**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff and Medical Director interviews the facility failed to protect a resident's right to be free of sexual abuse for 1 of 3 residents investigated for abuse (Resident #7). A moderately cognitively impaired male resident (Resident #39) was found beside Resident #7's bed, a severely cognitively impaired female resident, with his hand moving under the covers around her groin area when a staff member entered Resident #7's room. Resident #7's brief was open and there was stool on the outside of her brief and on her sheets, and Resident #39 had stool on his hands. Resident #39 was interviewed and stated he was playing around with Resident #7 down there and waved his hand in a circular motion around his groin area. Resident #39 stated he had done something stupid, and he should not have done it. Resident #7 did not have the cognition to express or understand consent for physical sexual advances, and a reasonable person would have been traumatized by unwanted physical sexual advances. Immediate Jeopardy began on 5/2/2024, when the facility failed to protect Resident #7's right to be free of sexual abuse. Immediate Jeopardy was removed on 5/17/2024 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remained out of compliance at a lower scope and severity level of D (no actual harm with potential for potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems that were put into place are effective. Findings included: Resident #7 was admitted to the facility on [DATE] with diagnoses of dementia and cognitive communication deficit. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #7 was assessed as severely cognitively impaired; was dependent on staff for rolling from side to side in bed; was totally dependent for transferring to and from the bed to wheelchair; was always incontinent of bowel and bladder and was sometimes understood by others and sometimes understood others The Care Plan for Resident #7 which was reviewed on 3/21/2024 indicated she had difficulty with making her own decisions. Resident #39 was admitted to the facility on [DATE] with diagnoses of dementia and stroke. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #39 was moderately cognitively impaired and had no behaviors. Resident #39's Care Plan was reviewed and on 3/29/2024 the Care Plan indicated Resident #39 had episodes of verbally aggressive behaviors and should be approached in a calm manner. A Care Plan problem added on 4/4/2024 to the Care Plan indicated Resident #39 had a history of depression, he had scheduled psychiatric visits ordered, and he had difficulty recalling recent events due to dementia. A review of a written statement made by Nurse Aide #6 on 5/2/2024 indicated she walked into Resident #7's room and Resident #39 was sitting next to her bed, and she saw something move under the covers that appeared to be Resident #39's hand. The statement further stated she asked Resident #39 what he was doing, and he said nothing. The written statement further indicated when Resident #39 left the room he had stool on his fingers and Resident #7's brief was open and there was stool on the outside of her brief and on her sheet. On 5/14/2024 at 1:11 pm Nurse Aide #6 was interviewed, and stated she cared for Resident #7 on 5/2/2024 and walked into her room between 9:00 am and 9:30 am and Resident #39 was sitting beside her bed in his wheelchair and his hand was under the covers and she saw his hand moving around her groin area. Nurse Aide #6 stated Resident #7 was not upset but she was severely cognitively impaired. Nurse Aide #6 stated she asked Resident #39 what he was doing and when she asked him to leave the room, she noticed he had stool on his hand. She stated after Resident #39 rolled himself in his wheelchair to his room, Nurse Aide #6 stated she returned to Resident #7 to clean her up and when she pulled the sheet down her brief was open and there was stool on the outside of her brief and on her sheet. Nurse Aide #6 stated Resident #39 was sometimes confused and sometimes he was clear. Nurse Aide #6 stated Resident #39 could get up unassisted, moved himself in his wheelchair without assistance, and he wandered around the facility. Nurse Aide #6 stated Resident #39 sat in the doorway of Resident #7's room a lot but 5/2/2024 was the first time she found him in her room. A written statement dated 5/2/2024 by the Social Worker stated she interviewed Resident #39 and asked him what he was doing in Resident #7's room this morning and he stated, I was just playing around and when asked to elaborate on what he meant he said, I was just playing with her down there and he took his hand and waved it in a circular motion around his groin area and said, down there. The Social Worker's written statement indicated Resident #39 stated, I was doing something stupid that I should not have done. The Social Worker's written statement stated she explained to Resident #39 that Resident #7 was cognitively impaired and could not give consent to being touched sexually and he verbalized understanding that he knew what he did was inappropriate. On 5/14/2024 at 2:15 pm the Social Worker was interviewed and stated Resident #39 was coming down the hallway toward her office between 9:30 am and 9:45 am on 5/2/2024 and he stated, I was playing around with Resident #7 in her room, and he did a circular hand motion towards his groin area. The Social Worker stated he said, I did something stupid and the Social Worker stated because he said he did something stupid he understood what he had done was wrong. The Social Worker stated he told the Police Officer that investigated the sexual abuse allegation the exact same thing about an hour after she interviewed him. The Police Officer explained to Resident #39 that Resident #7's family would have to decide to press charges and the Police Officer returned to the facility later that day and notified Resident #7 of his court appearance date and that he was charged with sexual battery. A Police Report dated 5/2/2024 at 9:54 am indicated Resident #39 was charged with sexual battery of Resident #7. The Police Report further indicated Nurse Aide #6 entered Resident #7's room and found Resident #39 at her bedside with his hand under the blanket. Nurse Aide #6 indicated Resident #39 hand was moving under the blanket and Nurse Aide #6 confronted Resident #39 about what he was doing, and he stated, nothing. Nurse Aide #6 reported there was stool on Resident #39's fingers and she found Resident #7's brief open and there was stool outside the brief and on the bed. The Police Report stated Resident #7 was cognitively impaired and could not recall the alleged abuse or give consent. The Police Report stated the Responsible Party was interviewed and stated Resident #7 had dementia and frequently repeats what is said to her. The Responsible Party indicated he wished to pursue charges for the incident on behalf of Resident #7. An interview was conducted by phone on 5/15/2024 at 10:05 am with the Police Officer who responded to the allegation of sexual abuse on 5/2/2024. The Police Officer stated he interviewed Nurse Aide #6 and she stated she entered Resident #7's room and found Resident #39 in his wheelchair sitting beside the bed with his hand under the covers and when she approached him and asked what he was doing he said nothing, but she noticed stool on his fingers. The Police Officer stated Nursing Aide #6 stated after Resident #39 left the room she saw that Resident #7's brief was open and there was stool outside the brief and on the sheet. The Police Officer stated Resident #39 admitted to touching Resident #7 sexually and seemed to understand what he did was sexual battery. The Police Officer stated Resident #39 took advantage of a situation where no one was around, and Resident #7 confusion prevented her from stopping him. During an interview on 5/14/2024 at 10:00 am with Resident #7's Responsible Party by phone he stated the facility notified him on 5/2/2024 at 9:30 am that Resident #7 had been sexually abused. He stated Resident #7 is severely cognitively impaired and would not have understood what happened to her. The Responsible Party stated he felt Resident #7 was sexually abused because she was unable to call for help or report what was done to her. He stated Resident #7 was a very good woman and would not have instigated a sexual encounter and would have been very upset if she understood what happened. A Physician's Progress Note stated 5/6/2024 by the Medical Director indicated he saw Resident #7 and evaluated her mental status and ability to give/withhold informed consent. The Progress Note further stated Resident #7 was a poor historian due to her cognition and information was obtained through chart review and discussion with medical staff; and she was not able to give informed consent. A Physician's Progress Note dated 5/6/2024 indicated the Medical Director evaluated Resident #39 for the ability to give/withhold informed consent. The Progress Report stated Resident #39 had a history of dementia; had no recent cognitive decline noted; and Resident had cognitive impairment with poor ability to give or withhold consent and was unlikely to understand the nature of his actions. On 5/14/2024 at 5:32 pm the Medical Director was interviewed by phone and stated he did not believe Resident #39 understood what he was doing when he evaluated him on 5/6/2024 after the incident that occurred on 5/2/2024. The Medical Director stated Resident #39 responded, it was bad when he asked if he understood what he did was bad; and he responded, it was bad when he asked Resident #39 if he understood why what he did was bad. Resident #39 was interviewed on 5/14/2024 at 11:20 am and he stated he has lived at the facility for 2 years. When asked if he had any altercations with another resident he stated, I got in trouble for touching another resident. Resident #39 stated he did not know the name of the resident and stated he did not remember how long ago the incident happened. The Director of Nursing was interviewed on 5/14/2024 at 5:37 pm and stated Unit Manager #2 reported to her on 5/2/2024 around 9:30 am to 9:40 am that Resident #39 was found in Resident #7's room by Nurse Aide #6 sitting beside her bed in his wheelchair with his hand under the covers. She stated Nurse Aide #6 reported Resident #7's brief was open, and stool was on the outside of her brief and on her sheet, and Resident #39 had stool on his hand. The Director of Nursing stated they began an investigation and had substantiated the sexual abuse. On 5/15/2024 at 8:42 am the previous Administrator was interviewed by phone and stated the facility had initiated an investigation when Nurse Aide #6 reported Resident #39 was found in his wheelchair beside Resident #7's bed with his hand under the covers. The Administrator stated the Medical Director spoke with Resident #39 and the Medical Director felt Resident #39 did not understand what he had done wrong. The previous Administrator stated the Medical Director prescribed Zoloft (an antidepressant) to treat Resident #39's libido and aggression after the incident. The previous Administrator indicated Resident #39 was put on every 15-minute observations by nursing after the incident was reported and the Medical Director felt that every 15-minute observations by nursing was sufficient to protect Resident #7 and other resident's safety. He stated Resident #39 did wander in the facility between the every 15-minute observations. An interview was conducted with the Administrator on 5/17/2024 at 3:32 pm and he stated the facility had provided education to all staff regarding their Abuse Prevention, Intervention, Reporting, and Investigation Policy. He stated the facility was responsible for protecting the residents from all forms of abuse. The Administrator was notified of immediate jeopardy on 5/15/2024 at 4:24 pm. The facility provided the following Credible Allegation of Immediate Jeopardy Removal: Identify Those recipients who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance. On 5/2/2024 NA #6 observed Resident # 39's hand under the covers of Resident #7 in her bed in resident #7's room at around 9:00am. NA # 6 announced for Resident #39 to abstain from touching Resident # 7. NA #6 removed Resident #39 from Resident # 7's room. Nurse #6 completed a skin assessment on Resident #7 during 7p-7a shift on 5/2/2024 with no noted injuries. Law enforcement was notified on 5/2/2024 around 9:30 am. Resident # 7's responsible party was notified of occurrence on 5/2/2024. Resident # 7's emergency contact was also notified of the occurrence on 5/2/2024. Resident #7 was transferred to another room on 5/2/24 for her protection. Resident #39 had no prior history of sexual aggression prior to the incident on 5/2/2024. Abuse questionnaires were completed by the Business Office Manager, MDS Nurse, Admissions Director and Unit Manager on all residents with Brief Interview for Mental Status (BIMS) score of 9 and above with no adverse responses. Questionnaires were completed on 5/15/2024. The questions asked were as follows, 1. Do you feel safe? 2. Has anyone ever touched you inappropriately? 3. Are you afraid of anyone in the facility? The Unit Manager and/or Floor Nurse completed skin assessment for all residents with a BIMS score below 9 as of 5/15/2024 with no negative findings. 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. On 5/2/2024 at 9:40am Social Worker talked with Resident #39 about the incident that occurred and explained to resident #39 what he had done wrong. On 5/7/2024 the physician changed resident #39's medication to add Zoloft 25mg tablet daily by mouth for aggression. As of 5/15/2024, around 5:30pm resident #39 has been placed on 1 on 1 observation. MDS Nurse updated resident #39's care plan to reflect new behavior of sexual aggression and interventions for managing behavior as of 5/16/2024. MDS Nurse updated care guide for resident #39 on 5/16/2024 and staff notified of changes through care guide on 5/16/2024. MDS Nurse will continue to update interventions as needed. As of 5/15/2024 the Staff Development Coordinator educated 100% of facility staff on the facility abuse policy to include residents right to be free from abuse to include sexual, physical, mental, verbal and misappropriation of property as well as signs of abuse and reporting of abuse or potential abuse. Staff development Coordinator will provide education for abuse training to new hires during orientation. 1:1 supervision will be documented and reported to the facility Administrator and Director of Nursing to ensure monitoring of resident. The Director of Nursing will ensure the 1:1 staff member is provided each shift with the staffing coordinator daily. As of 5/15/2024 all CNA's will be educated by the Director of Nursing/Staff Development Coordinator on supervision of resident during 1:1 duty. Education will include a goal of 1:1 in protecting other residents from any sexual aggression by resident #39 and ensuring resident #39 does not encounter resident #7 and documenting of any aggression during shift. On 5/15/2024 the facility completed Ad Hoc QAPI to review investigation and current action plan to ensure all components were done and followed. The facility administrator and Director of Nursing are responsible for continued compliance. Alleged date of IJ removal: 5/17/2024 Credible Allegation of IJ Removal: The Credible Allegation of IJ Removal was validated on 5/17/2024. The facility provided documentation of the in-service education that was provided to all facility staff which included review of the facility's Abuse Policy to include residents right to be free from abuse to include sexual, physical, mental, verbal and misappropriation of property; signs of abuse; and reporting of abuse or potential abuse. The Staff Development Coordinator provided the education to the staff which will also be covered in the facility's orientation of new employees. The Staff Development Coordinator was interviewed and stated they have ensured staff are educated on the abuse policy before they are allowed to care for residents. During interviews with staff from all departments, they were able to verbalize the types of abuse, resident's right to be free from abuse, signs of abuse, reporting of abuse and potential abuse and protection of residents from abuse. Observations were made of Resident #39 during the validation of the Credible Allegation, and he remained on 1 to 1 observation during the validation. The facility provided skin assessments that were completed on residents with a Brief Interview for Mental Status (BIMS) score of less than 9 and interviews forms that were completed on all residents with a BIMs score of 9 or above. The facility provided the minutes for their Quality Assurance Performance Improvement (QAPI) meeting which was completed on 5/15/2024. The alleged date of IJ removal of 5/17/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff and Medical Director interviews the facility failed to implement the following components of the abuse policy: (a) immediately report an allegation of sexual abuse of a severely cognitively impaired female resident (Resident #7) by a moderately cognitively impaired male resident (Resident #39) to the Administrator; (b) the facility failed to provide a physical examination of a severely cognitively impaired female resident (Resident #7) by a trained/licensed professional for signs of sexual abuse; (c) the facility failed to protect a severely cognitively impaired female resident (Resident #7) and all other residents from the possibility of sexual abuse when they failed to put Resident #39 on one-to-one observations when there was an allegation of sexual abuse against Resident #7; (d) the facility failed to assess all other residents in the facility when an allegation of sexual abuse was reported; and (e) the facility failed to report the allegation of abuse to the Adult Protective Services. This deficient practice affected 1 of 3 residents (Resident #7) investigated for allegations of abuse and had the high likelihood of affecting other vulnerable residents residing in the facility. Immediate jeopardy began on 5/2/2024, when the facility failed to immediately report an allegation of sexual abuse to the Administrator, provide assessment of the alleged victim of sexual abuse, provide protection for the alleged victim of sexual abuse and protect other residents in the facility from the possibility of abuse by assessing other residents in the facility for signs of sexual abuse. Immediate jeopardy was removed on 5/17/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remained out of compliance at a lower scope and severity level of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems that were put into place are effective. Findings included: 1.a. A review of the facility's Abuse Prevention, Intervention, Reporting, and Investigation Policy, revised 2/2021, indicated upon receiving an allegation of physical and sexual abuse the Executive Director and Director of Health Services should be notified immediately to arrange for the examination of the resident. Resident #7 was admitted to the facility on [DATE] with diagnoses of dementia, stroke, and cognitive communication deficit. Resident #39 was admitted to the facility on [DATE] with diagnoses of dementia and stroke. A written statement made by Nurse Aide #6 on 5/2/2024 stated she walked into Resident #7's room and Resident #39 was sitting next to her bed, and she saw something moving under the covers that appeared to be Resident #39's hand. The statement further stated Nurse Aide #6 asked Resident #39 what he was doing, and he said, Nothing. The written statement indicated when Resident #39 left the room he had stool on his fingers and Resident #7's brief was open and there was stool outside the brief and on her sheets. The written statement did not indicate who Nurse Aide #6 notified of the allegation of abuse. During an interview with Nurse Aide #6 on 5/14/2024 at 1:11 pm she stated she cared for Resident #7 on 5/2/2024 on the 7:00 am to 7:00 pm shift and she walked into the room between 9:00 am and 9:30 am and Resident #39 was sitting next to Resident #7's bed in his wheelchair and his hand was under the bed covers and she saw his hand moving around her groin area. Nurse Aide #6 stated Resident #7 was not upset but she is severely cognitively impaired. Nurse Aide #6 stated she asked Resident #39 what he was doing, and he said, Nothing. Nurse Aide #6 stated when asked Resident #39 to leave the room there was stool on his hand. Nurse Aide #6 stated when she returned to Resident #6, she pulled down the covers and her brief was open and there was stool on the outside of her brief and on the sheets. Nurse Aide #6 stated she told Medication Aide #4 about what she witnessed, and Medication Aide #4 told her she would notify Unit Supervisor #2. On 5/14/2024 at 1:29 pm Medication Aide #4 was interviewed and stated Nurse Aide #6 told her she found Resident #39 in Resident #7's room and he had his hand under Resident #7's covers and when he pulled his hand out from under the bed covers, he had stool on his hand and Resident #7's brief was open and there was stool on the outside of her brief and on the bed covers. Medication Aide #4 stated she told Unit Supervisor #2 about the allegation of sexual abuse about 30 minutes after Nurse Aide #6 told her because Unit Supervisor #2 was in a meeting, and she did not want to disturb the meeting. Medication Aide #4 stated when Unit Supervisor #2 came to the unit after the meeting she notified her of the allegation of sexual abuse. Unit Supervisor #2 was interviewed on 5/14/2024 at 1:35 pm and she stated she did not remember what time it was when she was notified of the allegation of sexual abuse, but it was before 10:00 am. She stated she was coming from the morning meeting, and she does a round of the facility after the meeting. When she went to 200-hall to check on Medication Aide #4 she was told about the allegation of sexual abuse. Unit Supervisor #2 stated she went to Resident #7's room and Nurse Aide #6 was providing incontinence care. She stated there was stool on the sheet, but the brief had been removed. Unit Supervisor #2 stated she reported the allegation of sexual abuse to the Director of Nursing after she checked on Resident #7. The Director of Nursing was interviewed on 5/14/2024 at 5:37 pm and stated she was in her office and between 9:30 am and 9:40 am on 5/2/24 when Unit Supervisor #2 came to her office and reported the allegation of sexual abuse of Resident #7. She stated she was told by Unit Supervisor #2 that Nurse Aide #6 went into Resident #7's room and Resident #39 was sitting beside her bed in his wheelchair with his hand under the sheet and when she came into the room, he pulled his hand out. The Director of Nursing stated she was told Resident #39 had stool on his hand. The Director of Nursing stated they began an investigation immediately and the police were called. She stated she was not aware Medication Aide #4 had not reported the allegation of sexual abuse to Unit Supervisor #2 until 30 minutes after it was reported to her. The Director of Nursing stated that all allegations of abuse should be reported immediately. The previous Administrator was interviewed on 5/15/2024 at 8:42 am and he stated he had moved to another facility but was the administrator of the building at the time of the allegation of sexual abuse. He stated he was told by the Director of Nursing about the allegation of sexual abuse, and an investigation was initiated immediately. He stated he was not aware Medication Aide #4 had not report the allegation until 30 minutes after she was told by Nurse Aide #6. He stated all allegations of abuse should be reported to the administration immediately. b. The facility's Abuse Prevention, Intervention, Reporting and Investigation Policy, revised 2/2021, indicated a physical examination of the resident should be conducted by an appropriately trained/licensed professional (attending physician, emergency room physician). Unit Supervisor #2 was interviewed on 5/14/2024 at 1:35 pm and she stated she was coming from her morning meeting on 5/2/2024 before 10:00 am, when she did a morning round, and went to the 200-hall to check on Medication Aide #4. She stated Medication Aide #4 told her Nurse Aide #6 walked into Resident #7's room and Resident #39 was sitting in his wheelchair beside the bed with his hand under the sheet. She stated she was told Resident #39 had stool on his hand and Resident #39's brief was open and there was stool on the sheet and on the outside of the brief. Unit Supervisor #2 stated she went to Resident #7's room and Nurse Aide #6 was providing incontinence care for Resident #7. Unit Supervisor #2 stated she did not assess Resident #7 and she did not know if anyone else assessed Resident #7. The Director of Nursing was interviewed on 5/14/2024 at 5:37 pm and she stated it was reported to her on 5/2/2024 between 9:30 and 9:40 am that Resident #39 was found by Nurse Aide #6 in Resident #7's room sitting beside her bed in his wheelchair with his hand under the covers. She stated when Resident #39 pulled his hand from the covers he had stool on his fingers and when Nurse Aide #6 pulled back Resident #7's covers her brief was open and there was stool on the outside of her brief and on the sheets. The Director of Nursing stated someone did assess Resident #7, but she was not sure who had provided the assessment. A follow-up interview was conducted with the Director of Nursing on 5/15/2024 and she stated there was not a physical assessment of Resident #7 immediately after the allegation of sexual abuse was reported. She stated there was a skin assessment completed on 5/2/2024 on the 7:00 pm to 7:00 am shift. A phone interview was conducted with Nurse #6 on 5/15/2024 at 12:03 pm and she stated she did a skin assessment on 5/2/2024 between 9:00 pm and 10:00 pm and Resident #7 did not have any bruising or injuries to her perineum. The previous Administrator was interviewed on 5/15/2024 at 8:42 am and he stated the Medical Director was made aware of the allegation of sexual abuse immediately, but he did not know when Resident #7 was physically assessed after the incident. c. The facility's Abuse Prevention, Intervention Reporting, and Investigation Policy stated a resident who is allegedly mistreated by another resident is removed from contact with that resident during the investigation. The policy further stated residents are to be protected during incident investigations; and residents will be protected from the alleged offender. A written statement made by Nurse Aide #6 on 5/2/2024 stated she walked into Resident #7's room and Resident #39 was sitting next to her bed, and she saw something moving under the covers that appeared to be Resident #39's hand. The statement further stated Nurse Aide #6 asked Resident #39 what he was doing, and he said, Nothing. The written statement indicated when Resident #39 left the room he had stool on his fingers and Resident #7's brief was open and there was stool outside the brief and on her sheets. During an interview with Nurse Aide #6 on 5/14/2024 at 1:11 pm she stated she cared for Resident #7 on 5/2/2024 on the 7:00 am to 7:00 pm shift and she walked into the room between 9:00 am and 9:30 am and Resident #39 was sitting next to Resident #7's bed in his wheelchair and his hand was under the bed covers and she saw his hand moving around her groin area. Nurse Aide #6 stated Resident #7 was not upset but she is severely cognitively impaired. Nurse Aide #6 stated she asked Resident #39 what he was doing, and he said, Nothing. Nurse Aide #6 stated when she sent Resident #39 out of the room there was stool on his hand. Nurse Aide #6 stated when she returned to Resident #6, she pulled down the covers and her brief was open and there was stool on the outside of her brief and on the sheets. Nurse Aide #6 stated she told Medication Aide #4 about what she witnessed, and Medication Aide #4 told her she would notify Unit Supervisor #2. Nurse Aide #6 stated Resident #39 was in his room when she went to tell Medication Aide #4 about the allegation of sexual abuse but there was not anyone with him and they did not put him on one-to-one observation until the Patient Care Associate (PCA) came to sit with him. She stated she did not know what time the PCA was assigned to Resident #39. On 5/14/2024 at 1:29 pm Medication Aide #4 was interviewed and stated Nurse Aide #6 told her she found Resident #39 in Resident #7's room and he had his hand under Resident #7's covers and when he pulled his hand out from under the bed covers, he had stool on his hand and Resident #7's brief was open and there was stool on the outside of her brief and on the bed covers. Medication Aide #4 stated she told Unit Supervisor #2 about the allegation of sexual abuse about 30 minutes after Nurse Aide #6 told her because Unit Supervisor #2 was in a meeting, and she did not want to disturb the meeting. Medication Aide #4 stated Resident #39 was not put on one-to-one observation until later that morning when the Patient Care Associate (PCA) was assigned to watch him and after she left at 3:00 pm that day he was put on every 15-minute checks. Medication Aide #4 stated staff were supposed to check to see where Resident #39 was every 15 minutes and document that we saw him. She stated she did not know why Resident #39 was not kept on one-to-one observation. Unit Supervisor #2 was interviewed on 5/14/2024 at 1:35 pm and she stated she did not remember what time it was when she was notified of the allegation of sexual abuse, but she stated it was before 10:00 am. She stated she was coming from the morning meeting, and she does a round of the facility after the meeting and when she went to 200-hall to check on Medication Aide #4 she was told about the allegation of sexual abuse. Unit Supervisor #2 stated she went to Resident #7's room and Nurse Aide #6 was providing incontinence care. She stated there was stool on the sheet, but the brief had been removed. Unit Supervisor #2 stated she reported the allegation of sexual abuse to the Director of Nursing after she checked on Resident #7. Unit Supervisor #2 stated Resident #39 was in the hallway away from his room when she went to check on Resident #7, she stated they did not put Resident #39 on one-to-one observation until after she reported the allegation of sexual abuse to the Director of Nursing and then he went to every 15-minute checks the next day. Unit Supervisor #2 stated Resident #39 is very mobile in his wheelchair and he wanders around the facility. The Police Officer was interviewed on 5/15/2024 at 10:05 am and he stated he came to the facility on 5/2/2024 at 9:58 am to investigate. He stated when he arrived at the facility Resident #7 was in his wheelchair in the hallway and no one was supervising him when he approached him to interview him. During an interview with the Patient Care Associate (PCA) on 5/14/2024 at 2:01 pm, who spoke only Spanish, and the Director of Nursing provided interpretation, the PCA stated she was assigned to Resident #39 at 12:15 pm on 5/2/2024 and she observed him until 3:00 pm. She stated she kept notes in her notebook of where he went during the one-to-one observation. The PCA stated Resident #39 tried to get close to Resident #7 once on 5/2/2024 when she was observing him, but she redirected him. On 5/14/2024 at 11:12 am Resident #7 was observed in her wheelchair on the 200-hall and she went up and down the hallway but did not go into any resident rooms. Staff were observed at the nurses' desk but did not redirect Resident #7 back to the 100-hall where she resided. Resident #7 rolled past Resident #39's room door twice in her wheelchair during the observation. Resident #7 was observed until 11:20 am. The Director of Nursing was interviewed on 5/14/2024 at 5:37 pm and she stated they put Resident #39 on one-to-one observation after the incident was reported. On 5/15/2024 at 3:08 pm the Director of Nursing was interviewed again and stated she was not aware Resident #39 was not put on one-to-one observation until 12:15 pm. She stated they decided to monitor him on every 15-minute checks after 3:00 pm on 5/2/2024 because they felt they could watch him closely enough with every 15-minute checks to ensure Resident #7 and all other residents were safe. d. The facility's Abuse Prevention, Intervention, Reporting, and Investigation Policy, revised on 2/2021, indicated the facility will assess and interview all residents who came in contact with the accused when investigating an abuse allegation. Unit Supervisor #4 was interviewed on 5/14/2024 at 5:25 pm and stated she had not physically assessed Resident #7 on 5/2/2024 after the allegation of sexual abuse was reported. Unit Supervisor #4 stated she was not asked to do assessments or interviews with any other residents after the allegation of sexual abuse was reported on 5/2/2024. During an interview with the Director of Nursing on 5/15/2024 at 3:08 pm she stated the facility did not complete physical assessments with residents that were cognitively impaired or interview any residents that were not cognitively impaired to see if there were any further allegations of sexual abuse in the facility when the sexual abuse allegation was reported on 5/2/2024. The previous Administrator was interviewed by phone on 5/15/2024 at 8:42 am and he stated when the allegation of sexual abuse of Resident #7 by Resident #39 was reported on 5/2/2024 the facility moved Resident #7 to another room on a different hallway; placed Resident #39 on every 15-minute checks; and the Medical Director and police were notified of the allegation of abuse. The previous Administrator stated he spoke with the Medical Director after the incident on 5/2/2024 to see if the facility needed to do anything else to protect Resident #7 and other residents and the Medical Director stated they had done everything they could do. The current Administrator was interviewed on 5/17/2024 at 4:42 pm and stated the facility's staff have received in-service education regarding the facility's Abuse Prevention, Intervention, Reporting, and Investigation Policy. The current Administrator stated the staff should have assessed all residents who came in contact with the accused when the allegation was reported on 5/2/2024. e. The facility's Abuse Prevention, Intervention, Reporting, and Investigation policy, revised 2/2021, indicated the facility would notify Adult Protective Services when an allegation of abuse is reported. The Director of Nursing was interviewed on 5/15/2024 at 4:03 pm and she stated the facility did not notify the North Carolina Division of Social Services, Adult Protective Services regarding the allegation of sexual abuse of Resident #7 that was reported on 5/2/2024. She stated she was not aware she should notify Adult Protective Services. The previous Administrator was interviewed by phone on 5/15/2024 at 8:42 am and he stated when the allegation of sexual abuse of Resident #7 by Resident #39 was reported on 5/2/2024 the facility moved Resident #7 to another room on a different hallway; placed Resident #39 on every 15-minute checks; and the Medical Director and police were notified of the allegation of abuse. The previous Administrator stated he spoke with the Medical Director after the incident on 5/2/2024 to see if the facility needed to do anything else to protect Resident #7 and other residents and the Medical Director stated they had done everything they could do. The Administrator was notified of immediate jeopardy on 5/15/2024 at 4:43 pm. The facility provided the Credible Allegation of Immediate Jeopardy Removal: F607 Abuse Reporting: The facility failed to implement the abuse policy related to reporting and protection. Identify Those recipients who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance. On 5/2/2024 CNA #1 observed Resident # 39's hand under the covers of Resident #7 in her bed in resident #7's room at around 9:00am. CNA # 6 announced for Resident # 39 to abstain from touching Resident # 2. CNA #7 removed Resident # 39 from Resident # 7's room. After an allegation of sexual abuse, a nurse was not notified immediately; staff was cleaning up the resident before a nurse came to the room, a nurse did not complete an initial assessment until that night on 7p-7a shift. The facility failed to provide a physical examination of a cognitively impaired female resident (Resident #7) by an appropriately trained/licensed professional for signs of sexual abuse or other forms of abuse immediately after a moderately cognitively impaired resident (Resident #39) was found in his wheelchair at her bedside with his hand under her covers on 5/2/2024. Resident #7 was not assessed by the Medical Director until 5/6/2024. Medical Director ordered Zoloft 25 milligrams by mouth daily for aggression on 5/6/2024. Resident # 39 was not put on 1 on 1 monitoring until 12:15 pm. The resident stayed on 1 on 1 until 3 pm and then was on every 15-minute checks. Resident #39 was placed on one-to-one supervision on 5/15/2024 at around 5:30 pm. The facility failed to assess if other residents had been abused until 5/15/2024. The facility failed to report the abuse allegation to APS until 5/16/2024. Abuse questionnaires were completed by the Business Office Manager, MDS Nurse, Admissions Director and Unit Manager on all residents with Brief Interview for Mental Status (BIMS) score of 9 and above with no adverse responses. Questionnaires were completed on 5/15/2024. The questions asked were as follows, 1. Do you feel safe? 2. Has anyone ever touched you inappropriately? 3. Are you afraid of anyone in the facility? The Unit Manager and/or Floor Nurse completed skin assessment for all residents with a BIMS score below 9 as of 5/15/2024 with no negative outcomes. 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. As of 5/15/2024 the Regional Director of Operations and Regional Clinical Nurse educated the Director of Nursing, Administrator, Medical and Staff Development Coordinator on abuse policy to include residents right to be free from abuse to include sexual, physical, mental, verbal and misappropriation of property as well as signs of abuse and reporting of abuse or potential abuse. Education also included the process and action to protect residents if any type of abuse including sexual abuse occurs according to facility policy and procedure on abuse. Actions to include assessment of all residents involved, immediate protection for all residents, immediate reporting to Management, state agencies, Ombudsman, APS, families, physician, immediate protection for all residents, and law enforcement. On 5/16/2024 Staff Development Coordinator and/or Director of Nursing educated all nursing staff on proper procedures for reporting any suspected abuse and immediate reporting to the Administrator and Director of Nursing for direction. Education will include direction for resident assessment immediately following incident, physician notification by Nurse for direction of care for resident and need to send out to hospital for further examination. On 5/2/2024 at 9:40am Social Worker talked with Resident #39 about the incident that occurred and explained to resident #39 what he had done wrong. On 5/7/2024 the physician changed resident #39's medication to add Zoloft 25mg tablet daily by mouth for aggression. As of 5/15/2024, around 5:30pm resident #39 has been placed on 1 on 1 observation. On 5/15/2024 the facility completed AdHoc QAPI to review investigation and current action plan to ensure all components were done and followed. The facility administrator and Director of Nursing are responsible for continued compliance. Alleged date of IJ removal: 5/17/2024 The Credible Allegation of IJ Removal was validated on 5/17/2024. The facility provided documentation of the in-service education that was provided to all staff which included the review of the facility's Abuse Policy and included immediate reporting of any allegations of abuse to the Administrator immediately; provide a physical examination by a trained/licensed professional for any signs of sexual abuse; provide protection for the resident that is the victim of abuse; provide protection for all other residents when an allegation of abuse is reported; and report any allegations of abuse to the proper authorities. The Staff Development Coordinator was interviewed and stated they have ensure all staff are educated regarding the reporting of abuse allegations to the administrator immediately; provide a physical examination by the physician or if the physician is not available send the resident to the emergency department for evaluation if there is an allegation of sexual abuse; provide protection for the abused individual and all other residents; and reporting of allegations of abuse to the proper authorities. She stated all staff that have been allowed to work have had the abuse education. During the validation of the Credible Allegation of IJ Removal observations of Resident #39 were made and the facility was providing one-to-one observation of the resident. The facility staff (sampled from all disciplines) were able to verbalize the types of abuse; what steps they should take to assess and protect the resident of an alleged abuse; and what authorities should be notified of allegations of abuse. The facility provided skin assessments that were completed on residents with a Brief Interview for Mental Status (BIMS) of less than 9 and interview forms that were completed on all residents with a BIMS of 9 or above that were conducted on 5/15/2024. The facility also notified Adult Protective Services of the allegation of sexual abuse for Resident #7 on 5/16/2024. The facility provided minutes of their Quality Assurance Performance Improvement (QAPI) meeting which was conducted on 5/15/2024. The alledged IJ removal date of 5/17 24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview with the attending physician, resident and staff, the facility failed to provide a safe transfer for a resident who was at high risk for fractures, was non-ambulatory and required extensive assistance with a mechanical lift for transfers. On 4/18/23 agency Nursing Assistants (NAs) #1 and #2 transferred Resident #1 from her wheelchair to bed utilizing a stand pivot method resulting in the resident's right lower leg getting caught under the bed during the transfer. The resident reported pain in her leg and NA #1 and NA #2 did not report the injury to a nurse. Resident #1 sustained a fracture of the right tibial plateau (a break of the large lower leg bone below the knee that breaks into knee joint itself), required a knee immobilizer, orthopedic care, and experienced pain rated a 10 out of 10 (with 0 indicative of no pain and 10 being the worst pain imaginable). NA #1 and NA #2 had no knowledge of where the resident's [NAME] (a care guide for NAs) was located and were unaware Resident #1 required a mechanical lift. This deficient practice was for 1 of 3 sampled residents reviewed for accidents (Resident #1). Findings included: Resident #1 was originally admitted to the facility on [DATE] with multiple diagnoses including hemiparesis (partial weakness/paralysis on one side of the body) and hemiplegia (complete loss of strength/paralysis on one side of the body) following cerebral infarction affecting the right dominant side. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had moderate cognitive impairment. The assessment further indicated the resident needed extensive assistance with two plus persons physical assist with transfers and ambulation did not occur over the entire 7-day period. Resident #1's [NAME] (resident care guide) completed on admission (undated) revealed that the resident was non-ambulatory, and the transfer method was mechanical lift. The [NAME] was observed on 5/8/23 at 2:30 PM in a binder located at the nurse's station. The Nurse Unit Manager was interviewed on 5/8/23 at 10:56 AM. She reported that Resident #1 had been using a mechanical lift for transfer for a long time, sometime in 2022. Review of the incident report dated 4/18/23 at 7:01 PM completed by Nurse #1 revealed Resident #1 was lying in bed with her right leg propped up on a pillow. Nurse #1 removed the pillow and the resident winced in pain and stated, can you please put that pillow back? Nurse #1 noticed the right leg was swollen and the resident stated that it hurt from her knee to her ankle. Resident #1 stated the pain was 10 on the scale of 1 to 10. The report indicated Resident #1 was alert and oriented to person, place, and time. A nursing progress note dated 4/18/23 at 10:02 PM revealed Nurse #1 went into Resident #1's room to obtain a urine specimen. The resident's right leg was propped up on a pillow. When the nurse removed the pillow under the resident's right leg, the resident winced for pain and stated, can you please put that pillow back? When asked, the resident stated her right leg hurt from her knee down to her ankle. She reported that when the 2 Nurse's Aides (NA #1 and NA #2) were transferring her from the wheelchair to bed, her foot got caught under the bed and she felt something pop, and it had been hurting bad. The resident was sent to the emergency room (ER) for evaluation. Nurse #1 was interviewed on 5/9/23 at 9:45 AM. She reported she had known Resident #1 since 2022. The resident was alert and oriented to person, place and time, and was reliable. The resident was non-ambulatory and had been using mechanical lift for transfer. The Nurse stated on 4/18/23 after 3:00 PM, she went to Resident #1's room and noticed a pillow under the resident's leg. She indicated when she removed the pillow under the resident's right leg, the resident winced in pain and requested to put the pillow back under her right leg. The nurse observed the resident's right leg to be swollen and the resident rated her pain as 10 on the scale of 1 to 10 when she removed the pillow. The nurse indicated nobody had informed her of the incident nor the resident's complaints of pain. The ER report dated 4/18/23 revealed that Resident #1 arrived in ER for an injury that happened approximately 2:00 PM at the nursing facility. The Emergency Medical Services (EMS) stated that resident's right lower leg got caught under the bed when the resident was being transferred back to bed from the wheelchair. The resident reported pain and swelling to lower leg and ankle. The resident was alert and oriented to person, place, date, and time. Evaluation in ER revealed a right tibial plateau fracture. She was placed in a knee immobilizer, non-weight bearing and Percocet (narcotic pain medication) for pain control and to follow up with the orthopedic in 1 week. The result of the Computerized Tomography (CT) of the lower right extremity dated 4/18/23 revealed acute, mildly depressed fracture of the anterior aspect of the lateral tibial plateau. Diffuse [spread or dispersing in many direction] severe osteopenia. Resident #1 was interviewed on 5/8/23 at 9:25 AM. She was in bed with a knee immobilizer on her right leg. She stated that she had the immobilizer since she fractured her leg and the Orthopedic Doctor had told her she would continue wearing the immobilizer for 4 more weeks. She reported that she fractured her right leg during transfer from the wheelchair to bed (on 4/18/23). She explained it was after lunch when she requested to be transferred back to bed. The 2 NAs (NA #1 and NA #2) transferred her, and during the transfer her right leg got caught under the bed. She heard a pop and her leg started to hurt badly. She screamed for pain and the NA stated she would let the nurse know. The resident indicated that she could not bear weight on her legs and the staff always use the mechanical lift for transfer. The written statement of NA #1 dated 4/20/23 was reviewed. The statement indicated that with the help of NA #2, she transferred Resident #1 from the bed to the wheelchair ready for her appointment. After the transfer, they left the room and started passing out breakfast trays. After breakfast, they started picking up breakfast trays when Resident #1 reported that she was sick and wanted to go back to bed. The statement indicated that NA #1 and NA #2 transferred the resident back to bed. NA #1 indicated that she was never told that Resident #1 was a mechanical lift for transfer. NA #1, an agency employee, was interviewed on 5/8/23 at 2:25 PM. She reported that 4/18/23 was her 3rd or 4th time working at the facility and she did not receive any orientation. She indicated she did not have access to the facility's kiosk, and she was not aware of the [NAME] that was available at the nurse's station. She stated that on 4/18/23, after picking up the lunch trays, she assisted NA #2 in transferring Resident #1 back to bed by using the stand pivot transfer. She stated nothing happened during the transfer, and she did not hear the resident complain of pain. NA #2, an agency employee, was interviewed on 5/8/23 at 2:45 PM. NA #2 reported that 4/18/23 was her first day working at the facility and she did not receive any orientation. She was assigned to Resident #1. She stated she did not have access to the facility's kiosk, and she was not aware of the [NAME] that was available at the nurse's station. She reported she was told that Resident #1 was two persons assist with transfers. She indicated that right after lunch, Resident #1 requested to be transferred back to bed from the wheelchair. NA #1 assisted her with the transfer using the stand pivot transfer. She reported that during the transfer, Resident #1 kept saying my leg hurts, my leg hurts and she told the resident that she would inform the nurse. NA #2 stated she did not inform the Nurse thinking that NA #1 did. NA #2 indicated she did not notice Resident #1's leg got caught under the bed during the transfer. NA #2 reported that she put a pillow under the resident's right leg since the resident was saying it hurt. The DON was interviewed on 5/8/23 at 10:05 AM. She reported she investigated the incident that happened on 4/18/23 with Resident #1. She interviewed Resident #1 on 4/19/23 and the resident reported that the 2 NAs transferred her from the wheelchair to bed. During the transfer, her right leg got caught under the bed. The resident indicated she screamed for pain and the NA told her she would inform the nurse. When in bed, a pillow was placed under her right leg. The DON indicated that the resident was alert and oriented to person, place and time and was reliable. The DON reported she interviewed NA #1 on 4/20/23 and obtained a written statement. NA #1 stated she was never informed that Resident #1 needed a mechanical lift for transfer. The DON reported she did not interview NA #2 since the NA had already left the building on 4/18/23 and she informed the agency not to send her back to work. A follow up interview was conducted with the DON on 5/9/23 at 11:05 AM. The DON revealed the resident's care summary including the resident's transfer status was posted in the kiosk, and the [NAME] was available at the nurse's station. She reported the Staff Development Coordinator (SDC) was responsible for making sure all staff including agency staff had access to the kiosk and the [NAME] at the nurse's station. She stated that if the agency staff did not know the transfer status of the resident, they should ask the nurse. The SDC was unavailable for interview. The Physician was interviewed on 5/9/23 at 11:53 AM. He stated Resident #1 had throat cancer and was on radiation therapy. She has a diagnosis of severe osteopenia and was a high risk for fractures. Using the lift for transfer could or could have not prevented the fracture. He indicated that minimal movement of resident with severe osteopenia could have caused spontaneous fracture. He stated that he expected the staff to use the appropriate transfer method for all residents to prevent injuries and to notify the nurse of any concerns voiced by the residents or any accident/injuries as they occur to the resident. The Administrator was interviewed on 5/9/23 at 10:15 AM. He stated he had just started as the administrator of the facility when the incident with Resident #1 happened. He reported the facility had plans to get rid of all the agency staff. He stated the incident was investigated by the DON, and a Quality Assurance and Performance Improvement (QAPI) was completed. A follow-up interview was conducted with the Administrator on 5/9/23 at 6:10 PM. He stated it was difficult to keep up with the agency staff. The facility received different staff from the agency every day, and it was unrealistic to educate each of them as they came. He reported the facility had planned to stop using agency staff. The corrective action with a compliance date of 4/25/23 was as follows: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the non- compliance: The facility failed to ensure staff provided transfer per care plan and failed to report the incident to the nurse. NA #1 and NA #2 transferred resident using stand pivot instead, when resident was care planned for a 2-person mechanical lift. On 4/19/2023 resident #1's care plan was updated to reflect transfer status by the Regional Minimum Date Set (MDS) Nurse. On 4/20/2023 interview with NA #1 on 4/20/2023 informed the Director of Nursing that on 4/18/2023 she and NA #2, were assisting Resident #1 from wheelchair to bed as resident had asked to return to bed because she was sick. During a stand pivot transfer resident stated, I heard a pop. NA #1 and NA #2 continued to assist resident #1 to bed. Resident told staff that her leg hurt, and NA #1 and NA #2 placed a pillow under Resident #1's leg and resident appeared to be comfortable. NA #1 stated she didn't know Resident #1 was a lift transfer. Resident stated this was sometime between 11:00 am and 1:00 pm when this happened. Nursing Assistant #2 stated, On April 18th I was given the 200-hall assignment with Resident #1. I was given an assignment run down by NA #1. NA# 1 and was told Resident #1 was a two person assist. I was notified that she was getting a shower because she had an appointment. On update of the resident 200 hall. I was only aware of one Hoyer lift patient. NA #1 and I were informed by the nurse that Resident #1's appointment had been canceled and to lay her down after lunch. After lunch NA #1 and I went to transfer resident #1 to the bed and she stated, that her leg was hurting and we continued to transfer her to bed. Once we got her to bed, we asked if she needed the nurse, and she said yes. NA #1 said she would notify the nurse. On 4/18/2023 around 4:00 pm NA# 3 entered the room to change the roommate and states that when she completed the roommate's care, she decided to do Resident #1's care. Nurse #1 entered resident #1 room to obtain a urine sample as NA #3 assisted. The nurse removed the pillow under resident #1's right leg and resident #1 asked her to put it back. The nurse replaced the pillow and asked Resident #1 if she had any pain, at that time Resident #1 stated, she felt pain from her knee to her ankle. Resident #1 reported a pain scale of 3, on a 0-10 scale. This was the first time the Nurse was made aware of pain. Resident #1 made the NAs aware earlier when the CNAs had to position the resident's leg on a pillow for the resident's comfort. The nurse proceeded to ask Resident #1 had anything happened. Resident #1 informed the nurse when NA # 1 and NA #2 were putting her to bed her foot got caught under the bed and she heard a pop. At this time Nurse #1 reported the incident to the Director of Nursing and Physician. Nurse #1 assessed Resident #1 and noted swelling to the right leg, orders were received to send Resident #1 to the hospital. Emergency Medical Services (EMS) were called, and Resident #1 agreed to go out to the hospital. X-rays were obtained at the hospital and the results showed a fracture of Tibial plateau. Resident #1 returned on 4/18/2023 with orders for orthopedic follow up, a knee immobilizer and order for Percocet 5-325 Milligrams (MG) take 1 tablet by mouth as needed every 6 hours for pain. As of 4/19/2023 Nursing Assistant (NA) #1 and NA #2 were suspended pending investigation by the Director of Nursing. Director of Nursing notified the agency of the incident involving NA #1 and NA #2 and to remove them from the scheduling of this facility. The Agency was informed on 4/19/2023 by Director of Nursing that NA #1 and NA #2 were a do not return to the facility. How you will identify other residents having the potential to be affected by the same deficient practice, and what corrective action will be taken; All residents requiring assistance with transfers are at risk of being affected by this deficient practice when receiving care. Director of Nursing and/or Nurse Managers completed complete audit of all resident's transfer status as of 4/19/2023 and updated care plan as needed. All residents with a change in status are referred to the Rehab Department by nurse for further evaluation and transfer status change. 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. As of 4/19/2023 4-point plan has been started to correct failing to follow proper transfers and reporting incident during transfer. Administrator and Director of Nursing completed 4-point Quality Assurance Improvement Plan (QAPI) as of 4/23/2023 to determine cause of incident. Investigation determined that re-education of care plan location and reporting of incident and accidents was needed. As of 4/19/2023 the Director of Nurses started education to ensure all licensed nurses and certified nursing assistants (full-time, part-time, as needed and agency) employees who do not complete the in-service training on transfers, resident transfer status and reporting change in condition related to pain will not be allowed to work until the training is completed. Staff Development Coordinator will ensure all new staff and agency staff have been educated. All nursing staff to include agency staff, must complete general orientation prior to working with residents. All staff, including agency staff, are given access to a kiosk prior to starting their shift. As of 4/23/2023 Director of Nursing and/or Staff Development Coordinator educated all licensed, non-licensed Nursing Staff and agency staff on proper transfer per care plan, resident transfer status location and reporting of resident pain or any change in condition. All employees to include agency staff, must complete general orientation prior to working with residents. AS of 4/23/2023 the Administrator, Director of Nursing and staffing coordinator will review staffing sheets daily to ensure staff scheduled have been educated and staff who have not been educated prior to starting their assignment receive education. As of 4/19/2023 Director of Nursing and or Nurse Manager will monitor 5 certified nursing assistants daily Monday- Friday for 4 weeks then 3 certified nursing assistants weekly for 3 weeks and then 3 certified nursing aides bi-weekly for 4 weeks to observe they are completing the transfer per care plan and reporting of any pain or change in condition. On 4/24/2023 Universal Healthcare at [NAME] conducted a QAPI meeting to review the findings of QAPI action plan and monitoring tools for effectiveness and any needed changes or improvements. Team consisted of Administrator, Director of Nursing, Nurse Managers, Social Worker, Rehab Director. Alleged Date of Compliance: 4/25/2023 On 5/16/23, as part of the validation process, the corrective action plan was reviewed and verified. Evidence of 100% auditing of residents' correct transfer and lift status on 4/19/23 and evidence of 100% all staff education on resident transfers, mechanical lifts and the [NAME] on 4/19/23 was reviewed and verified. The facility provided evidence of daily Quality Assurance auditing of proper use of lifts and correct lift status starting 4/19/23 and ongoing. Observations revealed correct transferring method and correct use of mechanical lift during resident care. Interviews with agency and in-house aides reported they were able to access the [NAME] and location of written [NAME] and were educated on immediately reporting any resident accidents or resident pain during or after a transfer to the nurse. The validation process verified the facility's date of compliance as 4/25/23.