**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement written policies that prohibit abuse for 1 of 4 residents reviewed ( Resident #2) in that: The facility failed to ensure CNA B reported, to the abuse coordinator, Resident #1's allegation of sexual assault after she was informed of it by Resident #1's roommate. An Immediate Jeopardy (J) situation was identified on 2/7/24 at 3:35 p.m. as PNC. The noncompliance began on 9/30/23 and ended on 10/12/23. The facility corrected the noncompliance before the survey began. This failure caused a delay in retrieving possible evidence and could have caused serious harm, if the abuse was allowed to continue. Findings included: Record review of resident #2 Face sheet dated 9/19/23 indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Some of her diagnoses were schizoaffective disorder, major depression, severe with psychotic symptoms, and dementia. Record review of Resident #2 quarterly MDS assessment dated [DATE] indicated the resident had moderate cognitive impairment. She required set up help with eating and hygiene, partial assist with showers and dressing. The resident was independent with rolling from left to right, and she required supervision with laying down and standing up. Record review of Resident #2 care plan dated 4/10/23. Indicated a Focus area of the resident received psychotic medication related to psychosis. The resident was taking antipsychotics before admission, and she went to outpatient program at the behavioral hospital three times a week. The resident had a history of giving things away and would forget that she gave them away. Some of the interventions were administer medication as needed, referred to psychiatric and social services as needed, and determine the cause of expressions, and if possible. Resident #2 Had a focused area of required limited assistance with ADLs. The resident required one person assist with transfers, and grooming and ADLs. Record review of Resident #2 Provider Investigation report dated 9/30/23 indicated the former roommate indicated Resident #2 was sexually abused by the outpatient clinic van driver. A full body assessment of the resident was conducted and showed no injuries. The resident attended a face-to-face appointment with her physician on 10/3/23 and a pelvic exam was completed. On 10/1/23 criminal investigation, division, interview resident with family member present. The local police department was notified and present at the facility on 9/30/23 to speak with the resident and family. The perpetrator was not employed with the facility. There were no other residents in the building were receiving services from the outpatient clinic . The resident was receiving weekly counseling services. Record review of a nursing progress note dated 9/30/23 at 12:15 p.m. indicated the nurse was informed the resident had alleged sexual assault and skin assessments were performed. At approximately 12:10 p.m. The sheriff's department spoke to the family and did not interview any other staff at that time. At 12:30 PM the sheriff came to the nurses' station and spoke to the writer and gave a description of the suspect, the writer called the behavioral hospital to get information on the van driver. At 3:39 PM. the nurse spoke to the resident's old roommate to see if she had heard of a confession from Resident #2. The roommate stated that the resident told her she was tired of being sexually assaulted. The roommate said Resident #2 would go to the outpatient clinic and her hair would look nice and she would come back in her hair was a mess. The roommate said Resident #2 told her that about three weeks ago. Record review of a statement written by CNA B dated 10/6/23 indicated when she was talking to the former roommate when she told her that Resident #2 had been molested at the Behavior Center around this time she stopped going to the outpatient clinic. She also thought that it was reported and that was the reason she was no longer going. The aid said she made a mistake by not going to report it to the Administrator. Because she thought it had already been reported. Record Review of labs collected from a pelvic exam on 10/3/23 with resulting labs completed 10/13/23 indicated there were no sexually transmitted diseases noted. Record review of a Corrective Action Form indicated CNA B was suspended due to failure to report an allegation of abuse to the abuse coordinator. The employee had been in-serviced on proper reporting requirements and was suspended pending investigation. The form did not have a date. Record review of an in-service conducted on 10/6/23 indicated staff were in-serviced on abuse and neglect and reporting abuse to the abuse coordinator. Record review of the QAPI Meeting sign-in sheet dated 10/12/23 indicated the medical director attended the meeting. The topic of discussion listed as Trauma informed and culturally competent care related to sexual abuse. The policy was required with QA and discussed the resident that experienced trauma due to sexual assault. Record review of the Sheriff's Office Report indicated it was initiated on 9/30/23 at 11:59 a.m. and closed on 12/15/23. The record indicated the case was closed due to lack of sufficient evidence. During an interview on 2/5/24 at 3:55 p.m., the Administrator said they called the Sheriff's Office, and the deputies came out the same day. She said a female deputy had interviewed Resident #2 multiple times. The Administrator said she did not know the outcome of those interviews; Resident #2 had not revealed anything to her staff. She said the SW and the counseling services had not gotten her to reveal anything to them. She said the Sheriff's office had basically handled the investigation; it was a criminal investigation. She suspended CNA B for not reporting the incident sooner. She said the police had not told her anything because the investigation was still on going. They had just suspended all services with the Behavioral Outpatient clinic at that time. However, they did not have any residents attending prior to being made aware of the incident with Resident #2. During an interview on 2/6/24 at 1:38 p.m. CNA B said Resident #2 was not going to the Outpatient Behavioral Clinic and seemed depressed. One day the roommate Resident #4 told her while they were in the bathroom that Resident #2 was upset because she had been F by the van driver. CNA B said she thought it was something that had already been reported because Resident #2 was no longer going to the program, so she did not report what the roommate had said. She said about 2 weeks later the family member came to her and said and something was wrong with Resident #2. The aide said at that time she told the family member what Resident #4 had told her. She said the family member was not aware and Resident #2 had never said anything. CNA B said she was suspended that day for not report the allegation to the Administrator. She said if anything like that ever happened again would report immediately. She said if she thought it was abuse or sounded like abuse she would report. CNA B said she knew what sexual abuse was but had not reported it because she thought the Administrator was aware. During an interview on 2/6/24 at 2:17 p.m., CNA C said she was aware of what abuse and neglect were; they were in-serviced all the time. She was able to identify the different types of abuse and neglect. She said if she heard or seen abuse, and she would immediately report to nurse and abuse coordinator. During an interview on 2/6/23 at 2:33 p.m. CNA D said he was able to identify the different types of abuse, multiple types of abuse, physical abuse, mental, verbal abuse, not seen or heard any abuse, and would report immediately to charge nurse and abuse coordinator. During an interview on 2/6/24 at 2:45 p.m., CNA E said she was able to identify different types of abuse and neglect. She said she had not seen or heard any abuse and would immediately report to the Administrator if she did. During an interview on 2/6/24 at 3:19, CNA G said she was familiar with abuse and neglect. She said if she heard or seen any abuse or neglect would report immediately to the abuse coordinator/Administrator. During an interview on 2/6/24 at 3:27 p.m., the DON said it was her understanding that Resident #2 was out to an outpatient service and one incident occurred. She said she did not know anything about the Resident #2's incident until they had taken statements. She said she knew the family stopped sending her to the outpatient clinic. She said Resident #2 never reached out to the facility staff, but apparently talked to the Sheriff's deputy. She said she did not know when occurred had to occurred sometimes before 9/14/23. She said when they go to outpatient treatment and the therapist recommended outpatient. The DON said she was not sure of what the process was. She said as far as she knew the resident may have requested to go, or the social worker may have completed a referral. She said they provided an outside service to the residents in the facility. The DON said the facility was responsible for getting them the clinic they provide their own transportation. During an interview on 2/6/24 at 4:00 p.m., Resident #2 said she did not remember the time frame for when she was molested by the van driver. She said she did remember the incident and provided details. She said she had not confided in anyone at the facility because she was embarrassed. She said she was feeling better now and was putting the incident behind her. During an interview on 2/6/24 at 4:22 p.m. the SW said she had worked at the facility for 3 years and during that time Resident #2 had never opened to her. She said she would try to explore things with her, but she never told her what happened. The SW said she went back and talked to her weekly and she would not tell me anything. She said the process that took place was the Outpatient liaison would come to the facility and did activities with the residents. The SW said if the liaison thought any of the patients qualified, and some with prior behavior hospital inpatients. She said she did not remember how long Resident #2 was the only resident attending the program. She said she discussed with the family member Resident #2's her depression. The SW said they started to note a change with Resident 2. The family member requested on 8/29/23 to change the amount of days Resident #2 attended from 5 days a week to 3 days a week. The Resident #2 continued to be depressed and lost weight and it was the family's decision to stop the Outpatient program. The SW said the family thought that may be too much for her so on 9/14/23 Resident #2 stopped attending the program. During an interview on 2/7/24 at 3:10 a.m. the Administrator said she had counseled CNA B about not reporting the incident with Resident #2 on 9/30/23 and she was suspended that day. The Administrator said she had spoken to the aide several times during the next few days, and they had done the counseling. The initial counseling started on 9/30/23. She said they had in serviced on abuse and reporting. They had also taken the issue to QA and discussed trauma informed care. Record review of the facility Abuse policy last revised April 2021 indicated If Resident abuse was suspected, the suspicion must be reported immediately to the administrator and other officials according to state law. Immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury or withing 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Resident has the right to be free from abuse. Protect residents form abuse from staff from other agencies, visitors, or any individual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident received adequate supervision and an environment free from hazards for 2 of 10 residents (Resident #1 and Resident #3) reviewed in that: 1. The facility failed to ensure Resident #1 did not sustain bruises due to her side rails. 2. The facility failed to ensure Resident #1 sustained bruises due to an improper transfer by an outside hospice aide. Resident #1 was a two person transfer and was transferred by one person. 3. The facility failed to ensure Resident #3 did not sustain at least two falls with side rails on his bed. 4. the facility failed to ensure Resident # 3 a resident did not suffer injuries from side rails. An IJ was identified on 2/8/24. The IJ began on 11/2/23and removed on 12/21/23. While the IJ was removed on 12/21/23, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm because (e.g.) all staff had not been trained on fall interventions for residents at a high risk for falls. These failures placed residents at risk for physical harm. Findings Included: Record review of Resident #1's Annual MDS assessment dated [DATE] indicated Resident #1'scogntition was moderately impaired. She required extensive assist with bed mobility of one person. She did not get out of bed often but required two people for assistance. Resident #1 required extensive assist with dressing, she was totally dependent on one staff for eating, dressing, and toilet use. The MDS indicated the resident had limited range of motion, she had lower and upper extremities impairment on the left and right sides. She used a wheelchair for mobility. The MDS also indicated she did not have any restraints. Record review of Resident #1's acute care plan dated 6/14/22 indicated to pad the bed rails. Record review of Resident #1's hospice care plan dated 6/6/23 indicated the patients ADLS and personal care needs will be met with hospice aide. Record review of Resident #1's initial assessment for use of physical restraints dated 6/19/23. The reason listed for use of physical restraint was to aide in turning and positioning. The alternatives attempted was listed as siderail. The decision to restrain was the family and resident requested the siderails. The form stated a physician order is required. The family and resident were educated regarding the risks and safety of siderails and wished to continue risks. Record review of a fax cover sheet dated 6/12/23 indicated was called to Resident #1's room for a bruise to the lower left forearm measuring 13 cm x 7 cm. There were no signs and symptoms of pain. The resident reported hitting it on the siderail. Record review of a physician communication form dated 6/14/23 indicated Resident #1 had a bruise on her forehead and left inner elbow. The Resident thinks she did it while repositioning. Record review of Resident #1's nursing notes indicated on 7/3/23 at 7:30 p.m., an aide reported a dark purple discoloration of 16 cm x 11 cm to Resident #1's right shoulder and extending down to the breast area with edema noted. There were no signs and symptoms of distress or complaint of pain at this time. The hospice, MD, DON, and Administrator were notified as well as the RP. At 8:00 p.m., received an order from the MD to have right shoulder x-rayed. At 11:00 p.m. the hospice nurse was in the facility. Signed by LVN A. Review of a nursing note dated 7/4/23 at 12:00 a.m. indicated the hospice physician wanted to hold Aggrenax (blood thinner) at this time. At 7:30 p.m. x ray results received. Record review of hospice notes dated 7/3/23 indicated a hospice Aide was at the facility around 9:30 a.m. and provided care to the resident. She gave her a bed bath, changed the sheet, and provided ADL services. Record review of a hospice RN note dated 7/3/33 at 11:17 p.m. indicated a head-to-toe assessment was completed. Resident #1 was lying in bed sleeping. She reported pain to a bruised area on the right side of chest and shoulder area with light palpation. The area had a bruise with edema noted to the right upper arm and chest. The patient had right sided paralysis with contractures to the right hand and hardened raises area near the right elbow. It was unknown if new finding or related to right sided contracture from stroke. The physician was informed and ordered x-rays. The facility reported new onset of bruising, swelling and pain to right shoulder and right chest. Routine medications used for pain relief in the last 24 hours Tylenol routine and PRN doses were administred. The resident reported the area had moderate, severe pain, was aching and sore, and painful on movement and all activities. Record review of Resident #1's discharge summary indicated she was discharged on 8/1/23 to a facility closer to family. During an interview on 2/6/24 at 11:57 a.m., LVN A said Resident #1 had bruise on her shoulder that was reported and one of the hospice CNAs had seen it. She said she was not sure about bruise on the head. LVN A said Resident #1 was a two-person transfer, and she would fight during care. She said hospice would come and give bed baths in the morning. During an interview on 2/6/24 at 12:45 p.m., the ADON said Resident #1 had a bruise and her investigation indicated she had a history of favoring her right side. She had a large hematoma, eventually it was drained. She stated the family did not want her going to the hospital; she was on hospice there were some broken ribs, but she did not receive treatment. It was several weeks later before she was sent to the hospital to have the hematoma drained. She said the blood pooled in one spot and formed a large knot. She was under hospice care when she was transferred and something put some pressure on it which caused bruising. The ADON said Resident # 1 was a resident of the facility for 11 years. She said that staff reported Hospice aide said she knew the bruise was there and Resident #1 required two people to transfer. The hospice aide transferred her by herself, and did not report the bruise. She knew the bruise was there that morning but did not report it to anyone in the facility or to the hospice agency. The ADON said the incident where the resident bumped her head, she could not have bumped it on the wall due to the way the bed was situated. She said it was a possibility she bumped her head on the siderail. Resident #3 Record review of Resident #3's Face sheet dated 9/19/23 indicated he was an [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were Parkinson's disease, abnormalities of gate and mobility, history of falling, trimmers, dementia, and anxiety. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #3's cognitive score was not listed. He required partial to moderate assistance to bed roll left to right, sitting to lying, lying to sitting on the side of the bed, sit to stand, chair to bed transfer and toilet transfer. The MDS indicated the resident required partial to moderate assist with walking 10 feet once standing and the ability to walk 150 in the corridor once standing did not occur. Record review of Resident #3 Care Plan dated 7/26/23 indicated a focused area of limited supervision with ADLs. Some of the interventions were. One to two aides to transfer the resident as needed. Assist with dressing and grooming by one to two CNA's and encourage the resident to assist as much as possible. A focused area that indicated Resident #3 had a history of Falls, related to gait pattern, changes, when walking, and functioning status, and unsteady gate. The resident had diagnoses of Parkinson's and Lewy body dementia. The resident had confusion. Disorientation, lack of familiarity with surroundings, and impaired judgments/decision-making. The plan had a note at the bottom that said see acute care plans for actual files, dated 10/19/23. Record review of Resident # 3 Fall assessment dated [DATE] indicated prior to admission. The resident had multiple falls, and he was on Psychotropics, and he had problems by exhibiting loss of balance while standing. Record review of Resident #3 bed Rail and Assistive Bar evaluation dated 7/3/23 indicated Resident #3 had half Rails on the left side of the bed. Record review of Resident #3 Incident report dated 9/10/23 indicated at 7:50 a.m. The resident was confused and disoriented bed rails were ordered, and bed rails were present. Called to the room and noted the resident laying on his back in between the chair and the bed feet towards the TV, head towards the head of the bed as resident what happened and he stated, I do not feel good. Record review of Resident #3 Acute care plan dated 9/10/23. Indicated the resident was observed on the floor in room between the bed and the chair. The approach was insured. The resident had proper footwear. Record review of Resident #3 Acute care plan dated 9/23/23 indicated the resident was observed on the floor in the room in front of the AC unit. The approach was to ensure the room has the proper comfortable temperature. Record review of Resident #3 Acute care plan dated 10/2/23 indicated the resident was observed on the floor against the bed with the laceration to the right eyebrow. The approach was to conduct a medication review. Record review of Resident #3 Acute care plan dated 10/ 29/23 indicated the resident was observed on the floor. Some of the approaches were to place mats by the bed and to conduct 15-minute checks. Record review of Resident #3 Incident report dated 11/2/23 indicated at 9:15 PM. The resident was confused and disoriented he had side rails ordered and the side rails were present. The aide alerted the nurse the resident had fallen. When in the room the resident was laying on his left side left side beside his bed. The resident cried out in pain when attempting to move his left leg, the resident was assessed and sent to the hospital. Record review of resident #3 Provider investigation report dated 11/2/23 indicated around 9:15 PM. The resident was found on the floor Resident #3 was laying on his left side on the floor by his bed with fall mat in place. The resident voiced pain and was sent to the hospital for evaluation. Resident #3 Was diagnosed with an acute displaced angulated fracture of the neck of the hip. The resident was admitted to the hospital for consultation with an orthopedic surgeon. Record review of Resident #3 Acute care plan dated 11/2/23 indicated the resident was observed on the floor. The goals were 15-minute check times 72 hours and 30-minute check times, and a scoop mattress. Record review of Resident #3 Hospital Records dated 11/3/23 indicated the patient had complained of severe pain on the left hip. His x-ray and CT scan of the pelvis found that the patient has a left hip fracture. Record review of Resident # 3's incident reports indicated he had 10 falls between 9/5/23 and 11/2/23. During an interview on 2/5/24 at 3:55 p.m. the Administrator said Resident #3 was found on the floor, sent to the hospital, and had a fractured. She said he had participated in therapy for few weeks and then they put him back on Hospice. She said he had a history of falls, diagnosis of Parkinson's and dementia. The Administrator said he passed away before Christmas. During an interview on 2/6/24 at 2:17 p.m. CNA C said she worked with Resident #3 and had laid him down on 11/2/23 around 9:15 p.m. He is usually up during the night, so we tried to put him down at the end of the shift, hoping he was all tired out. She said they (CNA E) left the room and it was only a few minutes. She said they heard a big bang. She said she thought he climbed over the rail. CNA C said Resident # 3's rail was up because she put them up before leaving the room. The aide said Resident #3 came over or around the half rail. CNA C said she had to re write the statement and take out the side rail part. She said she did not see him fall, but the rail was up. He his head was on the fall mat and his arm was under the chair. During an interview on 2/6/24 at 2:45 p.m. CNA E said we (CNA C) had just put Resident #1 in the bed on 11/2/23. She said they did everything right, went back to the seating area, heard a noise and he was on the floor. CNA E said Resident # 3 was a two person assist and he had two side rails on the bed. He was declining in his health, and he was restless. She said they were waiting for him to wind down and be ready to go to bed. She said she did not know how he got out of the bed, they heard a big boom, he was on the floor. She said the rail was still up when they went into the room. During interview on 2/6/24 at 3:04 p.m. LVN F said she thought Resident #3 was trying to get up to use the restroom. She said when she had gone in the room, he was on the floor between the bed and the chair. She said he could not stand unassisted, he could stand with two people assisting him, and could not bear all his weight. She said she did not remember if he had a scoop mattress or side rails. He did break his hip with that fall and had been on hospice prior to the fall. During an interview on 2/6/24 at 3:27 p.m., the DON stated Resident #3 fell out of his bed and sent to ER and had a fractured hip. He was admitted on hospice at that time. During an interview on 2/7/24 at 11:28 a.m. the ADON said she Resident #3 did not have side rails. He was not supposed to have any and if he did, she was not aware of the rails. She said she was working to reduce the side rails in the building.