**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility reported incident, record review, review of facility policy, and staff interviews, the facility failed to ensure residents remained free from abuse for 1 of 1 sampled resident (Resident #2) who experienced unwanted sexual contact from another resident. Failure to protect the resident from sexual abuse placed the resident at risk for mental and emotional distress. This citation is considered past noncompliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation occurred on 12/02/24. This policy, revised 07/15/22, stated, . It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse . 'Sexual Abuse' is non-consensual sexual contact of any type with a resident. Review of the facility reported incident, dated 11/27/24, stated, [Staff member #2] was walking in the hall and noticed [Resident #1] had his Right [sic] hand down [Resident #2's] pants in the front. - Review of Resident #1's medical record occurred on 12/02/24. A quarterly Minimum Data Set (MDS), dated [DATE], identified the resident as cognitively intact. Resident #1's nursing progress note dated 11/27/24 3:32 p.m. stated, Resident to resident incident reported by [staff member name] who witnessed incident between resident and other resident residing in [resident room number]. Incident reported to nursing staff, ED [Executive Director], and Social services. Local law enforcement notified of incident. This social worker attempted to interview resident, resident would not acknowledge or answer questions, laying in bed. Resident placed on temporary 1 to 1. This Social worker attempted to notify DPOA [durable power of attorney] no answer, unable to leave message. PCP [primary care physician] notified of incident. - Review of Resident #2's medical record occurred on 12/02/24. Diagnosis included dementia and Parkinson's disease. An admission MDS, dated [DATE], identified the resident with severely impaired cognition. Resident #2' nursing progress note dated 11/27/24 at 5:22 p.m. stated, Resident to resident incident observed by [staff title] which was reported to nursing staff, ED, and Social service. Resident was safely removed from vicinity of the other resident of [room number]. Local law enforcement was contacted by this social worker. Mood assessment completed-assessment score [number shows] s/s [signs and symptoms] of minor depression noted. Resident was able to briefly describe the incident. resident [sic] reports she does not feel in danger, and is not scarred [sic] of the other resident. Resident continues with normal routine. Daughter [name] notified of incident, PCP notified of incident. Resident to be monitored for any alterations in mood, behavior or changes in routine. During an interview on 12/02/24 at 10:30 a.m. an administrative staff member (#1) reported Resident #1 remained on 1 to 1 monitoring by staff and the resident was planning to discharge home on [DATE]. During an interview on 12/02/24 at 12:08 p.m. staff member (#2) confirmed on 11/27/24 around 2:00 p.m. staff member (#2) was down the hall and saw Resident #1 in the hall with his wheelchair side to side with Resident #2. Resident #1's right hand was down the front of Resident #2's pants. Resident #2 looked distressed and was swatting [Resident #1] away. Resident #1 started laughing and moved away before the staff member could get there. The facility failed to protect Resident #2 from non-consensual sexual contact. Based on the following information, non-compliance at F600 is considered past non-compliance. The facility implemented corrective actions for the resident affected by the deficient practice and put measures in place to ensure the deficient practice does not reoccur by: * Immediately implemented 1 to 1 staff supervision/monitoring for Resident #1. * Moved Resident #1's roommate to another room. * Reeducated staff regarding 1 to 1 supervision and on the abuse, neglect, and exploitation policy. * Interviewed other residents to determine if any other abuse occurred. * Reported the concern to the North Dakota Department of Health and Human Services, * Reported the concern to local Police Department. The surveyor determined a deficient practice existed on 11/27/24. The facility implemented corrective action and staff education on 11/27/24.

Based on record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to prevent the development of a pressure ulcer for 1 of 1 supplemental resident (Resident #138) identified as having a stage IV pressure ulcer and exposed hardware. Failure to evaluate risk factors that may impact the development of a pressure ulcer, and implement, monitor, and modify interventions to reduce those risk factors resulted in Resident #138 developing an avoidable, facility-acquired pressure ulcer. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include: Review of the facility policy titled Pressure Injuries and Non-pressure Injuries occurred on 05/16/24. This policy, revised 07/20/22, stated, . For those residents admitted with, or who subsequently developed a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity. Complete a head-to-toe skin check and document findings on the Skin Review - Weekly . Assess current wounds at least every seven days, or more frequently as needed (e.g., decline in wound, presence of infection, wound healed). Stage 4 Pressure Injury: Full-thickness skin and tissue loss with exposed or directly palpable fascia [connective tissue that surrounds cells, nerves, joints, and organs], muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar [dark, crusty tissue that covers a wound] may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. Review of Resident #138's medical record occurred on all days of survey. The physician's orders identified, . Right lateral malleolus [ankle bone] non healing surgical wound - Using sterile technique, cleanse with NS [normal saline] and pat dry. Apply a bordered foam dressing. Change daily and PRN [as needed] when soiled more than 50% or dislodged until healed. Monitor for signs/symptoms of infection one time a day . Right lateral malleolus stage IV pressure ulcer - Using sterile technique, cleanse with NS and pat dry. Apply Calcium Alginate AG [dressing] cut to fit wound bed and secure with a bordered foam. Change every 3 days and PRN when soiled more than 50% or dislodged until healed one time a day every 3 days . CAM high tide boot [orthopedic device that limits ankle and foot movement and protects the area during recovery], rt [right] ankle. May remove at rest for ROM [range of motion]. every shift . Notify DON [Director of Nursing] immediately if resident has any of the following: 1. pain to right outer ankle, 2. elevated temp [temperature], 3. redness to wound, 4. odor to wound every shift . The most recent care plan identified, The resident has . pressure ulcer or potential for pressure ulcer development . Administer treatment as ordered and monitor for effectiveness . Monitor/document/report PRN any changes in skin status, appearance, color, wound healing, s/sx [signs/symptoms] of infection, wound size . stage . Do not massage over bony prominences . Actual surgical incision at right leg r/t [related to] ORIF [a type of surgery used to stabilize and heal a broken bone] . Administer treatment per MD [medical doctor] order . Report evidence of infection such as purulent drainage, swelling, localized heat, increased pain . At risk for alteration in skin integrity related to immobility and weakness . Observe skin condition with ADL [activities of daily living] care daily, report abnormalities . Resident #138's progress notes identified the following: * 11/14/23 at 8:19 p.m., Resident got admitted to the building from . hospital . Resident is .here for PT [physical therapy] OT [occupational therapy] and over all strengthening. He was admitted to . hospital, because of a fall and a Brocken [sic] rt ankle . currently post-surgery to rt ankle. * 11/20/23 at 4:33 p.m., Resident had an appointment with Dr. [doctor] . for his S/p [status post] ORIF rt ankle. He was placed in CAM high tide boot, rt ankle. The weekly skin reviews, dated November 17-December 22, 2023, addressed bruising to Resident #138's bilateral upper extremities and right thigh, scabs to the right lower leg, redness to the buttocks, groin, and scrotum, and a pressure ulcer to the coccyx. Staff failed to address the surgical incision to Resident #138's right ankle. Additional progress notes identified the following: * 12/23/23 at 4:44 p.m., Dr. in to see resident at this time to look at resident's right ankle. Orders received for sterile dressing change daily and to monitor for signs/symptoms of infection. Currently no infection noted. Wound bed is pink and intact with minimal serous drainage. * 12/24/23 at 11:06 a.m., . On 12/23/23, DON was [sic] notified wound nurse that resident had hardware visible to right ankle. The current status is Res [resident] seen by provider. New orders received. Res admitted to [Hospital] for assessment of surgical repair. The weekly skin review, dated 12/23/23, identified, Pressure injury acquired . in house . Stage IV PU [pressure ulcer] to right lateral malleolus 4.5 x 6 x -.7 cm [centimeters] 80% hardware exposure and 20% granulation, 10% crust along the wound edge from approximately 11 to 3 o'clock which may be epibole. Shiney [sic] epithelial edge from 4 to 6 [o'clock]. Mild to moderate serosanguinous drainage smeared across the bedsheets. The [sic] denies pain, chills, N/V [nausea/vomiting] or feeling feverish. Was to see Dr. about weight bearing status and healing post hardware placement on 12/21 but missed the appointment. As per facility policy and the Resident 138's care plan, the facility failed to: * Assess/monitor Resident #138's right lateral malleolus non-healing surgical wound during the daily dressing changes. * Document/report any changes in wound status, appearance, color, wound healing, signs/symptoms of infection, wound size, and stage. * Identify the facility acquired pressure ulcer prior to it developing into a stage 4 ulcer with the exposed hardware. During an interview on 05/15/24 at 10:30 a.m., two administrative nurses (#1 and #4) indicated they recognized the issue and addressed it by educating their staff and initiating a performance improvement project. Based on the following information, non-compliance at F686 is considered past non-compliance. The facility implemented corrective actions for the resident affected by the deficient practice by: * Assessing the pressure ulcer to Resident #138 right ankle. * Completing an investigation into the facility acquired pressure ulcer. * Determining nursing staff failed to document wound measurements on the admission skin assessment. * Determining nursing staff failed to complete non-pressure weekly tracker assessments. * Determining nursing staff removed pressure relieving interventions from the care plan. The facility also put measures in place to ensure the deficient practice does not reoccur by: * Educating Resident #138 regarding the need for pressure relieving interventions. * Updating Resident #138's care plan. * Auditing other residents with surgical wounds and/or cam boots. * Updating other residents' care plans. * Educating staff regarding skin injuries and interventions. * Adding surgical skin areas and wounds to the wound tracker (computer program). * Completing weekly audits on skin injuries. This surveyor determined a deficient practice existed on 12/23/23. The facility implemented corrective action and completed all staff education by 12/27/23.