Resident #2 up in the middle of the night. MA #1 explained she had been charting at the desk at the nurses' station when she observed Resident #2 going into Resident #1's room, estimating the time to be before 4:00 a.m. but was unsure of the exact time. MA #1 further explained she took Resident #2 out of Resident #1's room and brought him to the nurses' station where he sat for approximately 15-20 minutes and then he was brought to his room. She stated after another 15-20 minutes or so, the call light for Resident #1's room came on, explaining it had been Resident #1's roommate (Resident #3) who had pressed the call light. MA #1 said she saw NA #1 go to the room to respond to the light and then heard NA #1 yell for Nurse #4 to go to the room. MA #1 said when NA #1 returned to the nurses' station, she described to her what she had witnessed in the room - that Resident #2 was in bed with Resident #1 and had his head between her legs. MA #1 clarified that she had not written a statement about the incident as she did not witness anything herself, however, she did witness the statements Nurse #4 had taken from the two resident's responsible parties. An interview was conducted with Resident #3 on 05/23/24 at 8:15 a.m. Resident #3 said the other night (referring to the 05/15/24 incident), Resident #2 probably would not have come into the room if Resident #1 had not invited him in. She said she was awake and although the curtain between the two beds was pulled and she could not see anything, she could hear the two of them whispering back and forth. Resident #3 said she could not really hear what they were whispering about, but she was adamant that Resident #1 never hollered out while Resident #2 was in the room. She said she pushed the call light button so someone would come and get him out of her room at that time of morning. An interview was conducted with Resident #1 on 05/21/24 at 11:10 a.m. She was observed sitting up in her bed and wearing a hospital gown. After introductions, Resident #1 asked, is this about [Resident #2]? and then, before any further conversation, Resident #1 said, I told him not to ever come back in here because he tried to come get in the bed with me. I had to hit him on the side of his head, and I stopped him from trying to get in bed with me. When asked if she had invited Resident #2 into her bed, she stated she had not and remarked that he had tried to go up under the covers and touch her leg and repeated what she had said moments before. Resident #1 then became focused on various body aches and pains and wanted to see her nurse and did not want to discuss the incident any further, therefore, the interview was stopped at this time. A second interview with Resident #1 was conducted on 05/21/24 at 1:42 p.m. during which she was more receptive to questions and conversation about the incident of 05/15/24. Resident #1 was adamant that Resident #2 did not sexually assault her and stated that he did try to touch her leg under her bed covers and wanted to talk with her however, she could not understand what he was saying and she had told him to get out of her room and to never come back. Resident #1 stated Resident #2 did not touch her vagina with his hands, mouth or tongue. She stated he would bring her red sodas and admitted he was not her friend nor was she afraid of him. Resident #1 acknowledged the fact that she prefers to wear hospital gowns and stated she frequently removes them because they are aggravating. She also said she has to wear an adult diaper however, the tabs come undone which is also aggravating, so she will take it off frequently. Resident #1 remarked that she did not want Resident #2 to get in trouble for trying to touch her and said, what's done is done. An interview with Resident #2 was conducted on 05/21/24 at 1:59 p.m. He was observed sitting in his wheelchair assisting the Activities Director who had been assigned to stay with him during his 1 on 1 observation that day. Resident #2 admitted that he and Resident #1 were friends and that he would occasionally buy her a red soda and bring it to her in her room. When asked, Resident #2 stated he did recall the 05/15/24 incident. He explained when he was in Resident #1's room, she encouraged him to perform oral sex on her when she pulled the covers back and had her legs open. Resident #2 stated he did not have intercourse with her and said that she was so nice that he had wanted to treat her like a girlfriend. He also stated that Resident #1 did not tell him to stop or get out of the room and that she did not hit him. He stated after the incident, he was moved to another room on the other side of the facility and that Resident #1 had been moved to another facility. An interview was conducted with the Unit Manager (Nurse #2) on 05/22/24 at 9:11 a.m. She confirmed that she worked on 05/15/24 from [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and physician interviews, the facility failed to notify the physician when Resident #1 developed an opened area the size of a nickel on his scrotum with significant amounts of pus or drainage. Resident #1 had a history of Fournier's gangrene (a rare, life-threatening bacterial infection of the scrotum, penis or perineum), abscess of corpus cavernosum (tissue forming the bulk of the penis), and sepsis. Resident #1 was assessed for abscesses at the emergency department of Hospital #1 and transferred to Hospital #2 for urology care. Hospital #2 operated on the scrotal abscess and debrided the Fournier's gangrene. Resident #1's post operative stay was complicated by continuing sepsis and end organ dysfunction (damage occurring in major organs fed by the circulatory system). This deficient practice occurred for 1 of 3 residents reviewed for notification of change (Resident #1). Immediate jeopardy began on [DATE] when the physician was not notified of a new open area Resident #1's scrotum. Immediate jeopardy was removed on [DATE] when the facility provided and implemented an acceptable allegation of Immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective and the completion of staff education. Findings included: Resident #1 was admitted to the facility on [DATE]. His medical history in the facility medical record included paraplegia, presence of urogenital implants, necrotizing fasciitis (a rare bacterial infection that spreads quickly in the body and can cause death), Fournier's gangrene (a rare, life-threatening bacterial infection of the scrotum, penis or perineum), abscess of corpus cavernosum (tissue forming the bulk of the penis), and sepsis. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed he was assessed as moderately cognitively impaired. His active diagnoses included wound infection, anemia, hypertension, heart failure, neurogenic bladder, diabetes mellitus, paraplegia and multiple sclerosis. He was documented to have an indwelling catheter and colostomy. During an interview on [DATE] at 10:21 AM Nurse #4 stated she provided wound care for Resident #1 on [DATE] and noted no skin breakdown areas to his scrotum. The nurse did not indicate there was any swelling or raised areas. During an interview on [DATE] at 11:28 AM Nurse #2 stated on [DATE] during the morning around 6:00 AM she went to administer a medication injection to Resident #1's stomach and when she pulled the sheets back, she thought they were wet with urine. She noted his indwelling catheter was kinked under his thigh. She unkinked the tubing, got urine flow, and she was able to give him his medicine. She indicated she informed him the nurse aides were going to clean him up. A short time later the nurse aides (Nurse Aides #1 and #2) told her Resident #1 had an open area to his scrotum that needed to be assessed. She stated she then went down to assess him and said, I heard you have something on your scrotum I need to look at, and he responded, no. She told him she needed to see it to make sure he was okay, and he told her You can look at it but don't touch it. She stated she visualized his scrotum, and there was an open area the size of a nickel with no bleeding or drainage. Resident #1 then covered it up, so she only had a brief look at it, and she told him they needed to take care of it. He indicated they could take care of it later. Nurse #2 reported she told Resident #1 she would let the oncoming nurse know about the area as the day shift provided wound care. She stated this was around 6:00 - 6:15 AM and the next shift started at 7:00 AM. She stated she then told Nurse #1 about the area at change of shift report. She concluded since she could not examine the wound, she did not have anything to report to the physician so she did not notify the physician as the day shift would do that when they completed wound care. During an interview on [DATE] at 10:55 AM Nurse Aide (NA) #1 stated Resident #1 needed to be cleaned up on [DATE] in the early morning and he often would refuse care. Both she and Nurse Aide #2 entered Resident #1's room. She stated they thought it was urine that had leaked everywhere when they first entered and assumed something had happened to his catheter. Resident #1 had a suprapubic catheter and when they removed a towel, which was on top of his scrotum, they noted it was not urine but fluid leaking from what appeared to be an open area to his scrotum. The right side of his scrotum appeared to have ruptured open leaving black tissue and yellow drainage to the area. The area covered the right side of his scrotum and was very alarming which they indicated to the nurse. She stated they ensured his comfort and then notified Nurse #2 to assess the area. NA #1 stated about 5 minutes later Nurse #2 came to her and indicated Resident #1 had refused to let her assess the area. NA #1 then told Nurse #2 that she was very concerned about that area and that he needed to be assessed as soon as possible as it was a very pressing issue. Nurse #2 then walked away, and NA #1 thought she was going back to Resident #1, so she did not report the concern to the oncoming nurse aide. This all happened around 6:00 AM and her shift ended at 7:00 AM. During an interview on [DATE] at 11:50 AM Nurse Aide #2 stated she cared for Resident #1 on night shift (7:00 PM to 7:00 AM) on [DATE] and [DATE]. On the night shift of [DATE] no concerns were noted with Resident #1 and his scrotum during her activities of daily living care that shift. The morning of [DATE] Nurse #2 came to her and requested she clean the resident as he had gotten urine all over himself. She stated this was unusual as he had a suprapubic catheter as well as a colostomy. She stated she went and got Nurse Aide #1 and went to the room to clean him up. They took his gown off and began cleaning him up and when they removed his brief to clean his groin area, they noted from his waist down to his knees the fluid did not have the appearance of urine but instead had the appearance of pus or drainage. She stated they continued to clean him up and on the right side of his scrotum there was area about the size of a dime that appeared slightly swollen but was not black but flesh colored and as they cleaned it, they noted that the drainage was coming from that open area and there was so much drainage that they had to use a brief like pad on the front part of his scrotum to keep him from becoming soaked again in drainage. She stated she then went and let Nurse #2 know that Resident #1 was cleaned up but had a new open area to his scrotum and they had cleaned up pus and drainage but no urine. The nurse indicated she was passing medications but then would go in and check on the resident after, so NA #2 did not report the concern to the oncoming nurse aide. She concluded her shift ended and she had no further involvement with Resident #1 and did not know if the nurse assessed the resident or not. During an interview on [DATE] at 10:13 AM Nurse Aide #3 stated she took report that morning, on [DATE], from Nurse Aide #2 and the nurse aide indicated Resident #1 had a bath and she had emptied his catheter and colostomy bags. Nurse Aide #2 did not mention anything which indicated Resident #1 had a change to his scrotum, so Nurse Aide #3 did not have a reason to visualize Resident #1's scrotum or request the nurse assess it. During an interview on [DATE] at 9:06 AM Nurse #1 stated she was his regular nurse. She further stated it was important to know Resident #1 had no feeling to his groin and scrotum so he could not tell if something was hurting him there. She stated on [DATE] she worked a 12-hour shift beginning at 7:00 AM. She was not notified of any concerns from Nurse #2 with Resident #1 during change of shift report, so she had no reason to assess or contact the physician regarding Resident #1. She worked her shift as normal and completed her medication passes and then was doing wound care around 6:00 PM that day when she was going in to provide wound care for Resident #1. She set up her equipment and pulled back his sheet and removed his brief. Nurse #1 stated Resident #1's scrotum had the appearance of an abscess that had ruptured and the best way she could describe it was to imagine boiling an egg and when the egg cracks, the white of the egg comes out. But in this case what came out was black and not normal looking tissue. She stated Resident #1 had Fournier's gangrene before and the tissue observed on [DATE] had a similar appearance. She reported she got the Director of Nursing (DON) to observe the area and they agreed Resident #1 needed to be sent out to the hospital. Nurse #1 stated she notified the on-call provider and the on-call provider ordered for the resident to be sent out to the hospital. Resident #1 was discharged from the facility at 6:50 PM. Nurse #1 denied that Nurse #2 reported the area to her at change of shift that morning. She indicated Nurse #2 should have called the physician when she was informed of the area from the nurse aides. She added that the physician should have been informed of the resident's refusal for treatment so that a decision could be made to send the resident out to be assessed. Nurse #1 concluded Resident #1 was discharged from the facility at 6:50 PM, and at no time did he ever have a temperature, other abnormal vital signs, or indicators of distress during her shift including as he discharged . Review of Hospital #1's records dated [DATE] revealed Resident #1 presented to the emergency department with an abscess to the groin and scrotum. General surgery was consulted for plan of care or transfer. The Consulting Surgeon wrote, they were consulted for scrotal and penile abscess and Resident #1 had a history of drainage of penile abscess, scrotal abscess, and debridement of Fournier's gangrene by urology at a different hospital a few years ago. The physical exam revealed the scrotum was swollen and had signs and symptoms of an infection. The wound had spread to the left side of the scrotum and penis and there was an abscess on the left side of the penis draining pus. The assessment noted dead tissue as well. The Consulting Surgeon documented the treatment was beyond the scope of his practice and recommended transfer to urology at Hospital #2. Review of Hospital #2's records revealed a history and physical dated [DATE] that noted Resident #1 had a history of multiple sclerosis, paraplegia, and prior debridement for Fournier's gangrene in April of 2022. The Physician noted Resident #1 was transferred from an outside hospital with hypotension and purulent drainage from his scrotum, penis and perineum concerning for Fournier's gangrene. Resident #1 was taken to the operating room on [DATE] for debridement (surgical procedure to remove dead or infected tissue) of scrotal abscess and Fournier's gangrene. The Discharge summary dated [DATE] revealed Resident #1's post operative stay was complicated by continuing sepsis and end-organ dysfunction, and he was transferred to hospice and expired on [DATE]. Attempts to contact physician at the hospital #1 were made on [DATE] at 2:20 PM, 2:44 PM, and 3:45 PM, and further attempts made on [DATE] at 9:52 AM and again on [DATE] at 5:18 PM. These attempts were unsuccessful. During an interview on [DATE] at 12:58 PM Physician #1 stated he was Resident #1's primary physician at the facility. He further stated he was not made aware of the open area on Resident #1's scrotum until after he had been hospitalized , and to his knowledge it was not reported to any on call provider until later that day, [DATE]. Even though Nurse #2 was unable to assess the area as the resident did sometimes refuse, she should have notified him or the on-call physician of the open area and the extent of the drainage. He concluded it was hard to say if Resident #1's outcome would have been different had the physician been notified earlier that day about the drainage and abscess, but he would have sent the resident out immediately upon being made aware of an open area on his scrotum with drainage even if the resident did not allow a full assessment. During an interview on [DATE] at 12:53 PM the Administrator stated the nurse should have notified the physician as soon as she was made aware of a new skin opening and drainage from Resident #1's scrotum by the nurse aide. He concluded the nurse and nurse aides should have reported the new open area to the oncoming shift. During an interview on [DATE] at 9:52 AM the Director of Nursing stated Nurse #2 should have attempted to assess the area or notify someone that Resident #1 was not allowing an assessment of the area. Nurse #2 should have notified the oncoming shift of the area, lack of assessment, and not having notified the doctor. Nurse #2 should have notified the doctor of the lack of assessment and of the new area when it was brought to her attention by the nurse aides. The Administrator was notified of the immediate jeopardy on [DATE] at 2:01 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 The facility failed to notify the Physician of a change of condition for Resident #1 in a timely manner and failed to have effective systems in place for Nursing staff to know what changes need to be reported and what needs to be reported immediately. The Director of Nurses and/or designee conducted a 30 look back to review other residents identified with a change in condition to verify Physician and/or Provider was notified in a timely manner. This review was completed by [DATE] and consisted of a thorough review of 24-hour reports, progress notes, and change of condition assessments. No additional concerns were identified. 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 Nurse Practice Educator and/or designee re-educated Licensed Nurses on Notification of Changes in Condition with emphasis on changes that require immediate physician notification and documentation by [DATE]. Changes requiring prompt notification include a significant change in resident physical, mental, or psychosocial status, an accident involving the resident that results in injury or the potential for requiring physician intervention, a need to alter treatment significantly, and a decision to transfer or discharge the resident. Additionally, re-education was completed with Certified Nursing Assistants on early identification of changes in condition and prompt notification of changes to the Licensed Nurse by [DATE]. The EInteract Stop and Watch tool/alert was introduced as an early warning tool to be utilized by direct care givers as another mechanism to communicate changes in condition to the Licensed Nurse. The Director of Nursing and/or Nurse Practice Educator will track and verify that employees with scheduled time off, on leave of absence (FMLA), vacation, or PRN staff will be re-educated prior to returning to duty. New hires will be educated by the Nurse Practice Educator during the orientation process. Effective [DATE], the Director of Nurses and/or designee will review changes in condition by reviewing the 24-hour report, progress notes, change in condition assessments, and stop and watch alerts in the morning Clinical Meeting to verify prompt and/or immediate notification is communicated to the Physician and/or Provider. Removal of Immediate Jeopardy is [DATE] The credible allegation for immediate jeopardy removal with a compliance date of [DATE] was validated on [DATE], as evidenced by staff interviews and in-service record reviews. The in-services included information on notification of the physician or on call provider of changes in residents, communication of change of conditions in residents between staff, and documenting the change in condition as well as who was notified. The facility's immediate jeopardy removal date of [DATE] was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and physician interviews, the facility failed to identify the seriousness of an open area on the scrotum that nurse aides reported had significant amounts of pus or drainage and failed to seek urgent medical attention once the resident refused an assessment. Resident #1 had paraplegia, had no feeling in his groin/scrotum area, and had a history of prior debridement for Fournier's gangrene. Fournier's gangrene is a type of flesh-eating disease (necrotizing fasciitis) that destroys the soft tissue of the scrotum, penis and perineum and is associated with a high mortality rate and requires immediate medical attention. Resident #1 was sent to Hospital #1's emergency department (ED) for evaluation. The ED Physician noted a scrotal abscess and drainage which were concerning for necrotizing infection as well. It was determined Resident #1 needed to be transferred to urology at Hospital #2 for continued care and surgical intervention. Resident #1 had surgery on [DATE] and his post operative stay was complicated by continuing sepsis and end-organ dysfunction (damage occurring in major organs fed by the circulatory system). He was transferred to hospice and expired on [DATE]. This occurred for 1 of 3 residents reviewed for notification of change (Resident #1). Immediate Jeopardy began on [DATE] when a high risk resident did not receive urgent medical attention. Immediate Jeopardy was removed on [DATE] when the facility provided and implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective and the completion of staff education. Findings included: Resident #1 was admitted to the facility on [DATE]. His medical history in the facility medical record included paraplegia, presence of urogenital implants, necrotizing fasciitis (a rare bacterial infection that spreads quickly in the body and can cause death), Fournier's gangrene (a rare, life-threatening bacterial infection of the scrotum, penis or perineum), abscess of corpus cavernosum (tissue forming the bulk of the penis), and sepsis. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed he was assessed as moderately cognitively impaired. His active diagnoses included wound infection, anemia, heart failure, hypertension, neurogenic bladder, diabetes mellitus, paraplegia and multiple sclerosis. The MDS indicated Resident #1 had a suprapubic catheter and colostomy. Resident #1's care plan dated [DATE] revealed he was care planned to be at risk for skin breakdown and has actual skin breakdown which included being sent to the emergency room for a ruptured abscess to groin. The interventions included providing preventative treatments as ordered, observe for verbal and nonverbal signs of pain related to wound or wound treatment, wound treatment and medication as ordered, and weekly skin assessments by licensed nurse. Review of a progress note completed by Nurse #1 dated [DATE] revealed a head-to-toe skin check was completed. Resident #1 had previously identified skin issues noted, and no concerns were identified with Resident #1's scrotum at that time. During an interview on [DATE] at 9:06 AM Nurse #1 stated she did a skin check on Resident #1 on [DATE] and found no new areas to his skin, just the already identified wounds to his sacrum, right foot, and left calf. During an interview on [DATE] at 10:21 AM Nurse #4 stated she provided wound care for Resident #1 on [DATE] and noted no skin changes to his scrotum. Record review for [DATE] revealed Nurse #2 did not document any concerns for Resident #1. During an interview on [DATE] at 11:28 AM Nurse #2 stated on [DATE] around 6:00 AM she went to administer a medication injection to Resident #1's stomach and when she pulled the sheets back, she thought they were wet with urine. She noted his indwelling catheter was kinked under his thigh. She unkinked the tubing, got urine flow, and she was able to give him his medicine. She indicated she informed him the nurse aides were going to clean him up. In the middle of her medication pass a short time later the nurse aides (Nurse Aides #1 and #2) told her Resident #1 had an open area to his scrotum that needed to be assessed. She stated she went down to assess him and said, I heard you have something on your scrotum I need to look at, and he responded, no. She told him she needed to see it to make sure he was okay, and he told her You can look at it but don't touch it. She stated she visualized his scrotum, and there was an open area the size of a nickel with no bleeding or drainage. Resident #1 then covered it up, so she only had a brief look at it, and she told him they needed to take care of it. He indicated they could take care of it later. Nurse #2 reported she told Resident #1 she would let the oncoming nurse know about the area as the day shift provided wound care. She stated this was around 6:00 - 6:15 AM and the next shift started at 7:00 AM. She stated she continued to complete her medication pass and then told Nurse #1 about the area at change of shift report. She concluded since she could not examine the wound, she did not have anything to report to the physician so she did not notify the physician as the day shift would do that when they completed wound care. During an interview on [DATE] at 10:55 AM Nurse Aide (NA) #1 stated Resident #1 needed to be cleaned up on [DATE] in the early morning and he often would refuse care. Both herself and Nurse Aide #2 entered Resident #1's room and she thought it was urine that had leaked everywhere when they first entered and assumed something had happened to his catheter. Resident #1 had a suprapubic catheter and when they removed a towel, which was on top of his scrotum, they noted it was not urine but fluid leaking from what appeared to be an open area to his scrotum. The right side of his scrotum appeared to have ruptured open leaving black tissue and yellow drainage to the area. The area covered the right side of his scrotum and was very alarming, which they indicated to the nurse. She stated they ensured his comfort and then notified Nurse #2 to assess the area. NA #1 stated about 5 minutes later Nurse #2 came to her and indicated Resident #1 had refused to let her assess the area. NA #1 then told Nurse #2 that she was very concerned about that area and that he needed to be assessed as soon as possible as it was a very pressing and acute issue. Nurse #2 then walked away, and NA #1 thought she was going back to Resident #1, so she did not report the concern to the oncoming nurse aide. This all happened around 6:00 AM and her shift ended at 7:00 AM. During an interview on [DATE] at 11:50 AM Nurse Aide #2 stated she cared for Resident #1 on night shift (7:00 PM to 7:00 AM) on [DATE] and [DATE]. On the night shift of [DATE] no concerns were noted with Resident #1's scrotum during her activities of daily living care that shift. The morning of [DATE] Nurse #2 came to her and requested she clean the resident as he had gotten urine all over himself. She stated this was unusual as he had a suprapubic catheter as well as a colostomy. She stated she went and got Nurse Aide #1 and went to the room to clean him up. They took his gown off and began cleaning him up and removed his brief to clean his groin area. NA#2 stated there was fluid from his waist to his knees and it did not have the appearance of urine but instead had the appearance of pus or drainage. She stated they continued to clean him up and on the right side of his scrotum there was an area about the size of a dime that appeared slightly swollen but was not black but flesh colored. As they cleaned it, they noted that the drainage was coming from that open area and there was so much drainage that they had to use a brief like pad on the front part of his scrotum to keep him from becoming soaked in drainage again. She stated she let Nurse #2 know that Resident #1 was cleaned up but had a new open area to his scrotum and they had cleaned up pus and drainage but no urine. Nurse #2 indicated she was passing medications but would go in and check on the resident after, so she did not report the concern to the oncoming nurse aide. She concluded her shift ended and she had no further involvement with Resident #1 and did not know if Nurse #2 assessed the resident or not. During an interview on [DATE] at 10:13 AM Nurse Aide #3 stated she took report that morning, on [DATE], from Nurse Aide #2 and the nurse aide indicated Resident #1 had a bath and she had emptied his catheter and colostomy bags. Nurse Aide #2 did not mention anything which indicated Resident #1 had a change of his scrotum, so Nurse Aide #3 did not have a reason to visualize Resident #1's scrotum or request the nurse assess it. Review of a progress note dated [DATE] at 7:05 PM revealed Nurse #1 went to Resident #1's room to provide wound care to resident and while attempting to turn the resident onto his left side, the nurse observed that Resident #1's scrotum was swollen and appeared to have an abscess that was ruptured. The on-call provider was contacted at 6:22 PM and made aware of the situation and an order was given to send to the emergency department for evaluation and treatment. The nurse contacted 911 at 6:24 PM. During an interview on [DATE] at 9:06 AM Nurse #1 stated she remembered Resident #1 and was his regular nurse. She further stated it was important to know Resident #1 had no feeling to his groin and scrotum so he could not tell if something was hurting him there. She stated on [DATE] she worked a 12-hour shift beginning at 7:00 AM. She was not notified of any concerns from Nurse #2 with Resident #1 during change of shift report, so she had no reason to assess or contact the physician regarding Resident #1. She worked her shift as normal and completed her medication passes. Around 6:00 PM it was time to provide wound care for Resident #1. She set up her equipment and pulled back his sheet and removed his brief. Nurse #1 stated Resident #1's scrotum had the appearance of an abscess that had ruptured and the best way she could describe it was to imagine boiling an egg and when the egg cracks, the white of the egg comes out. But in this case what came out was black and not normal looking tissue. She stated Resident #1 had Fournier's gangrene before and the tissue observed on [DATE] had a similar appearance. She reported she got the Director of Nursing (DON) to observe the area and they agreed Resident #1 needed to be sent out to the hospital. She added that the physician should have been informed of the resident's refusal for treatment so that a decision could be made to send the resident out to be assessed. Nurse #1 stated she notified the on-call provider and the on-call provider ordered for the resident to be sent out to the hospital. Resident #1 was discharged from the facility at 6:50 PM. Review of Hospital #1's records dated [DATE] revealed an emergency department (ED) Provider note that indicated Resident #1 had a history of necrotizing fasciitis and presented with a severe scrotal abscess with purulent foul-smelling drainage which were concerning for necrotizing infection as well. The Provider noted Resident #1 had no sensation to this area. A sepsis work up was ordered in addition to IV (intravenous) antibiotics and fluid resuscitation (due to hypotension). General surgery was consulted for plan of care or transfer. The Consulting Surgeon documented the entire scrotum was red and swollen and there was a large area, approximately 7 centimeters (cm) by 5 cm, on the right side of the scrotum that was necrotic (dead tissue) and draining foul smelling pus. The underlying testicle was exposed and appeared to be draining pus as well. It was also noted the left side of the penis had an abscess that was draining pus. The Consulting Surgeon documented Resident #1 had a history of drainage of penile abscess, scrotal abscess, and debridement of Fournier's gangrene by urology at a different hospital a few years ago. The assessment noted dead tissue as well. The Consulting Surgeon documented the treatment was beyond the scope of his practice and recommended transfer to urology at Hospital #2. Review of Hospital #2's records revealed a history and physical dated [DATE] that noted Resident #1 had a history of multiple sclerosis, paraplegia, and prior debridement for Fournier's gangrene in April of 2022. The Physician noted Resident #1 was transferred from an outside hospital with hypotension and purulent drainage from his scrotum, penis and perineum concerning for Fournier's gangrene. Resident #1 was taken to the operating room on [DATE] for debridement (surgical procedure to remove dead or infected tissue) of scrotal abscess and Fournier's gangrene. The Discharge summary dated [DATE] revealed Resident #1's post operative stay was complicated by continuing sepsis and end-organ dysfunction, and he was transferred to hospice and expired on [DATE]. Attempts to contact physician at Hospital #1 were made on [DATE] at 2:20 PM, 2:44 PM, and 3:45 PM, and further attempts made on [DATE] at 9:52 AM and again on [DATE] at 5:18 PM. These attempts were unsuccessful. During an interview on [DATE] at 12:58 PM Physician #1 stated he was Resident #1's primary physician at the facility. He further stated he was not made aware of the open area with drainage on Resident #1's scrotum until after he had been hospitalized , and to his knowledge it was not reported to any on call provider until later that day, [DATE]. Even though Nurse #2 was unable to assess the area as the resident did sometimes refuse, she should have notified him or the on-call physician of the open area and the extent of the drainage. He concluded it was hard to say if Resident #1's outcome would have been different had the physician been notified earlier that day about the drainage and abscess, but he would have sent the resident out immediately upon being made aware of an open area on his scrotum with drainage even if the resident did not allow a full assessment. During an interview on [DATE] at 12:53 PM the Administrator stated Nurse #2 should have notified the physician as soon as she was made aware of a new skin opening and drainage from Resident #1's scrotum by the nurse aides and was unable to assess the area. He concluded the nurse and nurse aides should have reported the new open area to the oncoming shift. During an interview on [DATE] at 9:52 AM the Director of Nursing stated Nurse #2 should have attempted to assess the area or notify someone that Resident #1 was not allowing an assessment of the area on his scrotum. Nurse #2 should have notified the oncoming shift of the area, lack of assessment, and not having notified the doctor. Nurse #2 should have notified the doctor of the lack of assessment and of the new area when it was brought to her attention by the nurse aides. The Administrator was notified of the immediate jeopardy on [DATE] at 2:01 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. The facility failed to conduct an assessment of Resident #1 and take appropriate actions when Resident #1 refused an assessment. The Director of Nurses and/or designee conducted a 30 look back to review other residents identified with a change in condition to verify a thorough assessment was completed by a Licensed Nurse. This review was completed by [DATE], and consisted of a thorough review of 24-hour reports, progress notes, and change of condition assessments. No additional concerns were identified. The Licensed Nurses and/or designee completed a skin assessment on all residents to identify skin changes in condition and verify the Physician and/or Provider was notified of changes by [DATE]. No additional residents were identified with necrotizing fasciitis and Fournier's gangrene. 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 Nurse Practice Educator and/or designee will provide education to Licensed Nurses on necrotizing fasciitis and Fournier's gangrene with specific emphasis on how rapidly it can progress, how detrimental it can be, and the seriousness/urgency of seeking immediate medical attention by [DATE]. A post-test has been created and is in progress to validate knowledge and/or comprehension of education. The Director of Nurses and/or Nurse Practice Educator will track and verify no Licensed Nurse (s) will be allowed to return to work with scheduled time off, on leave of absence (FMLA), vacation, or PRN until they have successful completed the education/training and post-test. New hires will be educated by the Nurse Practice Educator during the orientation process. The Nurse Practice Educator and/or designee will educate Licensed Nurses on the importance of conducting a thorough assessment, documenting the assessment, and on specific measures to take if a patient refuses an assessment to include notifying the Responsible Party, and Physician/Provider, and educating the resident on the importance of allowing an assessment to be completed, and re-approach by [DATE]. The Director of Nursing and/or Nurse Practice Educator will track and verify Licensed Nurses with scheduled time off, on leave of absence (FMLA), vacation, or PRN staff will be re-educated prior to returning to duty. New hires will be educated by the Nurse Practice Educator during the orientation process. The Nurse Practice Educator and/or designee re-educated Certified Nursing Assistants on early identification of changes in condition and prompt notification of changes to the Licensed Nurse by [DATE]. The EInteract Stop and Watch tool/alert was introduced as an early warning tool to be utilized by direct care givers as another mechanism to communicate changes in condition to the Licensed Nurse. The Director of Nursing and/or Nurse Practice Educator will track and verify that employees with scheduled time off, on leave of absence (FMLA), vacation, or PRN staff will be re-educated prior to returning to duty. New hires will be educated by the Nurse Practice Educator during the orientation process. Effective [DATE], the Director of Nurses and/or designee will review changes in condition by reviewing the 24-hour report, progress notes, change in condition assessments, in the morning Clinical Meeting to verify a thorough assessment has been completed. Removal of Immediate Jeopardy is [DATE] The credible allegation for Immediate Jeopardy removal with a compliance date of [DATE] was validated on [DATE], as evidenced by staff interviews and in-service record reviews. The in-services included information on identification of changes in residents, importance of assessments, documenting assessments, and measures to take if a resident refused an assessment. The education further included information on necrotizing fasciitis and Fournier gangrene with a focus on the speed at which it can cause a decline and requires emergent medical attention. The facility's Immediate Jeopardy removal date of [DATE] was validated.