**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of six residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when Resident #2 physically and allegedly sexually assaulted her on 06/18/25. An IJ was identified on 06/19/25. The IJ began on 06/18/25 and removed on 06/19/25. The facility took action to remove the IJ before the abbreviated survey began. While the IJ was removed on 06/19/25, the facility remained out of compliance at a scope of isolated and severity level of potential for more than minimal harm because all staff had not been trained on resident-to-resident abuse prevention. This failure could place residents at risk for abuse. Findings included: Record review of Resident #1's face sheet, dated 06/19/25, reflected Resident #1 was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's Quarterly MDS Assessment, dated 05/16/25, reflected a BIMs score was not calculated. Her active diagnoses included non-alzheimer's dementia (refers to any form of dementia other than Alzheimer's disease), anxiety disorder (characterized by excessive, persistent, and uncontrollable worry and fear about everyday situations), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and schizophrenia (a serious mental health condition that affects how people think, feel, and behave). Record review of Resident #1's Progress Notes reflected the following: - 06/18/25 at 7:35 PM, LVN A wrote: This nurse was summoned by assigned aide, upon walking towards resident this nurse noted redness to residents neck area '[NAME]/Love Bite' This nurse [sic] asked resident how she sustained those redness [sic]. Resident states 'He [sic] was sucking on my neck' Asked resident to show this nurse who was sucking on her neck and she pointed resident [sic] '[Resident #2's initials]'. Notified Administrator, DON, ADON. [sic] Also informed NP C with [Dr. E's] services and NP D with [Psych ]. Order received to monitor and separate residents. Informed residents responsible party [Resident #1's RP]. - 06/18/25 at 8:23 PM, LVN A wrote: Called 911 Non-emergency service called to report the incident. - 06/18/25 at 8:43 PM, LVN A wrote: [City Name] Police here [Police Officer's Name] and this nurse informed him of situation. Police requested for both parties information which was given by this nurse. This nurse also gives her personal information to the cop, then escorted/assisted him to female resident room to question/investigate situation. This nurse informs resident that the police officer is her [sic] to question her about the redness on her neck. Per resident, and [sic] she states. 'He came into my room, in my bed before lunch and pulled up my dress touching down there, he played with my titties, he started to hold my neck down to kiss me and I called for help and he left. After dinner, watching [sic] television he choked my neck, wanting to kiss me I didn't let him, so he suck my neck [sic], He [sic] tried to touch me down there and I didn't let him. Resident also stated that male resident never took off his clothes only used his hands [sic], when asked by the police officer. Police report Service [sic] number [police report number] [Police officer's Name and badge number]. - 06/18/25 at 9:13 PM, LVN A wrote: Received order from [Dr. E/NP C] to transfer resident to [Hospital Name F], possible protocol for a rape kit test to be carried out if applicable. This nurse informs [sic] RP of transfer and she agreed to transfer. - 06/18/25 at 11:21 PM, LVN A wrote: Resident out of the facility to [Hospital Name G] per facility transport. - 06/19/25 at 9:00 AM, the DON wrote: Writer along with regional interviewed resident regarding incident from last night. Resident was asked what happened, resident stated 'he tried to kiss me, he tried to suck on my neck, he tried to choke me, he tried to screw me, he tried to pull my diaper to the side, she stated she fought him off by crossing legs [sic] and he left, When [sic] asked Resident [sic] cannot remember who it was, and stated 'I am okay and I am sleepy. [sic] - 06/19/25 at 12:08 PM, RN I wrote: Resident arrived back to facility @ 0900 with after care papers. Assisted resident into assigned bed .no pain reported by resident; resident stated 'No .I'm ok' when asked if she had any pain .bruises around neck; skin intact, no bleeding, reddish skin discoloration around neck .Hourly resident rounds by this nurse. - 06/19/25 at 12:22 PM, RN I wrote: Alterations in Skin Integrity. Note location of any noted areas. Enter measurements in box provided.: [sic] Bruise Bruise: Note location of any noted areas. Enter measurements in box provided.: [sic] Bruise 1 neck area, Bruise 2 right, lateral chin Record review of a Trauma Informed Care Assessment for Resident #1, dated 06/19/25, reflected the following: Have you ever experienced, witnessed, learned about a physical assault? Other- 'I fought him'. Unable to determine context .Have you ever experienced, witnessed, learned about a sexual assault? Other- 'I don't want to have sex'. Unable to determine context .Did any of these events bother you? Yes .Comment on events resident was bothered by: Unable to determine context. When prompted with, 'How did that make you feel?' she stated 'Violated.' Record review of Resident #1's Hospital Records, dated 06/19/25, reflected: Patient is a [AGE] year-old female with a past medical history of schizophrenia and dementia who presents from her skilled nursing facility/nursing home for evaluation of endorsed sexual assault. History is somewhat limited secondary to patient's cognitive decline, endorses that a male resident in her nursing facility 'tried to kiss my neck', states 'he tried to kiss my titties', states 'he tried to force my legs open but I kept them crossed'. Patient is unable to confirm if sexual or vaginal or anal penetration occurred, does not endorse oral penetration. Per nursing home staff (transportation staff), nursing home staff has been notified, patient is kept in a secure memory unit, nursing staff is investigating alleged perpetrator for any other information regarding the case .Skin: Superficial bruising of anterior neck .has superficial abrasions over the anterior neck Observation and interview on 06/19/25 at 5:44 PM revealed Resident #1 lying down in her bed. Resident #1 had multiple red marks and purplish/reddish bruises, about the size of quarters, to the right and left sides of her neck. Resident #1 was asked what happened to her neck. Resident #1 replied, He sucked my neck and choked me. Resident #1 said this happened in the TV Room and in her room. Resident #1 said he held her down because he tried to kiss her and she would not let him. Resident #1 said earlier in the day he tried to push her on the bed, he lifted up her dress and touched her breasts, so she hollered out and yelled and then he left. Resident #1 said she had not seen this person at the facility anymore. Resident #1 said she felt safe and was not in any pain. Interview on the phone on 06/19/25 at 1:12 PM with Resident #1's RP revealed she received a call from a nurse at the facility who told her the resident had [NAME]-like bruises to her neck. Resident #1's RP said she was told the facility was going to file a police report and sent the resident to the hospital for further evaluation. Resident #1's RP said she saw the resident had a bruise on her chin towards the right side of her face, a few scratches on her neck, and hickeys on her collar bone and neck area. Resident #1's RP said she did not notice any changes to the resident's behavior when she saw her earlier in the day. Record review of Resident #2's face sheet, dated 06/19/25, reflected Resident #2 was a [AGE] year-old male who originally admitted to the facility on [DATE], readmitted on [DATE], and was discharged on 06/19/25. Record review of Resident #2's Quarterly MDS Assessment, dated 06/09/25, reflected a BIMS score was not calculated. Further review reflected he had no behaviors of any kind towards anyone. His active diagnoses included non-alzheimer's dementia (refers to any form of dementia other than Alzheimer's disease) and cerebellar stroke syndrome (occurs when there's a disruption of blood flow to the cerebellum at the back of the brain). Record review of Resident #2's care plan, edited 06/13/25, reflected the following: Problem Start Date: 10/03/24, Category: Behavioral Symptoms, [Resident #2] display inappropriate sexual behavior toward another female resident. [Resident #2] has risk for inappropriate sexual behaviors towards others including staff, and fellow female residents .Approach: Encourage activity involvement to for [sic] pleasurable distractions. Please ensure activity is at level of understanding for the resident. New orders and medications adjustment review with changes. 15 minutes check for the next 24 hours and tele visit from Psych NP. Record review of Resident #2's progress notes reflected the following: - 10/03/24 - A Previous DON wrote: Charge nurse reported housekeeping witnessed resident grab a female resident and forcefully give her a kiss on the mouth. Residents were separated, resident was place on q 15 min checks, MD, psych NP and family were notified - 06/18/25 at 8:43 PM, LVN A wrote: This nurse was summoned by assigned aide, upon walking towards aide on hallway this nurse noted redness to [Resident #1], female residents neck area [NAME]/Love Bite. This nurse asked female resident [Resident #1's room number] how she sustained those redness [sic]. Resident states ' He [sic] was sucking on my neck' Pointing to this male resident. Female resident, [Resident #1's initials and room number] pointed at this male resident 3 times in the television room. After separating both parties, This [sic] nurse asked male resident of what happened between him and female resident but he denies every question and states, 'I don't know anything with both hands up in the air' [sic]. Notified Administrator, DON, ADON. Also informed [NP C] with [Dr. E's] services and [NP D] with [Pysch]. Call placed to [Resident #2's Main RP] Voice [sic] message left but spoke with [Resident #2's Alternate RP and phone number]. Order received to monitor this resident Q 15 minutes and separate both parties, This [sic] nurse moves resident from [Resident #2's original room number] to [Resident #2's new room number]. Head to assessment [sic] completed, noted redness to left lower lip skin intact but red. - 06/18/25 at 9:15 PM, LVN A wrote: [City Name Police] here, [Police officer's name] and this nurse informed him of situation. Police requested for residents information [sic] which was given by this nurse. This nurse also gives [sic] her personal information to the cop, then escorted/assisted him to male residents room [Resident #2's new room number]. The police officer questioned this resident regarding what happened earlier on but resident states 'Nothing happened' Police officer asked him if he was being inappropriate with a female resident? Resident states 'I don't know a female resident' Resident threw both hands in the air that he doesn't know anything and he don't' [sic] remember anything. Police officer asked him if he had breakfast, lunch or dinner he replies saying 'No I don't, no food here' This nurse reminds him that he requested for extra pasta today from this nurse during dinner and asked if he remembers that, resident states 'OKAY' [sic]. Resident unable to give any detail or account of situation that transpired. Per police officer, I could arrest him but due to his condition they won't keep him but advised he needs a male unit. Resident continues to be 1:1/Q 15 MINS Supervision [sic]. - 06/19/25 at 12:52 AM, LVN J wrote: Res remains in room with 1 on 1 assigned. Res in bed with eyes closed .No attempted to get OOB or leave room noted. No episodes of sexual inappropriateness, aggression or agitation noted. - 06/19/25 at 10:41 AM, RN I wrote: No unusual behavior. Q15 monitoring checks in progress during this shift .surveillance program for wandering residents in progress .One on one sitter in room [Resident #2's new room number]. - 06/19/25 at 11:28 AM, the SW wrote: The social worker contacted [Resident #2's RP] didn't answer and the social worker left a message for her to call the facility back. - 06/19/25 at 11:31 AM, the SW wrote: The social worker fax [sic] the resident clinicals to [a different NF] . - 06/19/25 at 1:32 PM, the DON wrote: The social worker contacted another family member for the resident to inform [them] that due to the incident that happened on yesterday the resident will be transferred to a sister facility. The resident has been approved and gave the family member the name and address to the moving facility. - 06/19/25 at 1:34 PM, RN I wrote: Q15 surveillance checks ongoing during this shift. One on One [sic] sitter at all times during this shift. Instructed by Admin and DON [the DON] to pack up resident's belongings. No unusual behaviors .cooperative during this shift. Spent shift in assigned bed .Hourly rounds by this nurse. - 06/19/25 at 2:05 PM, RN I wrote: Resident discharged Observation and interview on 06/19/25 at 11:45 AM revealed Resident #2 was in his room lying in bed. The ADON was standing in his doorway a few feet away from him. Resident #2 said he was doing good today and felt safe in the facility. Resident #2 said he had never tried to touch or kiss anyone at the facility. Resident #2 said he did not have any of those desires and had never tried to hurt anyone. Attempted interview on 06/19/25 on the phone at 1:28 PM with Resident #2's Main RP was unsuccessful as she did not answer. Attempted interview on 06/19/25 on the phone at 1:29 PM with Resident #2's Alternate RP was unsuccessful as she did not answer. Interview on 06/19/25 at 2:12 PM with LVN J revealed she worked the 10:00 PM to 6:00 AM shift overnight and was told by the previous shift that around dinner time in the TV room, Residents #1 and #2 were together and Resident #1 was found to have hickeys on her neck. LVN J said she was told Resident #1 told staff Resident #2 had sucked on her neck and tried to touch her down there. LVN J said staff called the police and that was when Resident #1 told staff before lunch there was an incident where she hollered for help and Resident #2 left her room because he was trying to touch her down there and played with her titties. LVN J said she never noticed any physical or sexual behaviors from Resident #2 towards anyone at the facility before this, so she was surprised to hear about it. LVN J said Resident #2 was placed on one-to-one observations and staff sat with him overnight after it happened to keep eyes on him. LVN J said she was in-serviced and knew what to do in regards to: identifying/reporting/stopping sexual or physical behaviors from residents towards others, supervising residents at all times but especially in common areas, and what the types and signs of abuse were, who and when to report abuse. Interview on 06/19/25 at 2:22 PM with RN I revealed she was at the facility when Resident #1 came back from the hospital this morning and did a skin assessment on her. RN I said when she asked Resident #1 if she was in pain the resident reported she was not. RN I said she had not observed any changes to Resident #1's behaviors so far during this shift. RN I said the skin assessment she completed revealed redness around Resident #1's neck area and a purple-ish bruise to the right side of her lower cheek. RN I said Resident #1 did not have those bruises yesterday morning when she cared for her. RN I said she never observed or knew about Resident #2 having any physical or sexual behaviors towards anyone at the facility. RN I said Resident #2 mostly stayed in his bed in his room during her shift. RN I said she did not observe any interactions between Residents #1 and #2 during her shift yesterday (06/18/25). RN I said she did not believe Resident #2 went to Resident #1's room at all near lunch time because not only was she working and an aide working, but the ADON and Administrator were also present as well. RN I said she was in-serviced and knew what to do in regards to: identifying/reporting/stopping sexual or physical behaviors from residents towards others, supervising residents at all times but especially in common areas, and what the types and signs of abuse were , who and when to report abuse . Interview on 06/19/25 at 1:36 PM with CNA M revealed she worked on the unit yesterday (06/18/25) during the 6:00 AM to 2:00 PM shift. CNA B said she knew nothing about the situation involving Residents #1 and #2. CNA M said normally both residents laid in their own beds in their own rooms during her shift. CNA M said she did notice Resident #1 had bruises to her neck when she saw her today that were not there yesterday. CNA M said Resident #2 never showed any sexual or physical behaviors towards anyone, but if he had she would have immediately reported it to her nurse and stopped it. CNA M said she was in-serviced and knew what to do in regards to: identifying/reporting/stopping sexual or physical behaviors from residents towards others, supervising residents at all times but especially in common areas, and what the types and signs of abuse were, who and when to report abuse. Attempted interview on the phone on 06/19/25 at 2:39 PM with CNA K who worked with both Residents #1 and #2 was unsuccessful as she did not answer or call back. Attempted interview on the phone on 06/19/25 at 2:40 PM with LVN L who worked with both Residents #1 and #2 was unsuccessful as she did not answer or call back. Interview on 06/19/25 at 2:56 PM with CNA B revealed she was working the 2:00 PM to 10:00 PM shift yesterday (06/18/25). CNA B said she took a few residents out for their smoke break around 6:30 PM and came back inside at 6:45 PM. CNA B said she was going to start her next set of rounds on residents and saw Resident #1, Resident #2 and Resident #3 sitting in the TV room together. CNA B said she noticed Resident #1 had bruises and redness that looked like two hickeys, scratches, and other marks to her neck that were not there before during her shift, so she alerted LVN A. CNA B said LVN A came over and asked Resident #1 what happened. CNA B said Resident #1 told LVN A what happened and pointed to Resident #2 saying he sucked on [her] neck and choked her. CNA B said Resident #2 was just sitting in the TV room like nothing had happened. CNA B said LVN A called the police and they came to talk to both residents. CNA B said LVN A told her Resident #2 was put on every 15-minute checks and then someone came to sit in his room with him the rest of the night. CNA B said it was normal for Residents #1, #2 and #3 to all be in the TV room sitting together watching TV after dinner. CNA B said Resident #1 was sent to the hospital and Resident #2 stayed in his room the rest of the shift. CNA B said she was in-serviced and knew what to do in regards to: identifying/reporting/stopping sexual or physical behaviors from residents towards others, supervising residents at all times but especially in common areas, and what the types and signs of abuse were, who and when to report abuse. Interview on 06/19/25 at 3:17 PM with LVN A revealed she worked the 2:00 PM to 10:00 PM shift yesterday (06/18/25). LVN A said after dinner Resident #1 wanted to go to the TV room to watch TV like she normally did every evening. LVN A said she saw Resident #1 sitting there in the chair like she always had. LVN A said she started to make her rounds on the residents and noticed Resident #2's TV was not working for some reason and would not turn on, so she asked if he instead wanted to watch TV in the TV room which he did. LVN A said later on in the shift she heard CNA B asking for her near the TV room, so she went to the area and saw Resident #1's neck was red. LVN A said she asked Resident #1 what happened because her neck was not like that a few minutes ago. LVN A said Resident #1 pointed to Resident #2 and said he sucked on her neck. LVN A said she took Resident #1 to her room to further assess her and asked her again what happened. LVN A said she had also asked CNA B to take Resident #2 to his room, although his room was right next door to Resident #1 so they moved him across the hall to be able to watch him better and so he would be in an empty room. LVN A said she assessed Resident #1 further and asked her what happened but Resident #1 appeared to be ashamed and shut down, not talking. LVN A said she called the Administrator who was the Abuse Coordinator for the facility and then was told to call the police. LVN A said the police came to the facility and she went into the room with Resident #1 to talk to the police officer. LVN A said Resident #1 told them Resident #2 came to her room before lunch and tried to touch her by pulling up her dress and touched her titties and kissed her and choked her. LVN A said the police officer asked Resident #1 if she ever lost consciousness and the resident said yes, and she had also screamed for help but then Resident #2 got up and ran out of the room. LVN A said Resident #1 continued by saying after dinner and in the TV room, Resident #2 came again and tried to pull her dress up again but she crossed her legs and did not let him go down there but he played with her titties again and tried to kiss her, but she fought him off. LVN A said Resident #1 explained Resident #2 began to suck on her neck and she pushed him away. LVN A said during the skin assessment she completed earlier there were no additional findings of an assault, physical or sexual that she could see. LVN A said Resident #1's neck had 4 places where there were bruises that looked like hickeys on one side of her neck and small circles on the other that were consistent with someone holding a person down. LVN A said Resident #1's story matched the injuries she sustained, and she had no history of making up stories. LVN A said she was not told about anything that happened during the previous shift around lunch time and since she was not there, she was not sure what happened. LVN A said she only knew of one other situation involving Resident #2 kissing a different female resident which was a long time ago. LVN A said after that situation happened, Resident #2 was put on every 15-minute checks until the psych provider could see him. LVN A said since then, Resident #2 never gave any indication he would do something like that again. LVN A said she was in-serviced and knew what to do in regard to identifying, reporting, stopping sexual or physical behaviors from residents towards others, supervising residents at all times but especially in common areas, and what the types and signs of abuse were , who and when to report abuse. Interview on 06/19/25 at 3:44 PM with the ADON revealed yesterday (06/18/25) evening, after dinner, CNA B noticed some bruising to Resident #1's neck and alerted LVN A. The ADON said LVN A assessed Resident #1 and after explaining what happened to her, the nurse alerted the Abuse Coordinator who was the Administrator. The ADON said Resident #1 told LVN A Resident #2 put his hands on her neck and sucked on her neck and was inappropriate with her. The ADON said Resident #2 was placed on every 15-minute checks and once they secured a staff member they sat with him one-on-one until he discharged from the facility. The ADON said Resident #2 was discharged today (06/19/25). The ADON said Resident #1 was sent to the hospital for an evaluation, both residents' families were notified, and the MD was also notified. The ADON said she herself saw Resident #1's injuries when she came back from the hospital today and noticed there were red dime-sized marks on her neck that were not there before. The ADON said she was not sure if the injuries were the result of Resident #2 sucking or choking on Resident #1's neck. The ADON said Resident #2 was involved in another incident with a different resident last year in either September or October where he kissed a resident. The ADON said after that happened, Resident #2 was placed on every 15-minute checks until the psych provider could see him. The ADON said the facility took the same approach with the situation that happened with Resident #1, except he was also placed on one-to-one until he discharged . The ADON said when she asked Resident #2 what happened, he could not recall anything but that was normal for him. The ADON said she did not have the opportunity to talk to Resident #1 about what happened. The ADON said the facility also in-serviced all staff regarding abuse/neglect, resident-to-resident altercations, and sexual behaviors. The ADON said she was on the unit yesterday (06/18/25) during the lunch meal service around 11:15 AM or 11:30 AM and never saw Resident #2 out of his room nor did she see Residents #1 and #2 together at any point. The ADON said Resident #2 was discharged to a sister facility that had an all-male secured unit and the family was agreeable to the move. Interview on 06/19/25 at 4:03 PM with the DON revealed she received a call yesterday from the Administrator saying LVN A reported CNA B went to get Resident #1 out of the TV room and noticed marks to her neck. The DON said LVN A asked Resident #1 who did that to her neck and the resident pointed to Resident #2. The DON said the staff on duty automatically separated the two residents and staff began arranging for Resident #2 to be placed on one-on-one. The DON said Resident #1 was sent to the hospital, but they could not conduct a rape kit because there was only evidence of a physical assault, not a sexual assault. The DON said Resident #1 told staff he grabbed her neck and touched her, he tried to kiss her on her neck, he sucked on her titties, he had tried to screw [her], he tried to pull her diaper to the side and get on top of her but the resident crossed her legs and he left out of the room. The DON said she asked Resident #1 what he looked like, and she said the man was white with grey hair and a beard which matched Resident #2's description. The DON said Resident #3 was also in the room, but he was not a reliable witness as he was not interviewable due to his condition. The DON said Resident #1's injuries were to both the right and left sides of her neck and on the front too. The DON said Resident #1's injuries looked like one side was where she was choked and the other was where she had been sucked on causing the hickeys. The DON said she was not sure if that was exactly what happened but that was what it sort of looked like. The DON said she always saw Resident #2 in his bed in his room and since she had only been there for about 4 months, she was not aware of the prior incident where he had kissed another resident months ago. The DON said she believed Resident #1 had her times mixed up as to when the lunch incident happened because the ADON, a housekeeper, and a therapist were there around the same time as the nurse and aide as well and none of the staff saw the residents interacting in any way. The DON said she thought the earlier incident happened before dinner, if it happened at all. The DON said Resident #2 had to be discharged because of the extent of him violating Resident #1's privacy and attacking her. The DON said the facility also in-serviced all staff regarding abuse/neglect, resident-to-resident altercations, and sexual behaviors. The DON said what Resident #2 did to Resident #1 was considered abuse. Interview on 06/19/25 at 4:43 PM with the Administrator revealed she was on her way home yesterday (06/18/25) when she got a call from LVN A saying CNA B came in from smoking the residents and started doing her rounds to get everyone cleaned up. The Administrator said CNA B took Resident #1 from the TV room and noticed she had bruising to her neck, so she called LVN A over to assess the resident. The Administrator said LVN A and CNA B took Resident #1 to the dining room and asked her what happened to which they were told Resident #2 sucked on her. The Administrator said Residents #1, #2 and #3 were in the TV room together which was normal for them to be in that room after dinner together as it's a common area. The Administrator said due to Resident #3's condition he was not able to be interviewed or recall anything that happened. The Administrator said after Resident #1 identified Resident #2 as the Alleged Perpetrator, the staff started him on every 15-minute checks while the ADON tried to find staff to sit with him one-on-one until he could be discharged . The Administrator said LVN A called the doctor to let them know what happened and sent Resident #1 to the hospital to be further evaluated. The Administrator said LVN A also called the police department, and an officer arrived at the facility. The Administrator said the police officer explained there was no signs of a sexual assault, only a physical assault. The Administrator said the hospital explained since there was no penetration they would not be able to complete a rape kit exam. The Administrator said Resident #1 returned to the facility this morning around 9 AM while the facility was working on transferring Resident #2 out of the facility. The Administrator said she was sent pictures by LVN A of Resident #1's injuries and saw it looked like she had hickeys on her neck. The Administrator said she believed Resident #1 had her times mixed up and the lunch incident did not happen at that time but might have happened before dinner instead. The Administrator said she was on the unit a lot yesterday (06/18/25) and never saw anything that seemed unusual between Residents #1 and #2. The Administrator said nothing else was reported to her about the 2:00 PM to 10:00 PM shift from yesterday. The Administrator said Resident #1 did not have a history of making up stories and Resident #2 did not have a history of any sexual or physical behaviors with anyone. The Administrator said there was only one incident where Resident #2 kissed another resident on the lips months ago which had already been reported and investigated. The Administrator said it was normal for the residents to be sitting in the TV area together and nothing had ever happened prior to this incident amongst any of them. The Administrator said the facility also in-serviced all staff regarding abuse/neglect, resident-to-resident altercations, and sexual behaviors. The Administrator said all residents had the right to be free from abuse, the facility was their home, and they deserved to be in a safe environment with quality of care and life. The Administrator said all staff were responsible for ensuring residents were free from abuse. The Administrator said if Resident #2's actions were intentional this situation would be considered a form of abuse. The Administrator said if residents were not free from abuse that could cause some type of harm to them either emotionally or physically. The Administrator said staff were constantly monitoring residents to ensure they were free from any abuse. The Administrator said all staff were trained to monitor residents at all times. Record review of resident safe surveys reflected 14 were completed with residents on 06/19/25 with no additional findings of any other abuse in the facility. Record review of an in-service, dated 06/19/25, reflected 35 staff were in-serviced regarding resident-to-resident altercations, sexual expression, and abuse and neglect. Record review of a post test completed by 35 staff reflected they understood the facility's policy and procedures regard[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and interviews, the facility failed to ensure a resident's environment remained free of accidents or hazards and received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #22) reviewed for transfers in that: 1. The facility failed to ensure CNA O provided adequate supervision and transfer assistance for Resident #22 attempting to conduct a transfer without assistance or without an assistive device. 2. The facility failed to ensure that CNAs were knowledgeable about locating the resident's safe transfer status requirements for Resident #22. An immediate jeopardy existed from [DATE] - [DATE]. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. This deficient practice placed residents at risk for falls, injuries, and hospitalization. Findings included: Review of Resident #22's Face sheet dated [DATE] reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnosis that included Cerebral Infarction (stroke), Displaced fracture of the greater tuberosity of right humerus (fracture of the neck of the upper arm bone that did not break the skin), Pain, Muscle wasting and atrophy left thigh and left lower extremity, Adult failure to thrive, Hemiplegia and hemiparesis following Cerebral Infarction (paralyzation following a stroke). Review of Resident #22's Minimum Data Set (MDS) assessment dated [DATE] reflected in section GG titled Functional Abilities and Goals Resident #22 had limited range of motion and impairment on both sides of her body and required the use of a wheelchair. Resident #22 required substantial/maximal assistance to totally dependent in the following areas: Toileting hygiene, Shower/bathe, lower body dressing, and putting on/taking off footwear. Resident #22 required total dependent assistance (or the assistance of 2 or more helpers) to roll left or right, sit to lying, lying to sitting on edge of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Review of Resident #22's Care Plan dated [DATE] reflected Problem/Category: ADL's Functional Status/Rehabilitation Potential Resident #22 had self-care deficits and is at risk for a decline in ADL function related to physical impairments due to Cerebral Vascular Accident with HP and UE Fx. Resident #22 may require more assistance some days more than others. Approach: Transfers: mechanical lift (2 person assist). Further review of Resident #22's care plan revealed a newer entry dated [DATE] regarding transfers . Problem/Category: ADL's Functional Status/Rehabilitation Potential [Resident #22] is unable to use mechanical lift sling with transfer. Requires 6 staff members to transfer using sheet to wheelchair from bed .Approach: Transfer to w/c using sheet with 6 staff for assistance. Review of the Incident Accident report dated [DATE] to [DATE] Revealed Resident #22 suffered a fracture on [DATE] as the result of an improper transfer. Record Review of a written statement dated [DATE] signed and dated by CNA O and RN S reflected that . [CNA O] entered [Resident #22's] room and began to transfer Resident #22. CNA O sat resident #22 on the side of the bed, wrapped arms around the resident, began to move from bed to wheelchair. Resident #22's chair began to move slightly backwards, CNA O began to lower Resident #22 and braced her with knee, when she heard a pop. Resident #22 was positioned in wheelchair and charge nurse [LVN P] was notified. CNA O states she was not assigned to that hallway and was unaware Resident #22 was a Hoyer lift. Review of Resident #22's nursing progress notes revealed that CNA O reported to LVN P that she had heard a pop when transferring Resident #22 from the resident's bed to the resident's wheelchair. LVN P and the RN S assessed the resident and notified the MD and ordered an x-ray. The x-ray revealed a displaced closed fracture of Resident #22's right humerus. An attempt at an interview on [DATE] at 11:00 AM revealed that CNA O's listed contact phone number was disconnected. In an interview and observation on [DATE] at 11:12 AM Resident #23 was observed being transferred via a mechanical lift. CNA K and CNA L were observed to apply mechanical lift sling to the supine resident for transfer from bed to wheelchair. Bed put in lowest pos, resident raised without incident by both staff members. Resident appeared to tolerate transfer well no signs of pain or mental duress. Resident stated she had never had a problem with being transferred by the mechanical lift, being lifted was scary the first couple of times but now she stated she was used to being lifted. She stated that she felt safe at the facility and had no complaints regarding her care or treatment at the facility. In an interview and observation on [DATE] at 1:08 PM Resident #24 was observed being transferred via a mechanical lift device from her wheelchair to her bed. CNA M and CNA L were observed performing the transfer. Sling placed on resident, bed to lowest pos, resident legs kept closed by CNA during transfer and steadying/guiding Resident #24 to the bed while the other CNA lifted and pushed the machine. Resident observed to have tolerated the transfer well. No signs of pain or mental duress. Resident stated she had been lifted many times at the facility and had never felt in danger, the CNA's knew how to do it. She stated she had no complaints about her care or treatment at the facility. In an interview and observation on [DATE] at 3:01 PM Resisdent #25 was observed being assisted with with a transfer by CNA N. Resident# 25 was able to assist with her transfer with assistance from CNA N. Resident's wheel chair was set with brake engaged next to bed. Resident #25's bed was observed to be lowered to level of wheel chair, resident assisted to edge of bed and steadied by CNA N, resident was able to stand with assistance and guided to a seated posistion in wheel chair without incident. Resident #25 stated that the staff knew her routine well and assisted her many times without incident to her wheel chair and back to bed. She stated that she had no complaints about her care or treatment at the facility. In an interview on [DATE] at 4:19 PM the Regional RN stated that all of the CNAs had had access to resident profiles that listed if a resident is mechanical lift, two person assist, or minimal assist. The Regional RN new CNAs were trained during orientation training to have ben able to access resident profiles to see what level of assistance residents required. The Regional RN stated that the the Former Administrator had been in charge at the time of the incident and the current Administrator had been at he facility for only 6 days. The incident had occurred nearly a month before the current Administrator came to the facility. In an interview on [DATE] at 4:24 PM, the DON stated that CNA O had been immediately suspended during the investigation, did not return to the facility or answer any phone calls from the facility, and had been terminated that evening. Review of CNA O's personnel file revealed that CNA O started work at the facility on [DATE], and was terminated as a result of the transfer incident on [DATE]. No other incidents or complaints were discovered in her employee file. In an interview on [DATE] at 11:24 AM, LVN P stated that CNA Q, the CNA that was on that hall the evening that CNA O had the incident with Resident #22 and had asked CNA O to help assist with changing Resident #22. He stated that CNA O had come and reported to him that she had heard a pop while transferring Resident #22. He stated that he and RN S had then gone and immediately assessed Resident #22. He stated that mechanical lift residents were posted behind he nurses stations and that CNA's had access to resident profiles in the facility computer system An interview on [DATE] at 11:27 AM with CNA Q revealed she had been the CNA on Resident #22's hallway that day and that Resident #22 requested to be changed by a different aide, so she had asked CNA O to come and assist her with changing Resident #22. Resident #22 must had indicated to CNA O that she wanted to be transferred to her wheelchair before she had been able to get to Resident #22's room. She stated that CNA O was just supposed to start setting up the equipment needed to change and clean Resident #22. She stated that Resident #22 had been a Hoyer lift for a long time and that there were lists of residents that required Hoyer lifts posted behind every nurse station. She further stated, after the incident, all of the staff had been trained on Hoyer lifts, where to look up resident profiles, she had been observed performing Hoyer lifts and other transfers, and she had taken and passed a competency test. Review of sign in sheets for the following in-service trainings between the dates of [DATE] to [DATE] revealed that 89 staff involved in patient care were in serviced on the following topics: Proper Hoyer Lift Procedure, Abuse and Neglect, Pain, Hoyer Transfers and Safety, Gait Belt Use, How to Access Transfer Code Care Assist and Care for Resident #22's Arm Sling. Review of Observation/Competency Checks for Hoyer Lifts Procedures, Transfer Safety, Accessing Patient Care Profiles, revealed 89 staff members involved in patient care were tested and observed for all for the above competencies. All Competency tests/observations were signed by the ADM, DON, ADON and Regional Nurse. The results showed that staff had been retrained successfully. Review of Safe Surveys of 52 residents, representing the entire resident population dated [DATE] to [DATE] Entitled Transfer Safety found no negative findings about transfers from the residents. Interviews were conducted with 8 RNs, 11 CNAs, and 1 MA were conducted on [DATE]. All staff interviewed were able to recount all In-Service topics, stated that they had a pre-test before the in-services and after the in-services. All interviewed staff stated that they had been observed conducting Hoyer and other transfers while being observed by the Regional RN, DON or ADON. All staff were able to identify where and how to access residents' profile information. Review of the facility Safe Resident Handling/ Transfers policy last revised 10/2023 revealed: .It is the policy of this community to ensure that patients/residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the patient/resident while keeping the team members safe in accordance with current standards and guidelines . - All patients/residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the team members that assist them. The use of mechanical lifts is a safer alternative to manual lifting for patients, residents, and caregivers . Compliance Guidelines: - The interdisciplinary team or designee will evaluate and assess individual mobility needs, considering other factors as well, such as weight and cognitive status . - The mobility needs will be addressed on admission and reviewed quarterly, after a significant change in condition or based on direct care staff observations or recommendations . - Team members will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur . - Team members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment . - Lifting and transferring will be performed according to the individualized plan of care