**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, interviews and record reviews, the facility failed to ensure that Advanced Directives were correctly documented and/or implemented for 3 of 3 residents reviewed, Resident (R)5, R9, and R20. On [DATE] at 5:52 PM, the Interim Administrator (IA) was notified that the facility's failure to maintain and implement written policies and procedures regarding advanced directives caused a resident to not receive Cardiopulmonary Resuscitation, the IA was then notified that the allegation constituted Immediate Jeopardy (IJ) at F 578, with an effective date of [DATE] and the IJ template was presented. On [DATE] at 2:27 PM, the Director of Nursing (DON) provided an acceptable IJ removal plan for F 578. On [DATE], the immediacy of the IJ was removed and the IJ was lowered to the scope of severity of E, no actual harm with potential for more than minimal harm that is not IJ. Findings Include: Review of facility policy titled, Advance Directives: South Carolina with a review date of [DATE] revealed This healthcare center recognizes the right of patients/residents to control decisions related to their medical care. Advance Directives relate to the provision of care when the patient/resident lacks the capacity to make healthcare decisions. Advance Directives executed in accordance with state law will be honored by the healthcare center.The healthcare center shall enter in the patient/resident's medical record any change in or termination of the advance directive for health care that becomes known to the healthcare center. Review of R20's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Record review of R20's Hospice notes titled Skilled Nursing Visit Note dated [DATE] revealed that R20 stated that she wanted Cardiopulmonary Resuscitation (CPR) if her heart or lungs stop working which was evidenced/reaffirmed by patient/ responsible party. R20 also stated that they would like life-sustaining treatments other than CPR. Review of Skilled Nursing Visit Note under section titled Clinical Record Items- Advance Directive stated that the Document type/Instruction was Full resuscitation and a copy was supplied. A Physician's Order for R20 dated [DATE] revealed R20's was a Full Code. Review of R20's Care Plan with a last review date of [DATE] revealed that If the patient/ resident's heart stops, or if patient/ resident stops breathing, CPR WILL be initiated in honor of the wishes through the next review period. With Approaches listed as: All staff to be made aware of patient/ resident's wishes and Review Advance Directive with patient/ resident and/ or appointed health care representative quarterly. Notify MD of any changes Review of R20's Progress Notes dated [DATE] revealed Resident expired at 1430. DHS and Hospice made aware. Review of R20's medical record revealed no documentation of resuscitation or CPR occurring. During an interview with the DON on [DATE] at 12:15 PM, she confirmed CPR was not performed. Review of R9's quarterly MDS with an ARD of [DATE] revealed R9 scored 12 on a BIMS, indicating the resident has moderate cognitive impairment. Review of R9'S Face Sheet under section titled Advance Directives revealed that R9 is a Full Code. Review of R9's Hospice Notes titled, DNR dated [DATE] revealed a DNR Order stating that no resuscitative efforts be made in the event of cardiopulmonary arrest. Review also revealed a DNR authorization for Patient /Resident Without Decision-Making Capacity: Florida, North Carolina & South Carolina. Review of R5's quarterly MDS with an ARD of [DATE] revealed R5 scored 11 on a BIMS, indicating the resident has moderate cognitive impairment. Review of R5'S Face Sheet revealed that R5 is a Full Code. Review of R5's Hospice Notes titled, DNR dated [DATE] revealed a DNR Order stating that no resuscitative efforts be made in the event of cardiopulmonary arrest. Review also revealed a DNR authorization for Patient /Resident Without Decision-Making Capacity: Florida, North Carolina & South Carolina. Review of R5's Care Plan with a last revised date of [DATE] revealed Problem: Advanced Directive; Full Code with a goal of: If the patient/ resident's heart stops, or if patient/ resident stops breathing, CPR WILL be initiated in honor of the wishes through the next review period. Approaches listed as All staff to be made aware of patient/ resident's wishes and Review Advance Directive with patient/ resident and/ or appointed health care representative quarterly. Notify MD of any changes. Review of R5's Hospice Note titled, Skilled Nursing Visit Note dated [DATE], revealed that R5 expressed his wishes to be a DNR and did not want any resuscitative efforts made and was reaffirmed by resident representative. During an interview on [DATE] at 10:32 AM, R9's Representative stated that he told the facility that he wishes for the R9 not to be resuscitated in the event of an emergency. During an interview on [DATE], time unspecified, the Director of Nursing (DON) stated that the unit manager, MDS coordinator and the social worker all work together as a team when discussing resident advance directives. She also stated that it was the responsibility of the nurse to ensure that advance directive orders are placed. Attempted to contact Social Worker on [DATE] at 10:30 AM for an interview, no answer voicemail left. The removal plan for F 578 included: 1. R9 and R5 advance directives, orders and face sheet were reviewed and revised to reflect accurately the wishes of the resident(s)/resident representative(s) on 06-08-23. R20 no longer resides in the facility. 2. An audit of all current residing residents advance directives by a licensed nurse will be conducted to ensure the residents) and/or resident representative(s) wishes are reflective accurately in the resident's medical record, MatrixCare. This includes verifying the resident's order, advance directive wishes and the residents face sheet to ensure all areas are accurate and reflective without discrepancies. The facility appointed staff to include the Director of Health Services, Clinical Care Coordinator and/or the Infection Preventionist will in-service all licensed nurses on code status recognition in MatrixCare and to follow the desired wishes of each individual resident. Any licensed nurses currently out due to vacation and/or personal leave will receive education prior to next scheduled shift. All new hire licensed nurses will receive the same in-service information in orientation. The facility social worker will also receive the same education, as well as the process to verify advance directives are reflective accurately without discrepancy in the resident's medical record, according to the resident and/or resident representative wishes. Weekly the Social worker, Director of Health Services and/or Clinical Competency Coordinator will meet to review any resident who admitted that week and any current residing resident record where changes were made to advance directives wishes to validate the medical record reflects accurately without discrepancies. This review will be recorded on a monitoring tool. 3. The Director of Health and/or Administrator will present results of reviews to the QAPI Committee monthly x 3 months and/or until substantial compliance achieved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings include: Review of R10's medical record revealed the facility admitted the resident with diagnoses which included Acute and Chronic respiratory failure with hypoxia, atherosclerotic heart disease of native coronary artery with other forms of angina pectoris, presence of aorotocoronary bypass graft, acute pulmonary edema, acute on chronic systolic heart failure, personal history of transient ischemic attack, diabetes mellitus type two, dyslipidemia, and cerebral infarction. Review of the discharge MDS with an ARD of 02/05/23 revealed R10 had a BIMS score of 15, indicating the resident was cognitively intact. Review of R10's Care Plan, initiated on 02/05/23, revealed that the resident had a care plan for altered mental status (AMS) with an intervention to send the emergency room for evaluation and treatment. Review of R10's progress notes entered late on 02/06/2023 at 09:03 AM for 02/05/2023 at 12:58 PM stated CNA came to get nurse. Assessed resident at 11:10 AM. Noted AMS. Resident presented with swollen lips, pale tongue, slowed response to questions posed to resident. Resident speech was more slurred than usual. Baseline for resident is A+Ox4. Resident had family at bedside. Family requested resident be sent to MUSC Downtown. Called DHS 11:14 AM who agreed. Called On-call for order at 11:15 AM. 911 called and gave report to MUSC Downtown. EMS arrived and family left to meet resident at hospital. EMS assessed resident. Reported to nurse that was possible stroke and will take the Prisma Health Richland. Nurse notified family of change of location. Resident left facility at 1200 PM. During an interview on 06/07/23 at 1:59 PM, CNA2 stated she has been employed with the facility for over 40 years. CNA2 stated she had provided care for R10 that morning and R10 was her usual self. CNA2 went back into the room and tried to get the R10 to eat her meal, but R10 stated she did not want to eat at that time. R10's family came out of the resident's room later and asked to see the nurse. CNA2 tried to find the nurse but was unable to find LPN 3. She was able to locate LPN2 and LPN2 assessed the resident. LPN2 decided to send R10 to the hospital. R10's family was extremely upset and continued to scream, yell, curse, became belligerent until the LPN2 had to tell them the police would have to be called if they didn't calm down. The family eventually calmed down. EMS took R10 to the hospital. During an interview on 06/07/23 at 2:10 PM, LPN2 stated she has been employed at the facility for 2 years. LPN2 stated she was working on the first floor. A CNA stated that there was a family on the fourth floor that was upset and wanted their family member sent to the hospital. She was unsure who the CNA was at this time. LPN2 assessed R10 and found she was lethargic, but not unresponsive. LPN2 decided to send R10 to the hospital. LPN2 called the Emergency Medical Services (EMS) and stayed with R10 until they arrived. R10's family wanted R10 to be sent to Medical University of South Carolina (MUSC) of [NAME], but EMS decided to send the R10 to the nearest hospital because she was exhibiting signs of a stroke. She was not given report by the nurse who was taking care of R10. LPN2 stated she does not leave the building when going on break, especially if it's only one nurse working on the floor. Anything could happen to the residents and the nurse would not know. LPN2 also stated that she was unaware of LPN3 leaving the building to go on break. During an interview on 06/07/23 at 2:30 PM, LPN3 stated has been employed with the facility since September 2022. LPN3 stated she was working with R10 all morning and R10 was fine and was in no distress. LPN3 stated right before 11:00 AM she checked the R10's fingerstick blood sugar (FSBS) and it wasn't either high or low. LPN3 proceeded to tell CNA2 that she was going on break and LPN3 left the building to go on break. About 10 minutes after LPN3 left the building she received a call from CNA2 that something was wrong with R10. She stated she told CNA2 to call LPN2 because she was not in the building. LPN3 spoke with R10's daughter and told R10's daughter that she just left R10 and R10 was fine. LPN3 repeated R10's FSBS to R10's daughter. The facility only had one nurse on the floor that day. When it's only one nurse on the floor LPN3 stated she doesn't give report to another nurse when LPN3 goes to lunch. On 06/07/23 at 2:45 PM during an interview with the DON, she stated she received a call from the facility stating R10 was unresponsive. R10's daughter was upset that she found R10 that way and she could not find anyone to help her. DON stated she spoke with LPN2 and was told LPN3 was on break. LPN2 assessed R10 and decided to send R10 to the hospital. DON reviewed footage and CNAs and nurses were in and out of R10's room during the morning. Around 11:00 AM, LPN3 went on break and CNA2 was left on the floor. R10's daughter walked into the R10's room right after LPN3 left the floor. That's when R10's daughter found R10 and went to look for nurse. R10's daughter could not find the nurse, so CNA2 went to look. CNA2 found LPN2 and R10 was assessed. LPN2 stayed with the resident until the resident was sent out of facility. LPN3 was educated on giving report to another before leaving the floor. DON stated notifying the CNAs is not enough because anything can happen. During a review on 06/07/2023 at 3:30 PM of the SBAR Communication form completed by LPN2 on 2/5/23. The change in condition, symptoms, or signs observed and evaluated is/are AMS. This started on 2/5/23. Since this started it has gotten worse. The question of if this condition, symptom, or sign has occurred before was answered no. Vital signs were as followed: blood pressure was 116/64, Pulse 48, Respirations 20, Temperature 98.6, Pulse oximetry 83% on room air. During an interview on 06/08/2023 at 09:41 AM R10's daughter stated on 02/05/2023 she was calling her mom to check on her that morning with no answer. Since we could not get her mom on the phone, she took an Uber to the facility. Once she arrived at the facility, she found her mom unresponsive with her tongue hanging out of her mouth. She went into the hallway to get help but couldn't find anyone. When she did find the CNA, they went to look for the nurse and could not find her. She stated it took her 2 hours to find a nurse. When a nurse was found she had to ask the nurse to send her mom to the hospital. Additional findings include: Review of facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, revised on 07/29/2019, states- The state survey agency and the state agency for adult protected services should be notified in accordance with state law through established procedures of any allegations of Abuse, neglect, exploitation or mistreatment, including injuries of an unknown source and misappropriation of patient property, within 2 hours after the allegation is made if the event upon which the allegation is based involve abuse or result in serious bodily injury, and not later than 24 hours if the events upon which the allegation is based do not involve abuse and do not result in serious bodily injury. On 6/24/23 video evidenced recorded around 8:30 AM - 9:00 AM revealed CNA2 being verbally abusive toward R21. CNA2 was observed speaking loudly and aggressively while pointing her finger towards R21 in an aggressive manner. During the video, R21 stated that he was in pain and needed help with getting his urinal. CNA2 stated How am I supposed to know that you are in pain in an aggressive manner while standing over the resident and pointing in a demeaning manner. CNA2 also made statements such as Touch me again, and it's going to be a problem in an aggressive manner. In the video, CNA2 was explaining to Licensed Practical Nurse (LPN)2 that R21 grabbed them while their back was turned. LPN2 was observed telling R21 You can use your hands (grab your own urinal), you can roll over and do that without help. During the video, LPN2 was observed allowing CNA2 to verbally abuse R21 without de-escalating the situation. R21 was admitted to the facility on [DATE] with the diagnoses including but not limited to; intellectual disabilities, muscle weakness, blindness in right eye, conductive hearing loss (bilateral) and unsteadiness on feet. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date of 06/05/23 revealed R21 has the Brief Interview of Mental Status (BIMS) score of 99, which indicates that R21 is cognitively impaired. Further review of the MDS revealed R21 requires one-person physical assistance with transfers and bed mobility. An observation and attempted interview on 6/30/23 with R21 revealed that he was non-interviewable and had difficulty discussing the alleged verbal abuse. A phone interview on 6/30/23 at 10:38 AM with R21's Resident Representative (RR)1 revealed I was sent the video on Saturday (6/24/23) by my brother, R21. In the video I saw CNA2 being verbally aggressive towards R21. She (CNA)2 was upset because R21 touched her and was trying to get her attention to use his urinal that was out of reach. Further in the video, I saw CNA2 waving her finger and getting close to R21 in an aggressive manner. I came to the facility on the day of the incident (6/24/23) and spoke with R21, CNA2, and two other nurses, but I can't recall their names. I asked for CNA2 to not work with the resident any longer after this incident, because R21 had told me he had issues with this CNA previously, but he could not remember her name. On Monday (6/26/23), I came back to the facility and spoke with the Unit Manager Licensed Practical Nurse (LPN)1 and someone from the Business Office about the incident and filed a grievance against CNA2. A phone interview on 6/30/23 at 10:48 AM with R21's RR2 revealed I came to the facility on the day R21 sent us the video of CNA2 being verbally aggressive towards him. When I got to the facility, I spoke with CNA2 and another nurse about CNA2 being verbally abusive to R21. When I watched the video, I feel like the other nurse in the video (LPN2) did not attempt to de-escalate the situation. In the latter part of the video, CNA2 yelled at the resident If you touch me again we are going to have some problems. I was unsure what she meant by that statement, but to me, it sounded threatening and like she would hit him (R21) if he touched or grabbed her again. R21 told me that he meant no harm when he grabbed her arm, but he was trying to tell CNA2 that he needed to use his urinal. I am unsure if the resident is safe at the facility because I fear that someone might try to get back at him because he recorded the incident. An interview with the Director of Nursing (DON) on 6/30/23 at 11:37AM revealed that CNA2 was currently at the facility and working today. During an interview on 6/30/23 at 11:42 AM, CNA2 revealed I was working on Saturday (6/24/23) with R21. While I was in his room and bending over to reach for something, R21 grabbed me hard on the shoulder. I went and told LPN2 and the Unit Manager LPN1 about the incident. R21 is a bigger man, so when he grabbed me, it was rough, because he is strong. I have been working with R21 since he was admitted and had no idea that he was hard of hearing and had a vision impairment. Later that day, his family came to the facility and spoke with me because R21 had recorded the incident on his phone. After this incident, I received an in-service by the Clinical Coordinator and continued to work as normal the rest of the day and week and was not placed on suspension during the investigation. CNA2 further stated that she has not received any abuse or neglect training from the facility because I previously worked at this facility a few years ago and have been a CNA for many years. A phone interview on 6/30/23 at 12:39 PM with LPN2 revealed I was working on Saturday (6/24/23) when CNA2 came to the nurse's station upset because R21 had grabbed her on her shoulder. We went down to the room together and that's when CNA2 and R21 started going back and forth (arguing) with each other about the incident. CNA2 was yelling at the resident that the way that he grabbed her shoulder was assault and that she was going to press charges and call law enforcement if he did that again. I was trying to understand what was going on during this time when they were yelling at each other. I told LPN1 about this incident, but I am not sure what happened afterward or if it was reported to the state agency/DHEC and investigated as verbal abuse by the facility. LPN2 further stated that they were unsure if CNA2 had worked with R21 after this incident but on the day of the incident (6/24/23), had switched CNA2's assignment with another staff member. An interview on 06/30/23 at 12:52 PM with R21 revealed I have seen CNA2 on the unit since the incident, however, CNA2 has not worked with him since last weekend 6/24/23. When asking the resident if he felt safe, R21 replied No, I don't feel safe right now. An interview with the DON on 6/30/23 at 1:45 PM revealed that they were unaware of the verbal abuse between CNA2 and R21 that occurred on 6/24/23. She stated,If I would have heard about this incident, I would have pulled them all in and gotten interviews. The DON further stated that they spoke to R21's family, but not about this incident and only discussed a room change. The Infection Preventionist handled R21's RR's grievance and spoke with the family in a meeting on Monday (6/26/23). An interview on 6/30/23 at 2:00 PM with the DON and Infection Preventionist (IP) revealed I was not working on Saturday (6/24/23) when this incident between R21 and CNA2 occurred. On Monday this week (6/26/23), staff informed them that R21 and their family had concerns and needed a follow-up meeting. I spoke to the Unit Manger/LPN1 on Monday and the family discussed the issue regarding CNA2 and R21 wanting a room change. The resident stated that he didn't want to be in a nursing home due to old people and he switched rooms with a newer roommate with a similar diagnosis. After the meeting, I completed a grievance for R21 and his family and provided re-education to CNA2 related to communicating with individuals with hearing or vision issues. I spoke with CNA2 about what happened, and she said that the resident grabbed her on her shoulder and that she was not being ugly with him. The ICP further stated that she did not speak to the other nurse (LPN2) who was a witness, and this incident was not investigated or reported. An attempted phone interview with the Unit Manager/LPN1 on 6/30/23 at 2:08 PM was unsuccessful, a voicemail message was left with contact information. A phone interview on 6/30/23 at 2:13 PM with R21's RR3 revealed I was sent the video by R #21 on Saturday 6/24/23 and was very upset by this incident. R #21 has communication issues because of his hearing and will often touch others when he needs help. I do not think he meant to hurt C.N.A #2 that day but he told me he needed his urinal. When my family went to see the resident later that day on Saturday (6/24/23) I was on speaker phone when my family spoke to C.N.A #2. Even though I was on the phone I heard C.N.A #2 being disrespectful towards my family. I did not speak with anyone at the facility related to the incident, but I sent the video to the local Ombudsman's office and spoke with their staff about the incident. Record review of Grievance/Complaint Form dated 6/26/23 revealed Family of R21 wanted to speak to Unit Manager regarding an issue with CNA2 and R21. CNA2 told resident not to grab her like that, resident got upset. CNA2 was provided education on caring for residents with intellectual disabilities and hearing loss. The facility's removal plan on 06/30/23 for F 600 included: 1) R21 was referred to psychiatric services on 6/30/23 for psycho-social support to determine if there are any lasting effects from this event. 2) All staff will receive education by the DON, Clinical Competency Coordinator and/or licensed nurse designee on providing care to residents with intellectual disabilities as well as the facilities Abuse policies to include: Abuse Identification, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property. Any staff who are currently out on leave will receive education prior to the next scheduled shift. Education was initiated on 6/30/23 and we will have a 100 % completion dated of 7/3/23. 3) Any alleged and/or witnessed abuse, neglect, exploitation, mistreatment, and/or misappropriation of funds will be reported and investigated per regulation and facility policy by the Administrator and or DON and logged on a tool. The Administrator and /or DON will review each investigation to ensure that appropriate interventions are put in place to prevent reoccurrence. The Administrator and/or DON will review each grievance to ensure no reportable event was captured as a grievance as opposed to a reportable incident to the state agency and appropriate persons/ agencies. 4)The DON and or Administrator will present results of reviews to the Quality Assurance Performance Improvement (QAPI) Committee monthly for three months and/ or until substantial compliance is achieved. Based on interviews, record review, and facility policy the facility failed to ensure Resident (R)5 and R6 were free from sexual abuse. Additionally, the facility failed to give report to another Licensed Nurse to ensure residents needs were met before leaving the facility for break. Specifically, R10 On 1/23/23 at 7:45 PM, a staff member observed R5 lying on top of R6 with his genitals exposed. After separating the residents and body audits completed, the facility conducted interviews with both residents. The investigation revealed R5 stated that R6 was a woman and that he knew her from the past. R6 was interviewed and made sexual references that occurred by showing with happened with his hands. Both residents were fully clothed at the time of the incident. R5 had on a shirt and pants, and R6 had a nightgown and brief that was intact, neither resident's clothing was noted to be off or pulled down. Families were notified of this incident, and during the notification R5's Resident Representative stated that R5 has a history of wandering and was found in the past at a neighbor's house in their bathroom. On 6/8/23 at 5:52 PM, the Administrator and Director of Nursing (DON) were provided with a copy of the Centers for Medicare and Medicaid (CMS) Immediate Jeopardy (IJ) template, notifying the IJ existed at F600 due to the facility failure to prevent sexual abuse and notify law enforcement as required by federal regulations. On 6/9/23 at 2:27 PM, the DON provided an acceptable IJ removal plan relate to F600. The immediacy of the IJ was removed as of 6/9/23. The IJ was lowered to the scope of severity of E. Implementation of the removal plan was verified by interviews and record reviews. Upon implementation verification, the DON was notified the IJ was removed as of 6/9/23 at 2:27 PM. Upon QA Review by the SA, the survey team returned to the facility on [DATE] with additional concerns. From this review, IJ was found related to a new incident at F600. R21 was observed via a cell phone recording to have been verbally abused by CNA2, in the presence of LPN2, with no interventions. On 6/24/23 video evidenced recorded around 8:30 AM - 9:00 AM revealed CNA2 being verbally abusive toward R21. CNA2 was observed speaking loudly and aggressively while pointing their finger toward R21 in an aggressive manner. During the video, R21 stated that he was in pain and needed help with getting his urinal. CNA2 stated that How am I supposed to know that you are in pain in an aggressive manner while standing over the resident and pointing in a demeaning manner. CNA2 also made statements such as Touch me again, and it's going to be a problem in an aggressive manner. In the video, CNA2 was explaining to Licensed Practical Nurse (LPN)2 that R21 grabbed them while their back was turned. LPN2 was observed telling R21 You can use your hands (grab your own urinal), you can roll over and do that without help. During the video, LPN2 was observed allowing CNA2 to verbally abuse R21 without de-escalating the situation. The IJ template was presented to the Director of Health Services/DON on 06/30/23 with an effective date of 06/24/23. On 6/30/23 at 5:44 PM the DON provided an acceptable IJ removal plan related to F 600. The immediacy of the IJ was removed as of 6/30/23. The IJ was lowered to the scope of severity of E. Findings include: The facility's policy titled, Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property Mission statement, revised on 11/21/2016 indicated, It is the mission of [NAME] Health and its affiliated providers (collectively, the Organization) actively to preserve each patient's right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of patient property. R5 was admitted to the facility on [DATE] with diagnoses including but not limited to heart failure, Alzheimer's disease, legal blindness, and schizophrenia. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/24/23, R5 has a Brief Interview of Mental Status (BIMS) score of 11 out of 15, which indicates they are cognitively intact. Further review of the MDS revealed R5 has a history of wandering and had this behavior 1 -3 days a week during this assessment period. R6 was admitted to the facility on [DATE] with diagnoses including, but not limited to; cerebral palsy, seizures, dementia without behavioral disturbance, and communication deficit. Review of the Discharge MDS with an ARD of 3/15/23, revealed R6 has a BIMS score of 5 out of 15, which indicated cognitive impairment. An interview on 6/7/23 at 2:21 PM with Certified Nursing Assistant (CNA)1 revealed While I was passing trays, I noticed R5 in his room on top of his roommate (R6). I called the charge nurse to the room and we assisted R5 back to his bed and noticed that his penis was out of his pants. The resident kept saying that he knew that woman (R6). We kept explaining to R5 that R6 was a man and his roommate and that he should not be in bed with other residents without their consent. R5 was later moved into a private room and was put on one-to-one supervision for about a month. R5 at times still wanders but he is legally blind, so staff have to look to make sure he does not wander into other residents' rooms. An interview on 6/7/23 at 2:27 PM with Licensed Practical Nurse (LPN)1 revealed I was called to the room by CNA1 and told that R5 was lying on top of R6. R5 was assisted to his bed. When we moved R5, we saw that his penis was outside his pants, R6 was still clothed, and his brief was intact. When we spoke with R5, he believed that he was in bed with a woman that he knew, we explained to him that R6 was a man and his behavior was not appropriate. We notified the DON and R5 was moved into a private room with a sitter. I spoke with R6 he made a motion with his hands signaling that R5 was attempting to touch his private areas. R5 was later put on one-to-one supervision for a few weeks, he wanders at times but not as much as he used to. Record review on 6/8/23 of R5 Social Services Progress Notes with a Late- Entry on 2/14/23 at 4:19 for 1/23/23 revealed On 1/23/23 R5 was physically inappropriate with his peer (R6). Resident (R5) was placed on 1:1, moved to a private room, and a referral was made to psychiatric services. Social Worker (SW) visited the resident, and he was in his room watching. SW explained to R5 the limits of physical sexual aggression towards others. SW informed the resident representative and educated R5 on behavior and referral to psychiatric services. Resident representative acknowledged and gave consent for psychiatric services, staff will monitor for any potential mood/behavior changes. Record review on 6/8/23 of R5's Nurses Progress Note dated 1/23/23 at 9:02 AM revealed Nurse was called to the room by the CNA. The resident was inappropriately touching another resident. Assisted the resident back to his bed and notified the Director of Nursing. The resident was moved to another room and a sitter for one on one was placed at his bedside. The nurse practitioner and resident representative notified. Record review on 6/8/23 of R5 Nurses Progress Note dated 1/26/23 at 7:45 AM revealed C.N.A. reports resident noted wandering into neighbors' room through bathroom. The resident was noted sitting on another resident's bed. The resident was reoriented by the nurse through conversation. Resident placed back in bed where he remained throughout the night. Review of R5's Care Plan revealed Behavioral symptoms follow up with psychiatric services intervention for sexual disinhibition. Interventions include redirect resident and monitor behavior; document behaviors daily twice a day. Review of R5's care Plan revealed Resident experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety. Interventions include maintain a calm environment and approach to the resident; move to a private room due to wandering into another resident's room one-to-one was initiated for 24 hours 1/23/23-1/24/23; remove resident from other resident's rooms and unsafe situations. Record review on 6/8/23 of R6 Social Services Progress Notes with a Late- Entry on 2/23/23 at 4:18 PM for 1/23/23 revealed R6 roommate (R5) was sexually inappropriate towards R6. Social Worker (SW) asked R6 to explain the incident that occurred with his roommate and R6 stated that R5 touched him. R5 was moved to another room, the family was notified and requested a referral for psychiatric services for R6. R6 was also informed of psychiatric referral and roommate transferred. Record review on 6/8/23 of R6 Nurses Progress Notes dated 2/1/23 at 3:13 AM revealed resident resting in bed with eyes closed easily aroused with verbal stimuli. Patient with multiple episodes of crying throughout the shift, when asked what is wrong and why is crying, he shakes his head no and stated, 'Please don't leave me.' Denies pain and discomfort, assistance provided with all phases of Activities of Daily Living (ADLs), so signs or symptoms of distress. Record review on 6/8/23 of R6 Progress Notes dated 2/2/23 at 2:05 PM revealed Resident tolerated all his medications crushed without complaints. His niece came to visit and expressed some concern about his demeanor. She stated that he just seems a bit off. A staff member went to check on him and will continue to monitor. Record review of a Nurses Progress Note dated 2/4/23 at 1:08 AM revealed resident lying in bed watching television, able to communicate wants and needs to staff. Resident in a sad tearful mood, resident oriented with one-on-one with nurse and conversation. An interview on 6/8/23 at 11:01 AM with the DON revealed they were not working on the evening the incident occurred but instructed the Unit Manger to complete body audits and interview both residents related to the incident. R5 believed that R6 was a woman, R5 is legally blind and has a history of wandering but this was the first time an incident of this nature has ever occurred with him. After the incident and body audits were completed, R6 was observed with his brief still intact and with no signs of physical harm so we didn ' t send him to the hospital or call law enforcement. The policy for the facility is when a resident shows signs of harm or displaced clothing/ underwear is to transfer residents to the hospital and call law enforcement. Interventions for R5 after this incident included one-to-one supervision for 24 hours and relocation into a private room where the resident is still placed. Interventions for R6 included monitoring for mood changes, a body audit after the incident, and obtaining a psychiatric consult. A phone interview on 6/8/23 at 11:43 AM with the Psychiatrist Consult for the facility revealed that R5 was followed by psych services from 2/1/23-4/12/23 and was discharged due to being put on hospice. Further revealed that R6 was not followed by psych because, during the initial consult, the resident was not exhibiting any signs or harm/distress, further stated that the resident's insurance would not cover psychiatric services but if the resident was in distress during their assessment they would have referred R6 to a psych service that insurance and would cover. Mutiple attempts were made to contact R6 during the survey 6/7/23 - 6/9/23 with no success. The facility's removal plan for F600 included: 1) R6 received a psychiatric consult and was not referred for further services as no signs of harm/distress were exhibited post event. R5 was transferred to a private room and placed on one-to-one supervision. R5 was removed from one-to-one after exhibiting no indication that he would repeat a similar incident. R5 will remain in a private room for the duration of his stay at the facility. 2) R5 will be placed on one-to-one-supervision to prevent any further occurrences due to R5 cognitive impairment, blindness, and wandering at times. 3) All staff will receive education by the Director of Health Services/ DON, Clinical Competency Coordinator, and/or licensed nurse designee on the facility Abuse policies to include: Abuse Identification; Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, and Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property. Any staff who are currently out on personal leave and/or Family Medical Leave Act (FMLA) will receive education prior to the next scheduled shift. Education was initiated on 6/8/23, we have currently completed approximately 45% of all partner in-services and have a 100 % completion date of 6/16/23. Any alleged and/or witnessed abuse, neglect, exploitation, mistreatment, and/or misappropriation of funds will be reported and investigated per regulation and facility policy, by the Administrator and/or Director of Health Services/DON and logged on a tool. The Administrator and/or DON will review each investigation once the investigation is completed to ensure that appropriate interventions are put in place to prevent reoccurrence. 4) The DON and/or Administrator will present results of reviews to the Quality Assurance Performance Improvement (QAPI) Committee monthly for three months and/or substantial compliance achieved.