**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure residents the right to be free from abuse and neglect for 8 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7 and Resident #8) of 8 residents reviewed for abuse and neglect.The facility neglected to ensure enough staff to monitor the residents in the male secure unit which lead to the resident-to-resident abuse.The facility failed to prevent Resident #2 from abusing Resident #1 on 6/25/2025 when Resident #2 pushed Resident #1 down on the floor causing a fracture to the left 5th toe. The facility failed to prevent Resident #5 from abusing Resident #3 on 7/13/2025 when Resident #5 hit Resident #3 in the head twice.The facility failed to prevent Resident #4 from abusing Resident #3 on 7/30/2025 when Resident #4 slapped Resident #3 on the right side of the face from behind.The facility failed to prevent Resident #6 from abusing Resident #5 on 8/28/2025 when Resident #6 hit Resident #5 in the face.The facility failed to prevent Resident #7 from sexually abusing Resident #8 on 9/02/2025 causing Resident #8 to be admitted to the hospital. An IJ was identified on 9/03/2025. The IJ template was provided to the facility on 9/03/2025 at 3:36 PM. While the IJ was removed on 9/04/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place all residents in the facility at risk for injuries, hospitalization and severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being.Findings Included: 1.Record review of Resident #1's facility's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses include Alzheimer's Disease with history of psychotic disorder (problem with thinking and delusions), and Hyperlipidemia (high cholesterol). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 00 (resident is rarely to never understood), indicating she was severely cognitive impaired. She required supervision to limited assistance with one person assist for dressing, toilet use, personal hygiene and required supervision with ambulation. Record review of Resident #1's care plan dated 03/14/2025 revealed Resident #1 is an elopement risk/wanderer as evidenced by impaired safety awareness, with interventions that included, distract resident from wandering by offering pleasant diversions, structured, activities, food, conversation, television, book. 2.Record review of Resident #2's facility's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses include dementia with, severe, with other behavioral disturbance, delusional disorders, major depressive, lack of coordination, anxiety disorder and age-related cognitive disorder. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 00 (resident is rarely to never understood), indicating she was severely cognitive impaired. She required supervision to limited assistance with one person assist for dressing, toilet use, personal hygiene and required supervision with ambulation. Record review of Resident #2's care plan dated 01/03/2025 revealed Resident #2 is an elopement risk/wanderer as evidenced by impaired safety awareness, with interventions that included, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Record review of Resident #1 and #2's incident report dated 06/25/2025 revealed the incident description that Resident #1 was standing over Resident #2 who was sitting on the couch. Resident #1 said something to Resident #2 and resident # 2 shoved Resident #1 causing her to fall. Both residents were assessed for injuries. A skin tear to the left elbow and a raised area was noted to the left side of resident #1's head. An xray revealed age indetermination fifth digit proximal phalanx head fracture (fracture to left fifth toe) for resident #1. Record review of witness statement from CNA F dated 6/25/2025 revealed on the day of 6/25/2025. I saw [Resident #2] push [Resident #1], causing [Resident #1] to fall down. [Resident #2] was brought to the nurse's station and sat there during the process of notifying the psych doctor and then was placed on Q15 monitoring. During an interview on 9/4/2025 at 11:49 AM with RN L she said she had worked with Resident #1 and Resident #2, in the past and was not at work during the time of the incident between Resident #1 and Resident #2. She said Resident #1 was on hospice and not aggressive and was mostly bedridden. She said Resident #2 was normally not aggressive and to push someone was out of her normal character . 3. Record review of Resident #3's facility's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), cognitive communication deficit (difficulty communicating), Alzheimer's disease (memory loss, confusion, and other cognitive decline). Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 09, indicating he was moderately cognitive impaired. He required partial to substantial assist for dressing, toilet use and personal hygiene and required partial/moderate with walking. Section E of the MDS indicated Resident #3 had not had any behaviors. Record review of Resident #3's care plan dated 7/13/2025 indicated Resident #3 had a psychosocial wellbeing problem potential related to being hit in the face 2 times by Resident #5 on 7/13/2025 with interventions that included: residents separated and both placed on 1:1 (1 staff member to 1 resident) monitoring, assessed both residents for injury, emotional distress, and neuros for 72 hours, moved other resident to a room on another hall with continued 1:1 monitoring, Psych MD and both RPs notified, gathered witness statements from staff and both residents, BIMS done on both residents, started in-services on Abuse/Neglect and Resident to resident altercations. When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. Record review of Resident #3's care plan dated 7/30/2025 indicated Resident #3 had a psychosocial wellbeing problem potential related 7/30/2025 being slapped by Resident #4. Resident #3 backed his wheelchair into Resident #4 and when he moved his wheelchair forward Resident #4 slapped him from behind with interventions that included: Resident #4 placed on 1:1 monitoring, Resident #3 referred to Psych services. Both residents assessed for injuries and will be monitored for delayed injuries, none found in initial assessment. Psych MD and both RPs notified. Both residents assessed form emotional distress for 72 hours. In-services provided on Abuse/Neglect and resident to resident altercation. Record review of a progress note for Resident #3 dated 7/13/2025 at 4:50 PM written by LVN D indicated Resident #3's nurse was notified by staff that roommate Resident #5 had hit him twice in the head. He reported no injuries noted, no acute distress and no discomfort noted. The residents were separated, 1:1 monitoring initiated and every 15-minute monitoring, neuros initiated by the nurse and all parties were notified by nurse and RN. Record review of a progress note for Resident #3 dated 7/30/2025 at 5:53 PM written by LVN E indicated Resident #3 was sitting in the dining room at his table when Resident #4 hit him in the head from behind. Record review of a facility incident report dated 7/13/2025 at 4:25 PM indicated Resident #3 was physically hit twice in the head by his roommate Resident #5. An assessment was completed by his nurse and no injuries were noted and no pain or discomfort was noted. Record review of a facility incident report dated 7/30/2025 at 5:00 PM indicated Resident #3 was hit in the head from behind by Resident #4. Redirected other resident away from this resident, placed other resident on 1:1 monitoring. 4. Record review of Resident #4's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), cognitive communication deficit (difficulty communicating), bipolar disorder (mood swings ranging from depressive lows to manic highs). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 06, indicating he was severely cognitively impaired. He was dependent or required substantial to maximal assist for dressing, toilet use and personal hygiene. Section E of the MDS indicated Resident #4 had not had any behaviors. Record review of Resident #4's care plan dated 5/01/2025 and revised on 8/14/2025 indicated Resident #4 had demonstrated physical behaviors and hit another male resident in the face. Interventions included: Residents separated, Resident #4 placed on 1:1 monitoring, and Resident #3 was placed on Q15 monitoring. Both residents were assessed for injuries and will be monitored for delayed injuries, none found in initial assessment. Psych MD and both RPs notified. Both residents were assessed for emotional distress for 72 hours. Witness statements gathered from staff. In-services provided on Abuse/Neglect and resident to resident altercations. Record review of a progress note for Resident #4 dated 7/30/2025 at 5:21 PM written by LVN E indicated the resident was witnessed hitting other resident on the right side of their head from behind while attempting to come in back door. Psych MD notified and received new order to send to inpatient facility. Record review of a progress note for Resident #4 dated 7/30/2025 at 6:00 PM written by LVN E indicated the resident was placed 1 on 1 with housekeeping sitting with the resident at that time. Record review of a progress note for Resident #4 dated 7/31/2025 at 11:07 AM written by LVN E indicated the behavioral hospital was at the facility to pick the resident up. Record review of facility incident report dated 7/30/2025 at 5:00 PM indicated Resident #4 was witnessed hitting Resident #3 on the right side of his head from behind while attempting to go out the back door of the dining room to the smoking area. Resident #4 was redirected away from Resident #3 and out onto open floor with nurse so he could be 1 to 1 at that time. During a confidential interview on an undisclosed date and time the interviewee said on 7/30/2025 Resident #4 was trying to go outside, and Resident #3 was fussing at Resident #4 to not go outside and backed his wheelchair up and into Resident #4 and that was when Resident #4 slapped Resident #3 on the right side of the face from behind. During an interview on 9/04/2025 at 1:10 PM the ADON said Resident #4 had a history of physical aggression. She said prior to the incident with Resident #3, Resident #4 had hit his previous roommate because their wheelchairs had got tangled up. She said Resident #4 had gone out to a behavior hospital for that incident and had not had any aggressive behaviors since that time. She said on 7/30/2025 Resident #3 and Resident #4 were by the back door and Resident #3 backed his wheelchair up and into Resident #4's wheelchair and Resident #4 slapped Resident #3 on the right side of his face from behind. She said Resident #3 had not any incidents of verbal aggression prior to the incident. 5. Record review of Resident #5's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with the most recent admission on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), bipolar disorder (mood swings ranging from depressive lows to manic highs). Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed a BIMS score was not completed due to Resident #5 was rarely/never understood. He required partial to moderate assist for dressing, toilet use and personal hygiene and was independent with walking . Section E of the MDS indicated Resident #5 had verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others), other behavioral symptoms not directed at others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming). Record review of Resident #5's care plan dated 7/13/2025 indicated Resident #5 had potential to demonstrate physical behaviors related to dementia, poor impulse control. Resident #5 hit another resident 2 times in the face on 7/13/2025 with interventions that included: residents separated and both placed on 1:1 monitoring, assessed both residents for injury, emotional distress, and neuros for 72 hours, moved this resident to a room on another hall with continued 1:1 monitoring, Psych MD and both RPs notified, gathered witness statements from staff and both residents, BIMS done on both residents, started in-services on Abuse/Neglect and Resident to resident altercations. Record review of a progress note for Resident #5 dated 7/13/2025 at 4:35 PM written by LVN D indicated the nurse was notified by the CNA that the resident hit his roommate twice in the head and then had a shoe and was going to hit another resident but was redirected by the nurse> All parties were notified. The resident was placed on 1:1 and every 15-minute monitoring and separated. Record review of facility incident report for Resident #5 dated 7/13/2025 at 4:25 PM completed by LVN D indicated: Notified by the CNA Resident #5 hit roommate in the head twice and had a shoe in his hand. The resident was redirected. Resident #5 was assessed by the nurse no and issues were noted. Resident #5 was redirected by the nurse and placed on 1:1 monitoring. During an interview on 9/02/2025 at 10:20 AM CNA B said most days she was on the male secure unit as the only CNA. She said on the day of the incident were Resident #5 hit Resident #3 she was on the male secure unit as the only CNA. She said Resident #3 had wandered into Resident #5's room and Resident #5 hit Resident #3 in the middle of his forehead with a closed fist 2 times. She said she separated Resident #5 and Resident #3 and went and got the nurse. She said Resident #6 had been aggressive to both Resident #3 and Resident #5. She said it had been reported to the ADON and the DON multiple times by nothing had been done. She said the nurse came to the male secured unit while the nurse was making her round or when she was asked to come in by the CNA but that was the only time the nurse was on the male secure unit. She said MA M was on the male secured unit only while MA M was passing out medications. 6. Record review of Resident #6's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: schizoaffective disorder (hallucinations and delusions and mood disorder symptoms), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), and anxiety (excessive and persistent worry, fear, and nervousness that can interfere with daily life). Record review of Resident #6's admission MDS assessment dated [DATE] revealed a BIMS 06 score which indicated severe cognitive impairment. He was independent for dressing, toilet use and personal hygiene and was independent with walking. Section E of the MDS indicated Resident #6 had verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others), other behavioral symptoms not directed at others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming). Record review of Resident #6's care plan dated 8/27/2025 indicated Resident #6 required psychotropic medications with interventions that included: Monitor/record occurrence of target behavior symptoms (specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol. The care plan did not address behaviors prior to the incident. Record review of a progress note for Resident #6 dated 8/27/2025 at 12:00 AM written by FNP G indicated: Phone note change of condition: Nursing staff requested to address a documented psychiatric issue of concern that requires a timely evaluation and medical intervention. Symptoms included: verbal disruptions, threatening, yelling, hostility towards others, impulsive behavior, initiation of fights, highly irritable, physical aggression towards others, socially inappropriate behavior, verbal aggression, patient is targeting 2 specific male residents, trying to hit them, starting fights, unable to redirect. Record review of a progress note for Resident #6 dated 8/28/2025 at 12:00 AM written by FNP G indicated: Phone note change of condition: Nursing staff request to address a documented psychiatric issue of concern that requires a timely evaluation and medical intervention. Symptoms included: Hostility towards others, impulsive behavior, highly irritable, nurse reports that the resident continues to try and hit at a fellow male resident, staff is concerned that the resident may harm others and or himself, staff requesting the resident be sent out to an inpatient psych hospital. Record review of a facility behavior nurses note dated 8/27/2025 at 4:45 PM written by the ADON indicated Resident #6 had been verbally aggressive and targeting a specific resident, balling up fists, acting like he would hit the resident. The resident was redirected. Record review of a facility behavior nurses note dated 8/28/2025 at 11:55 AM written by the ADON indicated: Resident #6 had been verbally aggressive and targeting a specific resident, balling up fists, acting like he would hit the resident. The resident was redirected and placed 1:1 supervision. During a confidential interview on an undisclosed date and time the interviewee said Resident #6 was a recent admission from the behavioral hospital and said he came to the facility aggressive. She said Resident #6 had been bullying Resident #5 since he admitted 2 days prior to the incident. She said on 8/28/2025 Resident #5 was sitting at the table in the dining room and Resident #6 walked over to Resident #5 and hit him with a balled-up fist to the right side of the face and chin area. She said Resident #5 did not have any redness or bruising where he was hit. She said when the incident occurred, she was trying to keep a fall risk resident from falling. She said she felt like if there was a second CNA in the male secure unit the incident may have been to be prevented. During an interview on 9/2/2025 at 12:20 PM the DON said CNA A facetime called her and showed her how Resident #6 was acting. She said she then ordered Resident #6 to be placed on 1:1 monitoring. She said it was not a video that was sent to her, but it was an actual in real time facetime call. She said she does not allow videos of residents on her phone and said if there was a recorded video then Resident #6 must have attempted to hit Resident #5 more than once. During a confidential interview on an undisclosed date and time the interviewee said she had taken a video of how Resident #6 had been acting and sent the video via text message to the DON. She said she took the video as desperation to get more help on the male secure unit. Observation of a video on 9/02/2025 at 12:32 PM on 9/02/2025 at 12:32 PM taken on 8/28/2025 revealed Resident #5 was sitting at a table in the dining room of the male secure unit, and Resident #6 then walked over to Resident #5 and began attempting to hit Resident #5 multiple times. During an interview on 9/02/2025 at 1:14 PM Housekeeper O said on 8/28/2025 she saw Resident #5 and Resident #6 having a verbal altercation. She said Resident #6 balled up his fists, so she got in between the 2 residents. She said there was only 1 CNA on the male secure unit that day and she was in a room providing care to another resident when the incident she saw occurred. She said she never saw Resident #6 actually make contact with Resident #5 at that time. During an interview on 9/04/2025 at 1:10 PM the ADON said on 8/27/2025 the CNAs had reported to her that Resident #6 was targeting and taunting Resident #5 by acting like he was angry with Resident #5 and attempting to hit him. She said she notified to psych doctor and received an order to increase his medication. She said on 8/28/2025 she was the nurse working on the male secured unit and said CNA A reported to her that Resident #6 was being physically aggressive to Resident #5. She said she brought Resident #6 outside of the male secured unit to the nurse's station and kept him there until he discharged to the behavior hospital. She said Resident #6 was still at the behavioral hospital at the time of the interview. She said Resident #6 was still at the behavioral hospital at the time of the interview. During an interview on 9/04/2025 at 2:07 PM the DON said on 8/28/2025 CNA A was the only CNA on male secure unit that day. She said the ADON was the nurse for the male secure unit that day and reported to her that Resident #6 was becoming more aggressive and told her she had already notified the psych doctor and received the medication increase order and asked if she could put Resident #6 on 1:1 monitoring. She said it was never reported to her that Resident #6 had hit Resident #5. She said she had questioned herself if Resident #6 was appropriate for their male secure unit due to his aggressive behaviors. She said Resident #6 discharged to the behavior hospital on 8/28/2025. During an interview on 9/04/2025 at 3:07 PM the Administrator said it was never reported to her that Resident #6 had been physically aggressive to Resident #5. She said it was reported to her that Resident #6 had been sent out to the hospital, but she did not know it was a behavior hospital. She said it was after surveyor entrance that she read the 24-hour report that she discovered Resident #6 had been sent out to a behavioral hospital. She said they did normally discuss where residents were sent out to in the morning meetings, but she had taken a day off work and was not in the morning meeting the day after Resident #6 had been sent out. She said after she found out Resident #6 had been sent to a behavior hospital; she did not question anyone as to why he was sent to a behavior hospital. She said on 9/03/2025 after surveyors entrance it was discussed with the DON that she must be notified of any resident-to-resident altercations. 7. Record review of Resident #7's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), and seizures. Record review of Resident #7's admission MDS assessment dated [DATE] revealed a BIMS 09 score which indicated moderate cognitive impairment. He was dependent for dressing, toilet use and personal hygiene and did not attempt walking. Section E of the MDS indicated Resident #7 had not had any behavioral symptoms. Record review of Resident #7's care plan dated 7/15/2025 indicated Resident #7 had behaviors: Sexually inappropriate as evidenced by previous inappropriate behaviors. On 8/11/2025 vulgar, inappropriate comments to nurse during care. On 8/14/2025 sexually inappropriate comments to nurse. Interventions included: Male secure unit, listen/talk to the resident-see if they will tell you why they do the behavior, psychiatric services consult as needed, staff to be in-serviced on behavioral approaches designed to effectively manage unacceptable sexual advances, staff will be trained to respond, but not react to resident's behavior. Record review of Resident #7's care plan dated 9/02/2025 indicated Resident #7 had engaged in physical touch of a sexual nature toward another resident with interventions that included: Avoid leaving resident unsupervised in situations where inappropriate contact may occur, identify and document triggers or patterns leading to inappropriate behaviors, immediately intervene report and document inappropriate sexual contact, resident immediately placed on 1:1 supervision. Record review of a progress note for Resident #7 dated 9/02/2025 at 2:45 AM written by the Administrator indicated: the resident was involved in a resident-to-resident incident approximately 2:30 AM. The resident was placed on 1-on-1 monitoring and will be referred to psych services. Record review of a facility incident report for Resident #7 dated 9/02/2025 at 1:30 AM completed by LVN J indicated: this nurse entered residents' room at approximately 1:30 AM and found this Resident #7 lying on the right side behind Resident #8 facing the window. Observed Resident #7 having sexual intercourse with Resident #8. Upon entering and discovering Resident #7 removed penis and both residents remained lying quietly. This nurse requested help from CNA K to remove Resident #7 from behind Resident #8 and separate them so assessments and investigation of incident could be performed. Resident #7 verbalized that he knew what he had done and said this incident was the first time. When questioned further Resident #7 began stating he was sad after the recent loss of his son and did not want to discuss any further. Resident #7 requested medication for anxiety and nerves. This nurse medicated Resident #7. 8. Record review of Resident #8's facility's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), psychotic disorder with delusions due to known physiological condition (false beliefs), cognitive communication deficit (difficulties with communication due to underlying cognitive impairments). Record review of Resident #8's admission MDS assessment dated [DATE] revealed a BIMS 08 score which indicated moderate cognitive impairment. He required supervision or touching assistance for dressing, toilet use and personal hygiene and set up or clean up assistance with walking. Section E of the MDS indicated Resident #8 had not had any behavioral symptoms. Record review of Resident #8's care plan dated 7/25/2025 indicated Resident #8 had impaired cognitive function/dementia or impaired thought processes related to dementia with behaviors with interventions that included: communication: use the residents preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues-stop and return if agitated. Record review of a progress note for Resident #8 dated 9/02/2025 at 1:30 AM written by LVN V indicated: A nurse entered the resident's room and witnessed him being sexually assaulted by his roommate. This resident was immediately cleaned and moved to another room. No injuries or bleeding noticed by assessing nurse at the time. On-call Nurse notified as well as Administrator. [town] Police Department also called and resident is being sent out to ER to be assessed 0230 EMS and Police arrived.)253 Resident leaving facility in route in [Hospital] to be assessed. The resident RP also notified. Record review of hospital paperwork for Resident #8 dated 9/02/2025 at 1:29 PM indicated: Date/Time Patient Seen: 9/02/2025 at 3:42 AM. Chief Complaint: Presents for [Facility] with report of sexual assault by another male patient at the facility. Patient denies memory of incident or pain. Paramedic [name] reports that NH staff told him they cleaned him up before transport. History of Present Illness: The patient was brought in from a nursing home over concerns that the patient had been sexually assaulted. According to the nursing staff the nurse walked into the room and found the patient's roommate sexually assaulting him. At that point the patient was brought to the ER to be evaluated. The patient does not recall the events and has significant dementia. Medical Decision Making: The patient was signed out to the oncoming physician pending a SANE exam. Record review of a facility witness statement dated 9/02/2025 at 1:30 AM written by CNA K indicated: Nurse [LVN J] open door to resident room, she saw resident [#8] in the be with resident [#7], she called for me [CNA K] to come here, from shower room, when I walked in the room, both residents bottoms were off, I asked [Resident #8] why he was in the bed with [Resident #7] he stated he didn't know why, both were facing the window, [Resident #7's] arm was across [Resident #8's] waist, when [Resident #7] went to turn over on his back, we could clearly see his penis was in [Resident #8's] buttocks, [Resident #7] had BM on his hands and could see where he had placed his penis in [Resident #8] rectum, [Resident #8] he had BM on his butt cheek and around his rectum, myself and nurse helped [Resident #8] get up out the bed, got him cleaned up and clothes on and covered up in bed. He was weak and very confused to what was going on!! After removing [Resident #8] to another room, I asked [CNA N] to help me to get [Resident #7] cleaned up, had him to get up in his wheelchair, so bed could be cleaned up, he had took his soiled brief off and it was thrown at the end of the bed when we entered the room, (I) saw it, the bed had a small urine stain that was wet under where [Resident #7] was laying & BM on the sheet on the back side where he [Resident #7] was laying., he had BM on his hands, face, legs!! I asked [Resident #7] why he did that to [Resident #8], he stated he didn't know, I asked him had he did that to him before and he said NO!! End of Statement!!! During an interview on 9/02/2025 at 10:20 AM CNA B said Resident #7 would make sexual comments such as you can suck it or can you touch it while she would provide care. She said when she told Resident #7 to stop talking like that he would. She said she knew Resident #7 had made sexual comments to staff but she had never seen Resident #7 make inappropriate sexual comments or gestures to any other residents prior to the incident. During an interview on 9/02/2025 at 10:40 AM Resident #7 said he had been sexually inappropriate with another resident at the facility. He said it was not last night, but it was maybe a month ago and it was not his roommate. He refused to say what resident the incident had occurred with. Resident #7 said he never penetrated anyone with his penis, but he got in the bed with that resident and went through the sexual motions. When asked why Resident #7 did what he did to the other resident he said it was his sexual mind. During an interview on 9/02/2025 at 3:45pm the RCN and COO said they had not been told by the previous facility that Resident #7 had any sexual behaviors prior to being admitted to the facility. The COO then said he thought by placing Resident #7 in the male secure unit they did not think that there would be any inappropriate sexual behaviors since all prior inappropriate sexual behaviors had been towards female staff members. During an interview on 9/02/2025 at 6:18pm LVN J said she was doing a room check at 1:30am and said it was the first time she had seen Resident #7 or Resident #8 since the start of her shift at 6pm. She said when she opened the door to their room, she saw Resident #8 lying in Resident #7s bed with Resident #7

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 8 of 8 residents reviewed for accidents and supervision. (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, and Resident #8) The facility failed to adequately provide supervision to prevent Resident #2 from abusing Resident #1 on 6/25/2025 when Resident #2 pushed Resident #1 down on the floor causing a fracture to the left 5th toe. The facility failed to adequately provide supervision to prevent Resident #5 from abusing Resident #3 on 7/13/2025 when Resident #5 hit Resident #3 in the head twice. The facility failed to adequately provide supervision to prevent Resident #4 from abusing Resident #3 on 7/30/2025 when Resident #4 slapped Resident #3 on the right side of the face from behind. The facility failed to adequately provide supervision to prevent Resident #6 from abusing Resident #5 on 8/28/2025 when Resident #6 hit Resident #5 in the face. The facility failed to adequately provide supervision to prevent Resident #7 from sexually abusing Resident #8 on 9/02/2025 causing Resident #8 to be admitted to the hospital. The facility failed to adequately supervise residents on the secured unit to maintain safety and to prevent resident to resident altercations. An IJ was identified on 9/03/2025. The IJ template was provided to the facility on 9/03/2025 at 3:36 PM. While the IJ was removed on 9/04/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed all residents in the secured unit at risk of injury and death. Findings included: 1.Record review of Resident #1's facility's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis include Alzheimer's Disease with history of psychotic disorder (problem with thinking and delusions), and Hyperlipidemia. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 00 (Resident is rarely to never understood), indicating she was severely cognitive impaired. She required supervision to limited assistance with one person assist for dressing, toilet use, personal hygiene and required supervision with ambulation. Record review of Resident #1's care plan dated 03/14/2025 revealed Resident #1 is an elopement risk/wanderer as evidenced by Impaired safety awareness, with interventions that included, distract resident from wandering by offering pleasant diversions, structured, activities, food, conversation, television, book. 2.Record review of Resident #2's facility's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis include dementia with, severe, with other behavioral disturbance, delusional disorders, major depressive, lack of coordination, anxiety disorder and age-related cognitive disorder. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 00 (Resident is rarely to never understood), indicating she was severely cognitive impaired. She required supervision to limited assistance with one person assist for dressing, toilet use, personal hygiene and required supervision with ambulation. Record review of Resident #2's care plan dated 01/03/2025 revealed Resident #2 is an elopement risk/wanderer as evidenced by Impaired safety awareness, with interventions that included, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Record review of Resident #1 and #2's incident report dated 06/25/2025 revealed incident description that resident #1 was standing over resident #2 who was sitting on the couch. Resident #1 said something to resident #2 and resident # 2 shoved resident #1 causing her to fall. Both Residents was assessed for injuries, skin tear to left elbow and raised area noted to left side of resident #1's head. Xray revealed age indetermination fifth digit proximal phalanx head fracture (fracture to left fifth toe) for resident #1. Record review of witness statement dated 6/25/2025 CNA F stated on the day of 6/25/2025. I saw Resident #2 push Resident #1, causing Resident #1 to fall down. Resident #2 was brought to the nurse's station and sat there during the process of notifying the psych doctor and then was placed on Q15 monitoring. During an interview on 9/4/2025 at 11:49 AM with RN L she said she had worked with Resident #1 and Resident #2, in the past and was not at work during the time of the incident between Resident #1 and Resident #2. She said Resident #1 was on hospice and not aggressive and was mostly bedridden. She said Resident #2 was normally not aggressive and to push someone was out of her normal character. 3. Record review of Resident #3's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), cognitive communication deficit (difficulty communicating), Alzheimer's disease (memory loss, confusion, and other cognitive decline). Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 09, indicating he was moderately cognitive impaired. He required partial to substantial assist for dressing, toilet use and personal hygiene and required partial/moderate with walking. Record review of Resident #3's care plan dated 7/13/2025 indicated Resident #3 had a psychosocial wellbeing problem potential related to being hit in the face 2 times by Resident #5 on 7/13/2025 with interventions that included: residents separated and both placed on 1:1 monitoring, assessed both residents for injury, emotional distress, and neuros x72 hours, moved other resident to a room on another hall with continued 1:1 monitoring, Psych MD and both RPs notified, gathered witness statements from staff and both residents, BIMS done on both residents, started in-services on Abuse/Neglect and Resident to resident altercations. When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. Record review of Resident #3's care plan dated 9/03/2024 indicated Resident #3 required medications for behavior management with interventions that included: Monitor/record occurrence for target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Record review of Resident #3's care plan dated 7/30/2025 indicated Resident #3 had a psychosocial wellbeing problem potential related 7/30/2025 being slapped by Resident #4. Resident #3 backed his wheelchair into Resident #4 and when he moved his wheelchair forward Resident #4 slapped him from behind with interventions that included: Resident #4 placed on 1:1 monitoring, Resident #3 referred to Psych services. Both residents assessed for injuries and will be monitored for delayed injuries, none found in initial assessment. Psych MD and both RPs notified. Both residents assessed form emotional distress for 72 hours. In-services provided on Abuse/Neglect and resident to resident altercation. Record review of progress note for Resident #3 dated 7/13/2025 at 4:50 PM written by LVN D indicated Resident #3's nurse was notified by staff that roommate Resident #5 had hit him twice in the head. He reported no injuries noted no acute distress or discomfort noted. Residents were separated, 1:1 monitoring initiated and every 15-minute monitoring, neuros initiated by nurse and all parties were notified by nurse and RN. Record review of progress noted for Resident #3 dated 7/30/2025 at 5:53 PM written by LVN E indicated Resident #3 was sitting in dining room at his table when Resident #4 hit him in the head from behind. Record review of facility incident report dated 7/13/2025 at 4:25 PM indicated Resident #3 was physically hit twice in the head by roommate Resident #5; assessment completed by his nurse no injuries noted resident denies pain or discomfort. Record review of facility incident report dated 7/30/2025 at 5:00 PM indicated Resident #3 was hit in the head from behind by another resident. Redirected other resident away from this resident, placed other resident on 1:1 monitoring. 4. Record review of Resident #4's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), cognitive communication deficit (difficulty communicating), bipolar disorder (mood swings ranging from depressive lows to manic highs). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 06, indicating he was severely cognitively impaired. He was dependent or required substantial to maximal assist for dressing, toilet use and personal hygiene. Record review of Resident #4's care plan dated 5/01/2025 and revised on 8/14/2025 indicated Resident #4 had demonstrated physical behaviors and hit another male resident in the face. Interventions included: Residents separated, Resident #4 placed on 1:1 monitoring, and Resident #3 placed on Q15 monitoring. Both residents assessed for injuries and will be monitored for delayed injuries, none found in initial assessment. Psych MD and both RPs notified. Both residents assessed for emotional distress for 72 hours. Witness statements gathered from staff. In-services provided on Abuse/Neglect and resident to resident altercations. Record review of Resident #4's care plan dated 9/30/2024 indicated Resident #4 required medications for behavior management with interventions that included: Monitor/record occurrence for target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Resident #4 was at risk for elopement/wandering as evidenced by a history of attempts to leave facility unattended with interventions that included: Monitor location ever 2 hours and as needed. Document wandering behavior and attempted diversional interventions in behavior log. Record review of progress note for Resident #4 dated 7/30/2025 at 5:21 PM written by LVN E indicated resident was witnessed hitting other resident in right side of head from behind while attempting to come in back door. Psych MD notified and received new order to send to inpatient facility. Record review of progress note for Resident #4 dated 7/30/2025 at 6:00 PM written by LVN E indicated resident placed 1 on 1 with housekeeping sitting with resident at that time. Record review of progress note for Resident #4 dated 7/31/2025 at 11:07 AM written by LVN E indicated behavioral hospital was there to pick resident up. Record review of facility incident report dated 7/30/2025 at 5:00 PM indicated Resident #4 was witnessed hitting Resident #3 in right side of head from behind while attempting to come in back door. Resident #4 redirected away from Resident #3 and out onto open floor with nurse so he could be 1 to 1 at that time. During a confidential interview on 9/02/2025 at 10:54 AM She said on 7/30/2025 Resident #4 was trying to go outside, and Resident #3 was fussing at Resident #4 to not go outside and backed his wheelchair up and into Resident #4 and that was when Resident #4 slapped Resident #3 on the right side of the face from behind. During an interview on 9/04/2025 at 1:10 PM the ADON said Resident #4 had a history of physical aggression. She said prior to the incident with Resident #3, Resident #4 had hit his previous roommate because their wheelchairs had got tangled up. She said Resident #4 had gone out to a behavior hospital for that incident and had not had any aggressive behaviors since that time. She said on 7/30/2025 Resident #3 and Resident #4 were by the back door and Resident #3 backed his wheelchair up and into Resident #4's wheelchair and Resident #4 slapped Resident #3 on the right side of his face from behind. She said Resident #3 had not any incidents of verbal aggression prior to the incident. 5. Record review of Resident #5's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with the most recent admission on [DATE]. Diagnosis included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), bipolar disorder (mood swings ranging from depressive lows to manic highs). Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed a BIMS score was not completed due to Resident #5 was rarely/never understood. He required partial to moderate assist for dressing, toilet use and personal hygiene and was independent with walking. Record review of Resident #5's care plan dated 7/13/2025 indicated Resident #5 had potential to demonstrate physical behaviors related to dementia, poor impulse control. Hit another resident 2 times in the face on 7/13/2025 with interventions that included: residents separated and both placed on 1:1 monitoring, assessed both residents for injury, emotional distress, and neuros for 72 hours, Moved this resident to a room on another hall with continued 1:1 monitoring, Psych MD and both RPs notified, gathered witness statements from staff and both residents, BIMS done on both residents, started in-services on Abuse/Neglect and Resident to resident altercations. Record review of Resident #5's care plan dated 8/27/2025 indicated Resident #5 required medications for behavior management with interventions that included: Monitor/record occurrence for target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Record review of progress note for Resident #5 dated 7/13/2025 at 4:35 PM written by LVN D indicated notified by CNA to floor nurse that resident hit roommate twice in the head and then had a shoe and was going to hit another resident but was redirected by nurse, all parties notified, resident placed on 1:1 and every 15-minute monitoring and separated. Record review of facility incident report for Resident #5 dated 7/13/2025 at 4:25 PM indicated: Notified by CNA Resident #5 hit roommate in the head twice and had a shoe in his hand, resident was redirected. Resident assessed by nurse no issues noted, resident redirected by nurse and placed on 1:1 monitoring. During an interview on 9/02/2025 at 10:20 AM CNA B said most days she was on the male secure unit as the only CNA. She said on the day of the incident with were Resident #5 hit Resident #3 she was on the male secure unit as the only CNA. She said Resident #3 had wandered into Resident #5's room and Resident #5 hit Resident #3 in the middle of his forehead with a closed fist 2 times. She said she separated Resident #5 and Resident #3 and went and got the nurse. She said Resident #6 had been aggressive to both Resident #3 and Resident #5. 6. Record review of Resident #6's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included: schizoaffective disorder (hallucinations and delusions and mood disorder symptoms), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), and anxiety (excessive and persistent worry, fear, and nervousness that can interfere with daily life). Record review of Resident #6's admission MDS assessment dated [DATE] revealed a BIMS 06 score which indicated severe cognitive impairment. He was independent for dressing, toilet use and personal hygiene and was independent with walking. Record review of Resident #6's care plan dated 8/27/2025 indicated Resident #6 required psychotropic medications with interventions that included: Monitor/record occurrence of target behavior symptoms (specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others.etc) and document per facility protocol. Record review of progress note for Resident #6 dated 8/27/2025 at 12:00 AM written by FNP G indicated: Phone note change of condition. Nursing staff request to address a documented psychiatric issue of concern that requires a timely evaluation and medical intervention. Symptoms included: verbal disruptions, threatening, yelling, hostility towards others, impulsive behavior, initiation of fights, highly irritable, physical aggression towards others, socially inappropriate behavior, verbal aggression, patient is targeting 2 specific male residents, trying to hit them, starting fights, unable to redirect. Record review of progress note for Resident #6 dated 8/28/2025 at 12:00 AM written by FNP G indicated: Phone note change of condition. Nursing staff request to address a documented psychiatric issue of concern that requires a timely evaluation and medical intervention. Symptoms included: Hostility towards others, impulsive behavior, highly irritable, nurse reports that the resident continues to try and hit at a fellow male resident, staff is concerned that the resident may harm others and or himself, staff requesting the resident be sent out to an inpatient psych hospital. Record review of facility behavior nurses note dated 8/27/2025 at 4:45 PM written by the ADON indicated Resident #6 had been verbally aggressive and targeting a specific resident, balling up fist acting like he would hit this resident, resident redirected. Record review of facility behavior nurses note dated 8/28/2025 at 11:55 AM written by the ADON indicated Resident #6 had been verbally aggressive and targeting a specific resident, balling up fist acting like he would hit this resident, resident redirected, resident placed 1:1 supervision. During a confidential interview on 9/02/2025 at 10:54 AM She said Resident #6 was a recent admission from the behavioral hospital and said he came to the facility aggressive. She said Resident #6 had been bullying Resident #5 since he admitted 2 days prior to the incident. She said on 8/28/2025 Resident #5 was sitting at the table in the dining room and Resident #6 walked over to Resident #5 and hit him with a balled-up fist to the right side of the face and chin area. She said Resident #5 did not have any redness or bruising where he was hit. She said when the incident occurred, she was trying to keep a fall risk resident from falling. She said she felt like if there was a second CNA in the male secure unit the incident may have been to be prevented. During an interview on 9/2/2025 at 12:20 PM the DON said CNA A facetime called her and showed her how Resident #6 was acting. She said she then ordered Resident #6 to be placed on 1:1 monitoring. She said it was not a video that was sent to her, but it was an actual in real time facetime call. She said she does not allow videos of residents on her phone and said if there was a recorded video then Resident #6 must have attempted to hit Resident #5 more than once. During a confidential interview on 9/02/2025 at 12:32 PM She said she had taken a video of how Resident #6 had been acting and sent the video via text message to the DON. She said she took the video is desperation to get more help on the male secure unit. Observation of a video taken on 8/28/2025 showed Resident #5 sitting at a table in the dining room of the male secure unit, Resident #6 then walked over to Resident #5 and began attempting to hit Resident #5 multiple times. During an interview on 9/02/2025 at 1:14 PM Housekeeper O said on 8/28/2025 she saw Resident #5 and Resident #6 having a verbal altercation, she said Resident #6 balled up his fists, so she got in between the 2 residents. She said there was only 1 CNA on the male secure unit that day and she was in a room providing care to another resident when the incident she saw occurred. She said she never saw Resident #6 actually make contact with Resident #5 at that time. During an interview on 9/04/2025 at 1:10 PM the ADON said on 8/27/2025 the CNA's had reported to her that Resident #6 was targeting and taunting Resident #5 by acting like he was angry with Resident #5 and attempting to hit him. She said she notified to psych doctor and received an order to increase his medication. She said on 8/28/2025 she was the nurse working on the male secured unit and said CNA A reported to her that Resident #6 was being physically aggressive to Resident #5. She said she brought Resident #6 outside of the male secured unit to the nurse's station and kept him there until he discharged to the behavior hospital. During an interview on 9/04/2025 at 2:07 PM the DON said on 8/28/2025 CNA A was the only CNA on male secure unit that day. She said the ADON was the nurse for the male secure unit that day and reported to her that Resident #6 was becoming more aggressive and told her she had already notified the psych doctor and received the medication increase order and asked if she could put Resident #6 on 1:1 monitoring. She said it was never reported to her that Resident #6 had hit Resident #5. She said she had questioned herself if Resident #6 was appropriate for their male secure unit due to his aggressive behaviors. She said Resident #6 discharged to the behavior hospital on 8/28/2025. During an interview on 9/04/2025 at 3:07 PM the Administrator said it was never reported to her that Resident #6 had been physically aggressive to Resident #5. She said it was reported to her that Resident #6 had been sent out to the hospital, but she did not know it was a behavior hospital. She said it was not until after she read the 24-hour report that she discovered Resident #6 had been sent out to a behavioral hospital. She said they did normally discuss where residents were sent out to in the morning meetings, but she had taken a day off work and was not in the morning meeting the day after Resident #6 had been sent out. She said after she found out Resident #6 had been sent to a behavior hospital; she did not question anyone as to why he was sent to a behavior hospital. She said on 9/03/2025 after surveyors entrance it was discussed with the DON that she must be notified of any resident-to-resident altercations. 7. Record review of Resident #7's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), and seizures. Record review of Resident #7's admission MDS assessment dated [DATE] revealed a BIMS 09 score which indicated moderate cognitive impairment. He was dependent for dressing, toilet use and personal hygiene and did not attempt walking. Record review of Resident #7's care plan dated 7/15/2025 indicated Resident #7 had behavior: Sexually inappropriate as evidenced by previous inappropriate behaviors. On 8/11/2025 vulgar, inappropriate comments to nurse during care. On 8/14/2025 sexually inappropriate comments to nurse. Interventions included: Male secure unit, listen/talk to the resident-see if they will tell you why they do the behavior, psychiatric services consult as needed, staff to be in-serviced on behavioral approaches designed to effectively manage unacceptable sexual advances, staff will be trained to respond, but not react to resident's behavior. Record review of Resident #7's care plan dated 9/02/2025 indicated Resident #7 had engaged in physical touch of a sexual nature toward another resident with interventions that included: Avoid leaving resident unsupervised in situations where inappropriate contact may occur, identify and document triggers or patterns leading to inappropriate behaviors, immediately intervene report and document inappropriate sexual contact, resident immediately placed on 1:1 supervision. Record review of Resident #7's care plan dated 7/22/2025 indicated Resident #7 had impaired cognitive function/dementia or impaired thought processes related to dementia with interventions that included: Monitor/document/report to MD any changes in cognition function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Record review of progress note for Resident #7 dated 9/02/2025 at 2:45 AM written by the Administrator indicated: this resident involved in resident-to-resident incident approximately 2:30 AM resident placed on 1-on-1 monitoring and will be referred to psych services. Record review of facility incident report for Resident #7 dated 9/02/2025 at 1:30 AM completed by LVN J indicated: this nurse entered residents' room at approximately 1:30 AM and found this resident lying on right side behind other resident facing the window. Observed this resident having sexual intercourse with resident. Upon entering and discovering this resident removed penis and both residents remained laying quietly, this nurse request help from CNA K to remove resident from behind resident and separate them so assessments and investigation of incident could be performed. This resident verbalized that he know what he done and said this incident was the first time, when questioned further this resident began stating he is sad after the recent loss of his son and doesn't want to discuss any further, this resident request he as needed medication for anxiety and nerves, this nurse medicated this resident. 8. Record review of Resident #8's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), psychotic disorder with delusions due to known physiological condition (false beliefs), cognitive communication deficit (difficulties with communication due to underlying cognitive impairments). Record review of Resident #8's admission MDS assessment dated [DATE] revealed a BIMS 08 score which indicated moderate cognitive impairment. He required supervision or touching assistance for dressing, toilet use and personal hygiene and set up or clean up assistance with walking. Record review of Resident #8's care plan dated 7/25/2025 indicated Resident #8 had impaired cognitive function/dementia or impaired thought processes related to dementia with behaviors with interventions that included: communication: use the residents preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues-stop and return if agitated. Record review of Resident #8's care plan dated 7/31/2025 indicated Resident #8 required medications for behavior management with interventions that included: Monitor/record occurrence for target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Record review of hospital paperwork dated 9/02/2025 at 1:29 PM indicated: Date/Time Patient Seen: 9/02/2025 at 3:42 AM. Chief Complaint: Presents for [Facility] with report of sexual assault by another male patient at the facility. Patient denies memory of incident or pain. Paramedic [name] reports that NH staff told him they cleaned him up before transport. History of Present Illness: The patient was brought in from a nursing home over concerns that the patient had been sexually assaulted. According to the nursing staff the nurse walked into the room and found the patient's roommate sexually assaulting him. At that point the patient was brought to the ER to be evaluated. The patient does not recall the events and has significant dementia. Medical Decision Making: The patient was signed out to the oncoming physician pending a SANE exam. Record review of facility witness statement dated 9/02/2025 at 1:30 AM written by CNA K indicated: Nurse [LVN J] open door to resident room, she saw resident [#8] in the be with resident [#7], she called for me [CNA K] to come here, from shower room, when I walked in the room, both residents bottoms were off, I asked [Resident #8] why he was in the bed with [Resident #7] he stated he didn't know why, both were facing the window, [Resident #7] arm was across [Resident #8] waist, when [Resident #7] went to turn over on his back, we could clearly see his penis was in [Resident #8] buttocks, [Resident #7] had BMon his hands and could see where he had placed his penis in [Resident #8] rectum, [Resident #8] he had BM on his butt cheek and around his rectum, myself and nurse helped [Resident #8] get up out the bed, got him cleaned up and clothes on and covered up in bed. He was weak and very confused to what was going on!! After removing [Resident #8] to another room, I asked [CNA N] to help me to get [Resident #7] cleaned up, had him to get up in his wheelchair, so bed could be cleaned up, he had took his soiled brief off and it was thrown at the end of the bed when we entered the room, (I) saw it, the bed had a small urine stain that was wet under where [Resident #7] was laying & BM on the sheet on the back side where he [Resident #7] was laying., he had BM on his hands, face, legs!! I asked [Resident #7] why he did that to [Resident #8], he stated he didn't know, I asked him had he did that to him before and he said NO!! End of Statement!!! During an interview on 9/02/2025 at 10:20 AM CNA B said Resident #7 would make sexual comments such as you can suck it or can you touch it while she would provide care. She said when she told Resident #7 to stop talking like that he would. During an interview on 9/02/2025 at 10:40 AM Resident #7 said he had been sexually inappropriate with another resident here at the facility. He said it was not last night, but it was maybe a month ago and it was not his roommate. He refused to say what resident the incident had occurred with. Resident #7 said he never penetrated anyone with his penis, but he got in the bed with that resident and went through the sexual motions. When asked why Resident #7 did what he did to the other resident he said it was his sexual mind. During an interview on 9/02/2025 at 3:45pm the RCN and COO said they had not been told by the previous facility that Resident #7 had any sexual behaviors prior to being admitted to the facility. The COO then said he thought by placing Resident #7 in the male secure unit they did not think that there would be any inappropriate sexual behaviors since all prior inappropriate sexual behaviors had been towards female staff members. During an interview on 9/02/2025 at 6:18pm LVN J said she was doing a room check at 1:30am and said it was the first time she had seen Resident #7 or Resident #8 since the start of her shift at 6pm. She said when she opened the door to their room, she saw Resident #8 laying in Resident #7s bed with Resident #7 behind Resident #8 and both residents were laying on their right sides facing the window in the room. She said she was shocked with what she saw so she stepped back in the hallway and called for the CNA to come and help her. She said when they walked back in the room they said, what's going on? She said when they said that Resident #7 jumped and turned to see who was coming in the room which caused his penis to withdraw from Resident #8's rectum. She said both residents had a large amount of feces on them, but Resident #7 had feces caked in his front groin area. She said she asked both residents what happened, and Resident #8 said he did not know what happened. She said Resident #7 said he knew what he did and then said, I'm sad my son died. She said Resident #8 seemed to be extremely confused and k

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, when reviewing the facility for sufficient staffing for 2 of 4 hallways (Hallways A and B). The facility failed to adequately staff the A and B hallway (secured units) to prevent resident to resident abuse.The facility failed to ensure A Hall (male secured unit) had sufficient staffing to prevent Resident #2 from abusing Resident #1 on 6/25/2025 when Resident #2 pushed Resident #1 down on the floor causing a fracture to the left 5th toe. The facility failed to ensure A Hall (male secured unit) had sufficient staffing to prevent Resident #5 from abusing Resident #3 on 7/13/2025 when Resident #5 hit Resident #3 in the head twice.The facility failed to ensure A Hall (male secured unit) had sufficient staffing to prevent Resident #4 from abusing Resident #3 on 7/30/2025 when Resident #4 slapped Resident #3 on the right side of the face from behind.The facility failed to ensure A Hall (male secured unit) had sufficient staffing to prevent Resident #6 from abusing Resident #5 on 8/28/2025 when Resident #6 hit Resident #5 in the face.The facility failed to ensure A Hall (male secured unit) had sufficient staffing to prevent Resident #7 from sexually abusing Resident #8 on 9/02/2025 causing Resident #8 to be admitted to the hospital.An IJ was identified on 9/03/2025. The IJ template was provided to the facility on 9/03/2025 at 3:36 PM. While the IJ was removed on 9/04/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of injuries, abuse, severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings included:Record review of Resident #1's facility's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis include Alzheimer's Disease with history of psychotic disorder (problem with thinking and delusions), and Hyperlipidemia (high cholesterol). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 (Resident is rarely to never understood), indicating she was severely cognitive impaired. She required supervision to limited assistance with one person assist for dressing, toilet use, personal hygiene and required supervision with ambulation. Record review of Resident #1's care plan dated 03/14/2025 revealed Resident #1 is an elopement risk/wanderer as evidenced by Impaired safety awareness, with interventions that included: distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Record review of Resident #2's facility's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis include dementia with, severe, with other behavioral disturbance, delusional disorders, major depressive, lack of coordination, anxiety disorder and age-related cognitive disorder. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 00 (Resident is rarely to never understood), indicating she was severely cognitive impaired. She required supervision to limited assistance with one person assist for dressing, toilet use, personal hygiene and required supervision with ambulation. Record review of Resident #2's care plan dated 01/03/2025 revealed Resident #2 is an elopement risk/wanderer as evidenced by Impaired safety awareness, with interventions that included: distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Record review of Resident #1 and #2's incident report dated 06/25/2025 revealed that Resident #1 was standing over Resident #2 who was sitting on the couch. Resident #1 said something to resident #2 and resident # 2 shoved resident #1 causing her to fall. Both Residents were assessed for injuries. A skin tear to left elbow and raised area noted to the left side of Resident #1's head. An x-ray revealed age indeterminate fifth digit proximal phalanx head fracture (fracture to left fifth toe but unable to determine the age of the fracture) for Resident #1. A Record review of a witness statement from CNA F dated 6/25/2025 stated, on the day of 6/25/2025. I saw Resident #2 push Resident #1, causing Resident #1 to fall down. Resident #2 was brought to the nurse's station and sat there during the process of notifying the psych doctor and then was placed on Q15 monitoring. 3. Record review of Resident #3's facility's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), cognitive communication deficit (difficulty communicating), Alzheimer's disease (memory loss, confusion, and other cognitive decline). Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 09, indicating he had moderate cognitive impairment. He required partial to substantial assist for dressing, toilet use and personal hygiene and required partial/moderate assistance with walking. Record review of Resident #3's care plan dated 7/13/2025 indicated Resident #3 had a potential psychosocial wellbeing problem related to being hit in the face 2 times by Resident #5 on 7/13/2025. Interventions that included: residents separated and both placed on 1:1 monitoring (a staff member is assigned to stay with the resident at all times), assessed both residents for injury, emotional distress, and neuros for 72 hours (neurological assessment for 72 hours), moved other resident to a room on another hall with continued 1:1 monitoring, Psych MD and both RPs notified, gathered witness statements from staff and both residents, BIMS done on both residents, started in-services on Abuse/Neglect and Resident to resident altercations. When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. Record review of Resident #3's care plan dated 7/30/2025 indicated Resident #3 had a potential psychosocial wellbeing problem related to being slapped by Resident #4 on 7/30/2025. Resident #3 backed his wheelchair into Resident #4 and when he moved his wheelchair forward Resident #4 slapped him from behind. Interventions included: Resident #4 placed on 1:1 monitoring, Resident #3 referred to Psych services. Both residents assessed for injuries and will be monitored for delayed injuries, none found in initial assessment. Psych MD and both RPs were notified. Both residents assessed for emotional distress for 72 hours. In-services provided on Abuse/Neglect and resident to resident altercation. Record review of a progress note for Resident #3 dated 7/13/2025 at 4:50 PM written by LVN D indicated Resident #3's nurse was notified by staff that roommate Resident #5 had hit him twice in the head. He reported no injuries noted, no acute distress and no discomfort noted. The residents were separated, 1:1 monitoring initiated and every 15-minute monitoring, neuros initiated by the nurse and all responsible parties were notified by the RN. Record review of a progress noted for Resident #3 dated 7/30/2025 at 5:53 PM written by LVN E indicated Resident #3 was sitting in the dining room at his table when Resident #4 hit him in the head from behind. Record review of a facility incident report dated 7/13/2025 at 4:25 PM indicated Resident #3 was physically hit twice in the head by his roommate Resident #5. An assessment was completed by his nurse. No injuries were noted and the resident denied pain and discomfort. Record review of a facility incident report dated 7/30/2025 at 5:00 PM indicated Resident #3 was hit in the head from behind by Resident #5. Redirected Resident #5 away from Resident #3 and placed Resident #5 on 1:1 monitoring. 4. Record review of Resident #4's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), cognitive communication deficit (difficulty communicating), bipolar disorder (mood swings ranging from depressive lows to manic highs). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 06, indicating he was severely cognitively impaired. He was dependent or required substantial to maximal assist for dressing, toilet use and personal hygiene. Record review of Resident #4's care plan dated 5/01/2025 and revised on 8/14/2025 indicated Resident #4 had demonstrated physical behaviors and hit another male resident in the face. Interventions included: Residents separated, Resident #4 placed on 1:1 monitoring and Resident #3 placed on Q15 monitoring. Both residents were assessed for injuries and will be monitored for delayed injuries. None found on initial assessment. Psych MD and both RPs notified. Both residents were assessed for emotional distress for 72 hours. Witness statements gathered from staff. In-services provided on Abuse/Neglect and resident-to-resident altercations. Record review of a progress note for Resident #4 dated 7/30/2025 at 5:21 PM written by LVN E indicated resident was witnessed hitting other resident on the right side of their head from behind while attempting to come in the back door. Psych MD notified and received new order to send to inpatient facility. Record review of progress note for Resident #4 dated 7/30/2025 at 6:00 PM written by LVN E indicated the resident was placed 1 on 1 with housekeeping sitting with the resident at that time. Record review of a progress note for Resident #4 dated 7/31/2025 at 11:07 AM written by LVN E indicated a behavioral hospital was at the facility to pick the resident up. Record review of facility incident report dated 7/30/2025 at 5:00 PM indicated Resident #4 was witnessed hitting Resident #3 on the right side of his head from behind while attempting to come in the back door. Resident #4 was redirected away from Resident #3 with the nurse so he could be 1 to 1 at that time. 5. Record review of Resident #5's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with the most recent admission on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), bipolar disorder (mood swings ranging from depressive lows to manic highs). Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed a BIMS score was not completed due to Resident #5 was rarely/never understood. He required partial to moderate assist for dressing, toilet use and personal hygiene and was independent with walking. Record review of Resident #5's care plan dated 7/13/2025 indicated Resident #5 had potential to demonstrate physical behaviors related to dementia, poor impulse control. Resident #5 hit another resident 2 times in the face on 7/13/2025 with interventions that included: residents separated and both placed on 1:1 monitoring, assessed both residents for injury, emotional distress, and neuros for 72 hours, moved this resident to a room on another hall with continued 1:1 monitoring, Psych MD and both RPs notified, gathered witness statements from staff and both residents, BIMS done on both residents, started in-services on Abuse/Neglect and resident to resident altercations. Record review of a progress note for Resident #5 dated 7/13/2025 at 4:35 PM written by LVN D indicated the nurse was notified by the CNA that the resident hit his roommate twice in the head and then had a shoe and was going to hit another resident, but the resident was redirected by nurse. All parties were notified. The resident was placed on 1:1 and separated from other residents. Record review of facility incident report for Resident #5 dated 7/13/2025 at 4:25 PM indicated: Notified by the CNA Resident #5 hit roommate in the head twice and had a shoe in his hand. The resident was redirected. The resident was assessed by the nurse and no issues were noted. The resident was redirected by the nurse and placed on 1:1 monitoring. 6. Record review of Resident #6's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: schizoaffective disorder (hallucinations and delusions and mood disorder symptoms), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), and anxiety (excessive and persistent worry, fear, and nervousness that can interfere with daily life). Record review of Resident #6's admission MDS assessment dated [DATE] revealed a BIMS 06 score which indicated severe cognitive impairment. He was independent for dressing, toilet use and personal hygiene and was independent with walking. Record review of Resident #6's care plan dated 8/27/2025 indicated Resident #6 required psychotropic medications with interventions that included: Monitor/record occurrence of target behavior symptoms (specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others etc.) and document per facility protocol. Record review of a progress note for Resident #6 dated 8/27/2025 at 12:00 AM written by FNP G indicated: Change of condition. Nursing staff requested to address a documented psychiatric issue of concern that requires a timely evaluation and medical intervention. Symptoms included: verbal disruptions, threatening, yelling, hostility towards others, impulsive behavior, initiation of fights, highly irritable, physical aggression towards others, socially inappropriate behavior, verbal aggression, patient is targeting 2 specific male residents, trying to hit them, starting fights, unable to redirect. Record review of a progress note for Resident #6 dated 8/28/2025 at 12:00 AM written by FNP G indicated: Change of condition. Nursing staff requested to address a documented psychiatric issue of concern that requires a timely evaluation and medical intervention. Symptoms included: Hostility towards others, impulsive behavior, highly irritable. Nurse reports that the resident continues to try and hit at a fellow male resident. Staff is concerned that the resident may harm others and or himself, staff requesting the resident be sent out to an inpatient psych hospital. Record review of a facility behavior nurses note dated 8/27/2025 at 4:45 PM written by the ADON indicated Resident #6 had been verbally aggressive and targeting a specific resident, balling up fists acting like he would hit the resident. The resident was redirected. Record review of a facility behavior nurses note dated 8/28/2025 at 11:55 AM written by the ADON indicated: Resident #6 had been verbally aggressive and targeting a specific resident, balling up fists acting like he would hit the resident. The resident was redirected and resident placed 1:1 supervision. 7. Record review of Resident #7's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), and seizures. Record review of Resident #7's admission MDS assessment dated [DATE] revealed a BIMS 09 score which indicated moderate cognitive impairment. He was dependent for dressing; toilet use and personal hygiene and did not attempt walking. Record review of Resident #7's care plan dated 7/15/2025 indicated Resident #7 had behavior: Sexually inappropriate as evidenced by previous inappropriate behaviors. On 8/11/2025 vulgar, inappropriate comments to nurse during care. On 8/14/2025 sexually inappropriate comments to nurse. Interventions included: Male secure unit, listen/talk to the resident-see if they will tell you why they do the behavior, psychiatric services consult as needed, staff to be in serviced on behavioral approaches designed to effectively manage unacceptable sexual advances, staff will be trained to respond, but not react to resident's behavior. Record review of Resident #7's care plan dated 9/02/2025 indicated Resident #7 had engaged in physical touch of a sexual nature toward another resident with interventions that included: Avoid leaving resident unsupervised in situations where inappropriate contact may occur, identify and document triggers or patterns leading to inappropriate behaviors, immediately intervene report and document inappropriate sexual contact, resident immediately placed on 1:1 supervision. Record review of a progress note for Resident #7 dated 9/02/2025 at 2:45 AM written by the Administrator indicated: the resident was involved in resident-to-resident incident at approximately 2:30 AM. The resident was placed on 1-on-1 monitoring and will be referred to psych services. Record review of a facility incident report for Resident #7 dated 9/02/2025 at 1:30 AM completed by LVN J indicated: this nurse entered residents' room at approximately 1:30 AM and found the resident lying on his right side behind another resident facing the window. The nurse observed the resident having sexual intercourse with the other resident. Upon entering the room, the resident removed his penis from the other resident and both residents remained lying quietly. This nurse requested help from CNA K to separate the residents so assessments and investigation of incident could be performed. This resident verbalized that he knew what he had done and said this incident was the first time. When questioned further this resident stated he was sad after the recent loss of his son and doesn't want to discuss any further. This resident requested medication for anxiety and nerves. This nurse medicated this resident. 8. Record review of Resident #8's facility's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), psychotic disorder with delusions due to known physiological condition (false beliefs), cognitive communication deficit (difficulties with communication due to underlying cognitive impairments). Record review of Resident #8's admission MDS assessment dated [DATE] revealed a BIMS 08 score which indicated moderate cognitive impairment. He required supervision or touching assistance for dressing, toilet use and personal hygiene and set up or clean up assistance with walking. Record review of Resident #8's care plan dated 7/25/2025 indicated Resident #8 had impaired cognitive function/dementia or impaired thought processes related to dementia with behaviors with interventions that included: communication: use the residents preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues-stop and return if agitated. During an observation on 9/2/2025 at 10:42am of the female unit, there was one CNA providing care for 7 residents. 4 female residents were sitting in the common area watching TV, 2 female residents were sitting at the table doing activities (coloring) and one female resident was sitting outside alone smoking (in an enclosed sitting/smoking area and could be seen by staff through a large window). During an interview on 09/02/2025 at 11:40am the MA said staffing had been an issue due to people calling in or not showing up for work. She said there were times other staff had come in for extra shifts and times they could not get coverage for the workers who did not show up. She said the facility was staffed with only four CNAs and two nurses. One nurse worked the A & B halls (secured units), one nurse works C&D halls and one CNA staffed on each hall. She said she felt the facility would benefit from having more available CNAs and nurses. She said she felt the residents would receive a better quality of care with an increase of staff. During an interview on 9/4/2023 at 9:15am CNA-F said on most days more help was needed. She said she had worked up to 16 hours straight but had heard of other workers working 18 to 24 hours straight and going home for a 6-hour break and coming back for their regular 12-hour shift. She said staff volunteered to work the hours if the facility was short staffed. She said they had been provided walkie talkies on 9/04/2025 to call for help when needed, such as when giving a resident a shower, other resident needs or if they needed a break. She said she felt that more staff would be a plus to resident care. She said instead of doing the basic care staff would be able to provide a better quality of care and prevent things such as resident to resident altercation, falls, toileting and any negative incidents. During an interview on 9/4/2023 at 9:40am the Housekeeping Supervisor said she helped in the kitchen, housekeeping and monitored on the halls. She said she did not provide direct care for residents but did monitor the residents (kept residents separated) on the unit (A & B halls) when the CNA needed to take a break or leave the unit for short periods. She said staffing was an issue some days and more staff would be a plus when caring for residents. She said on the unit most days there were behaviors to address, and one person could not see that all needs were being addressed at all times. She said the female unit had 7 residents that wanted constant interactions of some kind. She said most of them just wanted continual attention from staff as if they felt lonely and it was hard for one staff to assure all needs were met. She said on the male unit there were 15 residents, most with aggressive behaviors or wanted constant attention and it was impossible for one staff to ensure all needs were addressed for all residents on any shift. She said she had not witnessed anyone working more than 12 hours per shift. She said she mainly did housekeeping and did not have to stay over. During an interview on 9/4/2025 at 11:49AM RN-L said she had worked with Resident #1 and Resident #2, in the past and was not at work during the time of the incident between Resident #1 and Resident #2. She said Resident #1 was on hospice and was not aggressive and mostly bedridden. She said Resident #2 was normally not aggressive and to push someone was out of her normal character. She said the incident may have been prevented if there were at least two staff working together on all halls especially the halls A&B (secured units) due to the residents with behavior issues were housed on those halls. She said daily staffing included 2 nurses, one for A&B hall and 1 for C&D hall, 1 med aid, 1 CNA on A hall, 2 CNAs on B hall, one CNA on C hall and one CNA on D hall. She said she felt like there should be sufficient staffing at all times, but not all employees showed up for work as scheduled. She said when staff did not show up to work the on-call person was notified, and they were responsible for getting someone to come in and cover that shift. She said she had not worked more than 12 hours at a time. She said the least amount of CNAs she worked with in the facility was 2 nurses and 2 CNAs. She said when there were only 4 workers in the building at night it left them one worker short. She said one CNA floated from hall to hall helping the other CNAs. She said she had witnessed staff working 6A to 10P due to short staffing. She said she had not seen anyone working close to 24 hours at a time and but did hear that it had happened. She said if there were more staff to cover shifts it would make a difference in the quality of care provided to residents. During an interview on 9/4/2025 at 4:00pm CNA-B said she had not worked 24 hours straight but knew that some of the other staff worked 20-24 hours at a time. She said she volunteered to work extra hours but no more than 12-16 hours straight. She said she was not asked to or felt forced to work the extra hours by the administrative staff. She said she they had been short staffed due to a Covid outbreak and some people quitting, calling in or just not showing up. During an interview on 9/4/2025 at 1:24PM the ADON said the staffing pattern was usually two CNAs on halls C and D, one CNA on hall A, 1 CNA on hall B, one MA and two nurses (1 on hall A&B and 1 on hall C&D) during the day. She said the only staffing changes for the night shifts was one aide on the B hall and no MA was scheduled for the night shift. She said when someone called in, she would come in and cover the shift or another staff was called in to work. If they could not find someone to work, the person on call would cover the shift. She said they had worked with only 4 workers for the entire building in the past. She said it was not ideal but when staff did not come to work, they did the best they could to ensure all of the residents' needs were met. She said they would pull a CNA from A hall, leaving one CNA on the male unit (hall A) occasionally to make sure every hall had at least one CNA. She said sometimes they were fully staffed and other times they were short staffed. She said due to Covid and staff quitting they were short staffed and needed to hire 3 CNAs before the facility would be fully staffed. She said they were trying to hire workers at that time. She said they did allow their staff to work 20 plus hours. She said they never asked staff to work 20 plus hours and knew it was not safe for staff or residents if staff worked exhausted. She said the facility was short staffed and some staff volunteered to work extra hours, and they were allowed to work such long hours due to being short staffed and the facility needing coverage. During an interview on 9/4/2025 at 1:24PM the Administrator said she had been notified of low staffing issues. She said the facility was in the process of hiring at least 3 more CNAs. She said the staff especially the CNAs had issues with calling in and not coming for their scheduled shift. She said they tried to staff 1 CNA on hall C and one CNA on hall D for daytime, 2 CNAs on Hall A (Male Unit) and 1 CNA on hall B (Female Unit). She said for the male secure unit there should always be at least 2 CNAs. She said she did not know that staff was working 20-24 hours straight and did not feel it was safe for the staff or the residents to work that many hours. She said she did not feel it was safe for the residents to have resident to resident altercations as someone could get hurt. She said there could be a decline in care if there was not enough staff to sufficiently always address the needs of all residents. Record review of the Facility assessment dated [DATE] indicated Staffing will be based upon the needs and acuity of the residents in-house. If acuity increases so will the staffing departments. This also goes for an overall increase in total census. The administrator will identify needs based on each admission and discharge and will make corrective action in staffing needs. Record review of the payroll detail indicated CNA-H worked 22.72 hours in a 24-hour time frame beginning on 8/25/25 at 5:46am through 8/26/2025 at 5:46am. Record review of the payroll detail report indicated CNA-B worked 23.67 hours in a 24-hour time frame beginning on 8/30/2025 at 1:25pm thru 8/31/2025 at 1:25pm. Record review of facility policy, dated September 2022, titled Resident to Resident Altercations indicated, .1. Facility staff monitor residents for aggressive/inappropriate behaviors toward other resident, family members, visitors, or to the staff.Record review of facility policy, Inservice: Redirecting Dementia Patients dated 06/25/2025 indicated, Objective: To equip staff with effective techniques for safely and respectfully redirecting residents with dementia during episodes of confusion, agitation, or repetitive behavior. Record Review of facility policy titled Hours of Work, Indicated, Our facility has established hours of work in accordance with resident needs and current regulations governing our facility's staffing requirements. *Employees take 8 hours break after working 16 hours. This was determined to be an Immediate Jeopardy (IJ) on 9/03/2025 at 3:36 p.m. The facility Administrator, and DON were notified. The Administrator was provided with the IJ template on 9/03/2025 at 3:36 p.m. and a plan of removal was requested. The facility's plan of removal was accepted on 9/04/2025 at 12:18 PM and included: The following is a plan of removal, which has been immediately implemented at [Facility], to remedy the immediate jeopardy which was imposed 9/3/25 at 3:32pm.All items listed will be completed by 9/4/25 at 2:00 pm with continued follow up for scheduled staff. 1. Resident #2 was placed on 1:1 while contact was made for psych services on 6/25/25. Psych services reviewed the information and initiated a medication review with change of medication order regarding the resident-to-resident altercation. Resident #1 was moved to Q15 minute checks on 6/25/25 and a telehealth visit was completed on 6/26/25. Resident #1 was monitored for emotional distress for 72 hours post the incident. 2. Resident #1 was assessed for pain and injuries on 6/25/25. Resident #1 was administered a medication for pain (OTC medication) following the event. Facility obtained orders for X ray per hospice regarding a fracture that resulted in age indeterminate fracture of the 5th digital proximal phalanx. Neuros were initiated per protocol for Resident #1 as well as injury monitoring for 72 hours. Resident #1 was monitored for emotional distress for 72 hours post the incident and none exhibited. Resident #2 was on hospice services and is now deceased . 3. 7/30/25 Resident #3 had emotional distress assessment completed for 72 hours post the incident of #3 being hit. 7/30/25 Resident #3 was assessed for injuries and no injuries were present from the altercation with Resident #4. Psych referral was completed on 7/31/25 for Resident #3 and NP visit took place on 8/11/25 with order changes. 4. 7/30/25 Resident #4 was placed on 1:1 following the incident. Resident #4's psych physician was updated regarding the incident 7/30/25 and gave an order for psych behavioral placement. Resident #4 left the faciity on 7/31/25.5. 7/13/25 Resident #5 was placed on 1:1 supervision in response to the incident that occurred. Resident #5 was moved to a different hallway on 7/13/25. A psych physician visit took place on 7/14/25 with orders for behavioral health placement. Resident #5 was admitted to behavioral psych services on 7/14/25.6. Resident #3 was assessed for injuries on 7/13/25 and none were present. Resident #3 had emotional distress monitoring completed for 72 hours post the incident with Resident #5. Neuros were initiated per protocol. Resident #3 had no emotional distress related to the incident with resident #5.7. Resident #6 was placed on 1:1 supervision in response to the resident-to-resident altercation with resident #5 on 8/28/25. Psych services was contacted on 8/28/25 regarding the incident and orders were obtained to send to behavioral health for review. Resident #6 left the facility per the order on 8/28/25. Resident #5 had no injuries in response to the incident.8. Resident #8 was assessed by the nurse and sent to the ER for evaluation and admitted for alternate placement as the admitting diagnosis. Resident #8 is set to return to the facility on 9/3/25 with no updated orders at this time and the facility will change interventions according to any new orders.9. Res

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were free from abuse for 1 of 7 residents (Resident #1) reviewed for resident abuse. The facility did not ensure Resident #1 was free from abuse when CNA A pushed and struck Resident #1 on his face causing him to fall. The noncompliance was identified as PNC (past non-compliance). The IJ (immediate jeopardy) began on 10/04/2023 and ended 10/05/2023. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of physical harm, mental anguish, or emotional distress. Findings include: Record review of a facility face sheet dated 03/12/2024 indicated Resident #1 was a [AGE] year-old male that admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses of Unspecified Dementia (altered thinking, usually due to aging process), psychotic disturbances with delusions (a mental disorder characterized by a disconnection with reality), and Alzheimer's disease (a neurodegenerative disease with moods swings and difficulty remembering). Record review of an admission MDS assessment dated [DATE] indicated Resident #1 had a BIMS of 09 indicating moderate impaired cognition. Section C indicated inattention and disorganized thinking were continuously present. Record review of comprehensive care plan with revision date of 11/29/2023 for Resident #1 revealed the care plan had been updated on 10/05/2023 with focus: The resident has a psychosocial well-being problem/potential related to physical aggression received. 10/04/2023 - Resident threw water on a staff member and staff member retaliated by shoving resident and hitting him on left side of face causing him to fall. Goal: The resident will have no psychosocial well-being problem by/through review. Interventions included: 10/05/2023 - CNA involved in incident suspended pending investigation and police notified and statements given, head to toe assessment, emotional distress assessment, and hall safe survey performed on all residents on A hall. Resident sent to emergency room for evaluation and neuro checks will be completed on return from hospital. Monitor/document residents' feelings relative to isolation, unhappiness, anger, or loss. Record review of a facility event report dated 10/04/2023 at 7:45 p.m. indicated CNA A reported Resident #1 had fallen in the dining area and did not hit his head. Resident #1 was assessed, and no injuries found, resident denied pain and was unable to give a description of what had happened. Record review of a facility event dated 10/05/2023 at 10:45 a.m. indicated the Administrator had reviewed video footage of the above reported incident in the dining area of the men's locked unit. It was reported to the nurse by the CNA that resident fell in the dining room. It was reported that resident did not hit his head. The nurse assessed resident and did not see any injuries. However, the morning of 10/05/2023, upon review of the surveillance cameras to see how the fall occurred, it was seen that resident (Resident #1) and CNA (CNA A) were standing by the water cooler in the dining room on A hall. CNA and resident are seen conversing with each other, and resident (Resident #1) becomes agitated and tosses a cup of water at the CNA, splashing her in the face and front of her shirt. CNA (CNA A) then reaches out and shoves resident on the shoulder and hits him (with what appears to be an open hand) across the left side of his head. Resident stumbles backwards, tripping, and falls on the floor, hitting his back on the chair behind him and his head on the chair seat. The CNA then walks away and gets a towel for her shirt. Record review of an emergency room summary report dated 10/05/2023 indicated Resident #1 had CT (computed tomography) scans of the head, face, spine, neck, chest, abdomen, and pelvis with no negative findings and was discharged back to the facility with no new orders. Record review of an employee file for CNA A indicated a hire date of 08/28/2023. The file included a termination report for CNA A with a suspension date of 10/05/2023 and termination dated 10/06/2023 due to workplace violence, violating federal or state care standards and was signed by the Administrator and DON. A completed criminal history check, nurse aide registry check and referrals indicated CNA A had an active certification and was employable. CNA A had completed abuse training on 08/24/2023 before her active hire date on 08/28/23. During an interview and observation on 03/11/2024 at 10:00 am CNA D was assisting CNA C with Resident #1 preparations for a shower. Resident #1 was walking in the hallway to the shower room. When asked if he was doing well today, Resident #1 looked up and nodded yes. CNA D stated he had cared for Resident #1 since his admission in September of 2023 to the male locked unit. CNA C said he has worked the unit for 10 years and resident altercations of abuse and must be reported to the administrator immediately. He said it is difficult with the A Hall locked unit being all male but by working with them for so long he can recognize a mood change and intervene early but sometimes the newer residents you don't know their signs yet. He said that Resident #1 he gets aggravated quickly and will strike out towards other residents and staff. He said Resident #1 had been to the Psych hospital after the incident on 10/04/23. He said he had been better recently. CNA C said all abuse physical, verbal, mental, financial, and sexual was to be reported immediately to the administrator. He said if a resident reports something it was his responsibility to report so the resident was protected. He said once things are reported the administrator starts her investigation and reports the abuse to the state. He said that residents have to be able to report without being afraid and no staff should retaliate against a resident or family for reporting. CNA C said if retaliation occurs the administrator will terminate them. He said he has been trained on deescalating behaviors and how to deal with difficult behaviors. He said at no time can a staff member hit a resident. During an interview on 03/11/2024 at 3:14 pm LVN C said he has worked at the facility for 1 ½ years and resident altercations are reported to the DON and Admin. He said he tries to recognize a behavior change early before an altercation occurs but does not always work that way. He said if an altercation occurs residents are separated and depending on the severity 1:1 and or every 5 min checks are done. 1:1 continues until behavioral hospital admission or psych MD evaluates and makes changes, it really depends on the resident and their behaviors. No 2 incidents are the same. LVN C said he has been trained on abuse and knows the types of abuse: physical, verbal, sexual, mental and financial. He said no one is to take any resident belongings or money at no time. He said that all forms of abuse must be reported immediately to the administrator and then management starts their investigation. He said all abuse should be reported to the state. He said no matter how difficult the resident is never okay to hit or harm them. He said they have been trained on how to report abuse, preventing abuse, dealing with dementia and how to deescalate behaviors and to use those training tools to deal with difficult residents. During an interview on 3/11/2024 at 4:00 pm the Administrator said she would see if she could retrieve the video footage of the incident involving Resident #1 and CNA A, since it had been some time since the incident of abuse occurred on 10/04/23. The Administrator said she gave the Chief of Police a copy for his investigation when she reported the abuse to the required authorities. The Administrator said she reported to the police department, HHS, the Ombudsman, Resident #1's medical doctor and psychiatric doctor and his family after she saw the footage of the strike made by CNA A. She said the DON received orders to send Resident #1 to the emergency room for evaluation. Resident #1 had several CT scans and returned to the facility, there were no injuries. The Administrator said the staff were in serviced on 10/05/23 on numerous topics to prevent and ensure reporting and she would provide evidence of those trainings. She said the incident was reviewed by the QAPI team on 10/05/23 to determine if any other topics needed to be addressed. During an interview on 03/12/2024 at 10:20 am with the Chief of Police, he said there was an open case #OR- 100423-01 for the arrest of CNA A. He said he had conducted an investigation after receiving a report of abuse from the facility Administrator on 10/05/23 at 10:55 am. The Chief of Police said the administrator had advised him when she arrived at work on the morning of 10/05/23 she had been advised that one of the residents (Resident #1) had gotten disruptive during the evening of 10/04/23 and had fallen but had no injuries. The Chief of Police said the Administrator had told him she located the video footage of the dining area for viewing, as she usually does after an incident in the area. The Administrator was able to determine the event was not as previously reported by the CNA, as the resident (Resident #1) was pushed and hit by CNA A and had not just fallen as reported by CNA A. The Chief of Police said he had viewed the video footage of the incident on 10/04/2023 involving Resident #1 and CNA A provided to him by the Administrator. He said he had concluded his investigation, which included assessing for injuries and making pictures of the resident at the facility but was not able to document any injuries from the resident being hit and knocked down. He said based on the video evidence which shows the suspect intentionally and knowingly striking an elderly person over the age of 65 ([AGE] years of age) with a closed fist, causing bodily injury, a warrant for injury to the elderly was requested. The Chief said there was an open warrant for CNA A's arrest, but she had not been apprehended yet. He said that most likely until she had a traffic violation or another issue, it would remain outstanding. Record review of a facility policy titled Abuse and Neglect-Clinical Protocol dated March 2018 indicated Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse includes deprivation by an individual, including a caretaker or goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental, or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology .willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Treatment/Management 3. The physician will order measures required to address the consequences of an abuse situation. The facility took the following action to correct the non-compliance on 10/05/2023: The facility conducted a physical assessment including skin assessments on all residents in the locked unit, safe surveys were completed on all residents 10/05/2023. In-services included: Retaliation, abuse, preventing resident accidents and incidents, Reporting abuse to the abuse coordinator, Reporting abuse to facility management, Recognizing signs and symptoms of abuse, Abuse investigations, Abuse, neglect, exploitation and misappropriation-reporting and investigating, Investigating resident injuries, Quick safety de-escalation in healthcare, Preventing accidents and incidents, were conducted with all staff on 10/05/2024 then was referred to QAPI (quality assurance performance improvement) committee for efficacy of plan and monitoring frequency. Record Review of a QAPI meeting dated 10/05/2023 indicated the committee meet for discussion of the event involving abuse. A Performance Improvement plan was developed including all reviewed trainings and assessments on 10/05/2023. Record review of an In-service Training report named Retaliation, abuse, preventing resident accidents and incidents, dated 10/05/2023 and conducted by the DON to the facility staff included: Complaints are reported in good faith, it is illegal for the facility or any employee to intimidate or retaliate in any way against the resident or the family reporting. Record review of an In-service Training report named Reporting abuse to the abuse coordinator dated 10/05/2023 and conducted by the DON to the facility staff included: The abuse coordinator is the administrator. Record review on an In-service Training report named Reporting abuse to facility management dated 10/05/23 conducted by the DON to facility staff included: Condemnation of resident abuse, retribution for reporting abuse, responsibility of reporting resident abuse, notifying agencies/individuals of resident abuse, notifying administration of resident abuse, methods of resident abuse, contents of notice of abuse. Record review on an In-service Training report named Recognizing signs and symptoms of abuse/neglect, dated 10/05/23 conducted by the DON to facility staff included: signs and symptoms of abuse, neglect, and psychological abuse and neglect. Record review on an In-service Training report named Abuse investigations, to facility staff dated 10/05/23 conducted by the DON to facility staff included: Nursing facility must report no later than two hours after an allegation is made for abuse. The investigation process including all reports of abuse/neglect and injuries will be promptly reported and investigated. Record review on an In-service Training report named Abuse, neglect, exploitation, and misappropriation- reporting and investigating, to facility management dated 10/05/23 conducted by the DON to facility staff included: Definitions of Abuse, neglect, exploitation and misappropriation, steps of reporting and investigations. Record review on an In-service Training report named Investigating resident injuries, to facility staff dated 10/05/23 conducted by the DON to facility staff included: Facility policy stating all resident injuries are investigated. Record review on an In-service Training report named Quick safety de-escalation in healthcare, to facility management dated 10/05/23 conducted by the DON to facility staff included: De-escalation is the first line response to prevent potential violence and aggression. Record review on an In-service Training report named Preventing accidents and incidents, to facility staff dated 10/05/23 conducted by the DON to facility staff included: Facility will work to prevent any accident or incident. The facility will change the plan of care in the event of an accident and or incident. All new hires will continue to be required to complete the abuse training on hire as required by regulation. Interviews with staff members, (CNA A, CNA B, CNA C LVN E, LVN F) starting at 11:45 am - 2:00 pm on 03/12/2024, revealed they were in-serviced and verbalized training regarding Abuse. All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) could identify understanding of Retaliation, abuse, preventing resident accidents and incidents. All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized understanding of when to report abuse to the abuse coordinator, All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized when Reporting abuse to facility management, All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized when Recognizing signs and symptoms of abuse, All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized understanding of Abuse investigations, All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized understanding Abuse, neglect, exploitation, and misappropriation-reporting and investigating. All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized understanding of Investigating resident injuries. All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized understanding of Quick safety de-escalation in healthcare. All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized understanding of Preventing accidents and incidents. During an interview on 03/12/2024 at 3:00 pm the Administrator stated she expected her staff to report any abuse, neglect or exploitation. She said that retaliation was not tolerated. She stated that the monitoring would continue with the facility QAPI meetings. During an interview on 3/12/2024 at 3:15 pm the DON said she expected all staff to treat the residents with dignity and respect. The DON said that abuse will not be tolerated in the facility and any staff members that is accused of abuse will be immediately placed on suspension and terminated pending the investigation. The DON said her focus is now on her hiring process to ensure that quality staff members are brought into the facility. The noncompliance was identified as PNC. The IJ began on 10/04/2023 and ended 10/05/2023. The facility had corrected the noncompliance before the survey began. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 of 2 residents reviewed for resident rights (Resident # 46 and Resident #54) in that: On 6/19/23 CNA A took a video of Resident # 46 on the secured unit of him kicking the door and posted the video on social media. On 6/19/23 CNA A took a video of Resident # 54 on the secured unit of him making inappropriate sexual advances and posted the video on social media. The non-compliance was identified as past non-compliance. The IJ began on 6/19/23 and ended on 6/19/23. The facility had corrected the noncompliance before survey began. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Resident #46: Record review of a facility face sheet dated 8/8/23 for Resident #46 indicated that he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), schizoaffective disorder bipolar type (episodes of mania and sometimes major depression), anxiety, and hypertension (high blood pressure). Record review of the Quarterly MDS for Resident #46 dated 5/29/23 indicated that he was rarely/never understood and had severe cognitive impairment. Question E0200 indicated that resident exhibited physical, verbal, and other behaviors 4-6 times a week to daily. Record review of the comprehensive care plan revised on 6/13/22 for Resident #46 indicated an intervention stating .when the resident becomes agitated, intervene before agitation escalates: guide away from the source of distress, engage calmly in conversation . Record review of a progress note dated 6/19/23 and signed by previous ADON for Resident #46 stated .there is a reported incident of a staff member recording the patient and posting him to social media, [name] Administrator, RP [name] notified, and [name] NP notified . During an observation on 08/07/23 at 09:11 AM Resident #46 observed lying in bed sleeping. Resident did not speak when spoken to. Resident #54: Record review of a facility face sheet dated 8/8/23 for Resident # 54 indicated that he was an [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), hypotension (low blood pressure), and personality change due to known physiological condition (may include being unable to think ahead or understand the consequences of their actions). Record review of the Quarterly MDS for Resident #54 dated 7/6/23 indicated a BIMS score of 6, indicating severe cognitive impairment. Question E0200 indicated that resident exhibited verbal and other behaviors 1-3 times a week to daily. Record review of comprehensive care plan initiated on 6/14/23 for Resident #54 indicated that he had poor impulse control related to dementia and would sometimes make sexually inappropriate comments to staff. Interventions included: .when the resident becomes agitated, intervene before agitation escalates; guide away from the source of distress, engage calmly in conversation . Record review of a progress note dated 6/19/23 and signed by previous ADON for Resident #54 stated .there is a reported incident of a staff member recording the patient and posting him to social media, [name] Administrator, RP [name] notified, and [name] NP notified . During an observation on 8/9/23 at approximately 6:00 pm, video of Resident #54 showed him standing in front of the camera making inappropriate sexual advances. A female voice could be heard laughing at him and asking him to repeat what he said. Interviews with facility staff above indicate that the female voice in the video was that of CNA A. Video of Resident #46 had been deleted and was no longer available for observation. During an interview with the DON on 8/9/23 at 8:15 am, she said that Resident #54 had been discharged home on 7/25/23. She said that he had been admitted to the unit for sexual inappropriateness and had inappropriate behaviors with females. She said that on 6/19/23, CNA A had worked the weekend before, that was her first weekend and she was going to be prn, not full time. She said that on Monday afternoon (6/19/23) about 4 pm, CNA G on the female side was made aware of a video and showed a paused image to her. It was in the dining room of the men's unit and there was 1 resident in the still image. The DON asked the aide where she got the video and CNA G replied that someone had seen it on [social media app] and sent it to her on [social media app]. She said that in the video you could hear CNA A's voice off camera, and Resident #54 was talking to the aide, standing in front of her. CNA A kept asking him what he said, and he said, do you want to fuck, he repeated it twice and she laughed about it. The DON said that they called the family and notified them immediately, and they also immediately called CNA A. She said that CNA A was told she was suspended pending investigation and she never came back. She was told that it was against policy, and she said that she didn't realize it was a big deal. She said that the facility has a direct policy regarding social media. The DON said that immediately after the incident, an in-service training was conducted with a 3-question test on what was considered questionable for private health information. She said that they reported the video to the police, and they came out immediately. From that incident prompted agency to no longer be staffed in the unit by themselves, especially overnight and she added an extra aide to the night shift as a float. She said it took about 2 days for the video to be taken down. A phone call was attempted on 8/9/23 at 8:55 am with CNA G, but there was no answer and surveyor was unable to leave a voicemail. During an interview with the previous ADON on 8/9/23 at 9:16 am, she said that the day she was notified about the video on 6/19/23, she was sitting in her office and CNA G told her to look at what was sent to her in a video. She said there was a video of Resident #54 and CNA A was sitting with the camera facing him and enticing him to say what he wanted to do with her, and he was asking her if he could have sex with her and she kept asking him to say it again and would laugh about it. She said the camera was in his face and he was the only resident in the video. She said that she called CNA A and informed her that she broke HIPPA and told her to take the video down. She had posted the video to [social media app]. The Previous ADON said that the aide did not think she had done anything wrong. She said the police were contacted and the officer was sent a copy of the video. She said that the aide was informed that she was suspended pending investigation for 3 days. During an interview with CNA A on 8/9/23 at 9:25 am, she said that she had only worked at the facility for one week. She said that she had posted 2 videos, one of Resident #46 kicking the door and the other of Resident #54. She said the video included Resident #54 talking to her. She said that he was just saying crazy stuff. She said that she was never specifically trained regarding posting on social media. She said that she did not talk to the police regarding incident. Said that she immediately deleted the videos after the facility asked her to on 6/19/23. She said that she only posted it because she thought that it was funny. She said that she did not think that it was a HIPAA violation. She said that she understands now that it was not funny, and she would probably be upset if this had happened to one of her family members. During an interview with family member of Resident #46 on 8/9/23 at 9:50 am, she said that the facility had called her around 6/19/23 and told her that a video had been posted. She said that she has not seen the video but was told that Resident #46's face was covered up. She said that she did not talk to the police. She said that when she heard about the video, it made her sad to think that her family member had been treated that way. She said that it was wrong to make fun of people when they can't help it. She said that she was not upset with the facility in any way because she said that they could not control an employee's actions. She doesn't think that he would be able to understand if he was told about the video because he doesn't understand things day to day anyway. She said that she has not noticed any behavior changes in him since the incident. During an interview with the family member of Resident #56 on 8/9/23 at 10:15 am, she said that she had not seen the video. She said that [another family member]had seen it. She said that she does not think the incident has affected his behavior at all, as he does not understand due to his dementia. She said that she was extremely upset about the video, and about it being posted on social media. She said that it upsets her to think that the aide was making fun of her family member and posted it for everyone to see. She said that the facility told her the employee was terminated and reported to State. During an interview with family member B of Resident #56 on 8/9/23 at 3:30 pm, she said that the facility had called and told her about the incident around 6/19/23, and she was very upset. She was crying while on the phone with the surveyor. She said that her family member was no longer himself since the dementia and Alzheimer's had gotten so bad. She was very upset that the aide was treating her family member like that and posting it on the internet. She said that he cannot help his behavior due to the dementia and did not deserve to be treated like that. During an interview on 8/10/23 at 10:00 am, the DON said that in the videos, Resident #46's face was covered with a smiley face emoji, but anyone that worked here would know who it was. She said that she expected it to not happen again. From now on, new hires were not allowed to work until after a personal interview by her. She said that they have now changed recruiting companies and no longer allow prn staff to work in the unit, and also have 2 aides at all times. During an interview on 8/10/23 at 9:25 am CNA J said he had been working at the facility for about a week and a half. He said that he had been trained on abuse, neglect, exploitation. He said that he had never witnessed any in the facility but if he did, he would immediately take steps to protect the resident and then immediately report to the Administrator/DON. He said that he had been trained on the social media policy and to not be on his cell phone while working or to video residents. During an interview on 8/10/23 at 9:45 am CNA K said that she had been employed by the facility for about 10 years. She said that she had been trained on abuse, neglect, and exploitation. She said that there were in-services the day of the incident with the video on the men's unit. She said that she had never witnessed any abuse, neglect, or exploitation, but would immediately intervene to protect the resident and then report to administrator/DON if she did. She said that she had been trained on social media and cell phone policy. She said that they are not allowed to be on their cell phones while working, and they are also not allowed to video residents without consent. During multiple observations on multiple occasions during onsite 8/7/23-8/10/23, no staff members were observed taking photos or videos of residents, and no staff were observed on their phones while working. Record review of a personnel file for CNA A indicated that her hire date was 6/1/23. Criminal history check indicated that it had been performed on 5/24/23. Employee misconduct registry check indicated a date of 5/24/23. No unemployable actions on either were indicated. Record review of a witness statement dated 6/19/23 signed by CNA F stated .On June 19th around 4:15 pm I saw a [name of social media app] of one of our residents online and immediately reported it to my ADON [name]. She had me send her the video and write a statement . Record review of a witness statement dated 6/19/23 signed by CNA G stated .On June 19th around 4:15 pm I acknowledged a [name of social media app] that was sent to my phone after another employee seen the same video on her 'fyp' on the [name of social media app]. I immediately recognized the unit the video was taken on and reported it to my DON and ADON [names] in the office . Record review of a police statement, undated, signed by DON stated .on 6/19/23 I was made aware of a video that had been posted on [social media name] that had one of our residents in it. The video was inappropriate in nature because this resident had dementia and inappropriate behaviors due to his disease process. This video showed his face and violated his rights to privacy, and his family did not consent to social media posts. We immediately reported the event and suspended that employee. The employee who posted it was [name] (CNA A). Her [social media app] name is[screen name]. [Name] CNA G found the video when it was sent to her and reported it to me . Record review of a police statement, undated signed by CNA G indicated .On June 19th around 4 pm I seen a [social media app] online consisting of footage containing one of our residents. I immediately reported this to my supervisors . Record review of QAPI notes dated 6/20/23 indicated that the meeting was attended by the following members: Administrator, DON, ADON, MDS nurse, Activity Director, Dietary Manager, Maintenance Supervisor, Social Worker, Rehab Director, and Medical Director. The interventions and plan for correction included: 1. Inservice over abuse and neglect policy and procedure. In-services dated 6/19/23 included the following topics: Abuse, Neglect, Exploitation, and Misappropriation, Recognizing Signs and Symptoms of Abuse/Neglect, Protection of Residents During Abuse Investigations, Abuse/Neglect Clinical Protocol, and Use of Electronic Communications and Social Media 2. Inservice over social media policy with 3 question posttest. In-service dated 6/19/23 and post test completed by all current staff between the dates of 6/19/23 and 6/26/23. Staff were required to complete this before being allowed to return to work if they had been off. 3. New hires will be required to complete additional Relias course including policies and HIPAA guidelines before first day of orientation. 4. Cell phone policy re-instated and enforced. All current staff re-educated and new hires must complete training before allowed to work. Record review of sign in sheets for all in-services dated 6/19/23 indicated that 59 staff members had signed the sign in sheet for the in-services on Abuse, Neglect, Exploitation, and Misappropriation, Recognizing Signs and Symptoms of Abuse/Neglect, Protection of Residents During Abuse Investigations, Abuse/Neglect Clinical Protocol, and Use of Electronic Communications and Social Media Record review of an Associate Separation Report dated 6/19/23 for CNA A indicated that she was terminated on 6/19/23 for violating social media policy, failure to protect resident rights, as well as violation of cell phone policy. Record review of an in-service dated 6/19/23 covering Social Media indicated .residents have rights, and they have the right to privacy. Under no circumstance is it acceptable to video them or record them. Especially, the residents on our secure units are there because they no longer can care for themselves, and it is not a matter to take lightly or record and share for your entertainment. It is disgusting and shameful to record them while they do not know what they are saying or doing. This is an immediate termination, and possibly revoking of your license . Three question posttest indicated .1. Resident pictures and videos are considered health care records. True or False; 2. Taking pictures or videos of residents and posting them to any social media outlet or sharing them with friends is a violation of resident's rights. True or False; and 3. If you suspect a staff member has or is taking pictures or videos of a resident, you need to report this to the Abuse Coordinator immediately. True or False . Sign in sheet indicated that all current staff have completed questionnaire. Record review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2001 with revision date of April 2021 indicated .Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems . Record review of facility policy titled Videotaping, Photographing, and Other Imaging of Residents dated 2001 with revision date of April 2017 indicated that .Residents will be protected from invasion of privacy and/or abuse that might occur from photographs, videotapes, digital images, and recordings during resident care or other facility activities . and .transmitting unauthorized images of any resident through email, internet or social media is considered a violation of resident rights. Any image or recording taken that may be construed as humiliating or demeaning to a resident or residents is considered abuse and will be reported and investigated as such . Record review of facility policy titled Abuse and Neglect - Clinical Protocol dated 2005 with revision date of March 2018 indicated .Abuse is defined .as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .it includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology . On 8/9/23 at 2:48 pm Administrator, DON and Corporate staff were informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 6/19/23 and ended on 6/19/23. The facility had corrected the noncompliance before survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents the right to be free from abuse for 2 of 2 residents reviewed for abuse (Resident # 46 and Resident #54) in that: On 6/19/23 CNA A took a video of Residents # 46 on the secured unit of facility and posted the video on social media of him kicking the door. On 6/19/23 CNA A took a video of Resident # 54 on the secured unit of facility making inappropriate sexual advances and posted the video on social media. The non-compliance was identified as past non-compliance. The IJ began on 6/19/23 and ended on 6/19/23. The facility had corrected the noncompliance before survey began. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Resident #46: Record review of a facility face sheet dated 8/8/23 for Resident #46 indicated that he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), schizoaffective disorder bipolar type (episodes of mania and sometimes major depression), anxiety, and hypertension (high blood pressure). Record review of the Quarterly MDS for Resident #46 dated 5/29/23 indicated that he was rarely/never understood and had severe cognitive impairment. Question E0200 indicated that resident exhibited physical, verbal, and other behaviors 4-6 times a week to daily. Record review of the comprehensive care plan revised on 6/13/22 for Resident #46 indicated an intervention stating .when the resident becomes agitated, intervene before agitation escalates: guide away from the source of distress, engage calmly in conversation . Record review of a progress note dated 6/19/23 and signed by previous ADON for Resident #46 stated .there is a reported incident of a staff member recording the patient and posting him to social media, [name] Administrator, RP [name] notified, and [name] NP notified . During an observation on 08/07/23 at 09:11 AM Resident #46 observed lying in bed sleeping. Resident did not speak when spoken to. Resident #54: Record review of a facility face sheet dated 8/8/23 for Resident # 54 indicated that he was an [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), hypotension (low blood pressure), and personality change due to known physiological condition (may include being unable to think ahead or understand the consequences of their actions). Record review of the Quarterly MDS for Resident #54 dated 7/6/23 indicated a BIMS score of 6, indicating severe cognitive impairment. Question E0200 indicated that resident exhibited verbal and other behaviors 1-3 times a week to daily. Record review of comprehensive care plan initiated on 6/14/23 for Resident #54 indicated that he had poor impulse control related to dementia and would sometimes make sexually inappropriate comments to staff. Interventions included: .when the resident becomes agitated, intervene before agitation escalates; guide away from the source of distress, engage calmly in conversation . Record review of a progress note dated 6/19/23 and signed by previous ADON for Resident #54 stated .there is a reported incident of a staff member recording the patient and posting him to social media, [name] Administrator, RP [name] notified, and [name] NP notified . During an observation on 8/9/23 at approximately 6:00 pm, video of Resident #54 showed him standing in front of the camera making inappropriate sexual advances. A female voice could be heard laughing at him and asking him to repeat what he said. Interviews with facility staff above indicate that the female voice in the video was that of CNA A. Video of Resident #46 had been deleted and was no longer available for observation. During an interview with the DON on 8/9/23 at 8:15 am, she said that Resident #54 had been discharged home on 7/25/23. She said that he had been admitted to the unit for sexual inappropriateness and had inappropriate behaviors with females. She said that on 6/19/23, CNA A had worked the weekend before, that was her first weekend and she was going to be prn, not full time. She said that on Monday afternoon (6/19/23) about 4 pm, CNA G on the female side was made aware of a video and showed a paused image to her. It was in the dining room of the men's unit and there was 1 resident in the still image. The DON asked the aide where she got the video and CNA G replied that someone had seen it on [social media app] and sent it to her on [social media app]. She said that in the video you could hear CNA A's voice off camera, and Resident #54 was talking to the aide, standing in front of her. CNA A kept asking him what he said, and he said, do you want to fuck, he repeated it twice and she laughed about it. The DON said that they called the family and notified them immediately, and they also immediately called CNA A. She said that CNA A was told she was suspended pending investigation and she never came back. She was told that it was against policy and considered resident abuse, and CNA A said that she didn't realize it was a big deal. She said that the facility has a direct policy regarding social media. The DON said that immediately after the incident, an in-service training was conducted with a 3-question test on what was considered questionable for private health information. She said that they reported the video to the police, and they came out immediately. From that incident prompted agency to no longer be staffed in the unit by themselves, especially overnight and she added an extra aide to the night shift as a float. She said it took about 2 days for the video to be taken down. A phone call was attempted on 8/9/23 at 8:55 am with CNA G, but there was no answer and surveyor was unable to leave a voicemail. During an interview with the previous ADON on 8/9/23 at 9:16 am, she said that the day she was notified about the video on 6/19/23, she was sitting in her office and CNA G told her to look at what was sent to her in a video. She said there was a video of Resident #54 and CNA A was sitting with the camera facing him and enticing him to say what he wanted to do with her, and he was asking her if he could have sex with her and she kept asking him to say it again and would laugh about it. She said the camera was in his face and he was the only resident in the video. She said that she called CNA A and informed her that she broke HIPPA and told her to take the video down. She had posted the video to [social media app]. The Previous ADON said that the aide did not think she had done anything wrong. She said the police were contacted and the officer was sent a copy of the video. She said that the aide was informed that she was suspended pending investigation for 3 days. During an interview with CNA A on 8/9/23 at 9:25 am, she said that she had only worked at the facility for one week. She said that she had posted 2 videos, one of Resident #46 kicking the door and the other of Resident #54. She said the video included Resident #54 talking to her. She said that he was just saying crazy stuff. She said that she was never specifically trained regarding posting on social media. She said that she did not talk to the police regarding incident. Said that she immediately deleted the videos after the facility asked her to on 6/19/23. She said that she only posted it because she thought that it was funny. She said that she did not think that it was a HIPAA violation or resident abuse. She said that she understands now that it was not funny, and she would probably be upset if this had happened to one of her family members. During an interview with family member of Resident #46 on 8/9/23 at 9:50 am, she said that the facility had called her around 6/19/23 and told her that a video had been posted. She said that she has not seen the video but was told that Resident #46's face was covered up. She said that she did not talk to the police. She said that when she heard about the video, it made her sad to think that her family member had been treated that way. She said that it was wrong to make fun of people when they can't help it. She said that she was not upset with the facility in any way because she said that they could not control an employee's actions. She doesn't think that he would be able to understand if he was told about the video because he doesn't understand things day to day anyway. She said that she has not noticed any behavior changes in him since the incident. During an interview with the family member of Resident #56 on 8/9/23 at 10:15 am, she said that she had not seen the video. She said that [another family member]had seen it. She said that she does not think the incident has affected his behavior at all, as he does not understand due to his dementia. She said that she was extremely upset about the video, and about it being posted on social media. She said that it upsets her to think that the aide was making fun of her family member and posted it for everyone to see. She said that the facility told her the employee was terminated and reported to State. During an interview with family member B of Resident #56 on 8/9/23 at 3:30 pm, she said that the facility had called and told her about the incident around 6/19/23, and she was very upset. She was crying while on the phone with the surveyor. She said that her family member was no longer himself since the dementia and Alzheimer's had gotten so bad. She was very upset that the aide was treating her family member like that and posting it on the internet. She said that he cannot help his behavior due to the dementia and did not deserve to be treated like that. During an interview on 8/10/23 at 10:00 am, the DON said that in the videos, Resident #46's face was covered with a smiley face emoji, but anyone that worked here would know who it was. She said that she expected it to not happen again. From now on, new hires were not allowed to work until after a personal interview by her. She said that they have now changed recruiting companies and no longer allow prn staff to work in the unit, and also have 2 aides at all times. During an interview on 8/10/23 at 9:25 am CNA J said he had been working at the facility for about a week and a half. He said he was not agency staff, but regular facility staff. He said that he had been trained on abuse, neglect, exploitation. He said that he had never witnessed any in the facility but if he did, he would immediately take steps to protect the resident and then immediately report to the Administrator/DON. He said that he had been trained on the social media policy and to not be on his cell phone while working or to video residents. He said that he was required to complete the trainings on abuse, neglect, exploitation and social media and cell phone policies before he was allowed to begin working. During an interview on 8/10/23 at 9:45 am CNA K said that she had been employed by the facility for about 10 years and was not agency staff. She said that she had been trained on abuse, neglect, and exploitation. She said that there were in-services the day of the incident with the video on the men's unit. She said that she had never witnessed any abuse, neglect, or exploitation, but would immediately intervene to protect the resident and then report to administrator/DON if she did. She said that she had been trained on social media and cell phone policy. She said that they are not allowed to be on their cell phones while working, and they are also not allowed to video residents without consent. During multiple observations on multiple occasions during onsite 8/7/23-8/10/23, no staff members were observed taking photos or videos of residents, and no staff were observed on their phones while working. Record review of a personnel file for CNA A indicated that her hire date was 6/1/23. Criminal history check indicated that it had been performed on 5/24/23. Employee misconduct registry check indicated a date of 5/24/23. No unemployable actions on either were indicated. Record review of a witness statement dated 6/19/23 signed by CNA F stated .On June 19th around 4:15 pm I saw a [name of social media app] of one of our residents online and immediately reported it to my ADON [name]. She had me send her the video and write a statement . Record review of a witness statement dated 6/19/23 signed by CNA G stated .On June 19th around 4:15 pm I acknowledged a [name of social media app] that was sent to my phone after another employee seen the same video on her 'fyp' on the [name of social media app]. I immediately recognized the unit the video was taken on and reported it to my DON and ADON [names] in the office . Record review of a police statement, undated, signed by DON stated .on 6/19/23 I was made aware of a video that had been posted on [social media name] that had one of our residents in it. The video was inappropriate in nature because this resident had dementia and inappropriate behaviors due to his disease process. This video showed his face and violated his rights to privacy, and his family did not consent to social media posts. We immediately reported the event and suspended that employee. The employee who posted it was [name] (CNA A). Her [social media app] name is[screen name]. [Name] CNA G found the video when it was sent to her and reported it to me . Record review of a police statement, undated signed by CNA G indicated .On June 19th around 4 pm I seen a [social media app] online consisting of footage containing one of our residents. I immediately reported this to my supervisors . Record review of QAPI notes dated 6/20/23 indicated that the meeting was attended by the following members: Administrator, DON, ADON, MDS nurse, Activity Director, Dietary Manager, Maintenance Supervisor, Social Worker, Rehab Director, and Medical Director. The interventions and plan for correction included: 1. Inservice over abuse and neglect policy and procedure. In-services dated 6/19/23 included the following topics: Abuse, Neglect, Exploitation, and Misappropriation, Recognizing Signs and Symptoms of Abuse/Neglect, Protection of Residents During Abuse Investigations, Abuse/Neglect Clinical Protocol, and Use of Electronic Communications and Social Media 2. Inservice over social media policy with 3 question posttest. In-service dated 6/19/23 and post test completed by all current staff between the dates of 6/19/23 and 6/26/23. Staff were required to complete this before being allowed to return to work if they had been off. 3. New hires will be required to complete additional Relias course including policies and HIPAA guidelines before first day of orientation. 4. Cell phone policy re-instated and enforced. All current staff re-educated and new hires must complete training before allowed to work. Record review of sign in sheets for all in-services dated 6/19/23 indicated that 59 staff members had signed the sign in sheet for the in-services on Abuse, Neglect, Exploitation, and Misappropriation, Recognizing Signs and Symptoms of Abuse/Neglect, Protection of Residents During Abuse Investigations, Abuse/Neglect Clinical Protocol, and Use of Electronic Communications and Social Media Record review of an Associate Separation Report dated 6/19/23 for CNA A indicated that she was terminated on 6/19/23 for violating social media policy, failure to protect resident rights, as well as violation of cell phone policy. Record review of an in-service dated 6/19/23 covering Social Media indicated .residents have rights, and they have the right to privacy. Under no circumstance is it acceptable to video them or record them. Especially, the residents on our secure units are there because they no longer can care for themselves, and it is not a matter to take lightly or record and share for your entertainment. It is disgusting and shameful to record them while they do not know what they are saying or doing. This is an immediate termination, and possibly revoking of your license . Three question posttest indicated .1. Resident pictures and videos are considered health care records. True or False; 2. Taking pictures or videos of residents and posting them to any social media outlet or sharing them with friends is a violation of resident's rights. True or False; and 3. If you suspect a staff member has or is taking pictures or videos of a resident, you need to report this to the Abuse Coordinator immediately. True or False . Sign in sheet indicated that all current staff have completed questionnaire. Record review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2001 with revision date of April 2021 indicated .Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems . Record review of facility policy titled Videotaping, Photographing, and Other Imaging of Residents dated 2001 with revision date of April 2017 indicated that .Residents will be protected from invasion of privacy and/or abuse that might occur from photographs, videotapes, digital images, and recordings during resident care or other facility activities . and .transmitting unauthorized images of any resident through email, internet or social media is considered a violation of resident rights. Any image or recording taken that may be construed as humiliating or demeaning to a resident or residents is considered abuse and will be reported and investigated as such . Record review of facility policy titled Abuse and Neglect - Clinical Protocol dated 2005 with revision date of March 2018 indicated .Abuse is defined .as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .it includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology . On 8/9/23 at 2:48 pm Administrator, DON and Corporate staff were informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 6/19/23 and ended on 6/19/23. The facility had corrected the noncompliance before survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate supervision and assistance to prevent accidents for 1 of 1 resident reviewed for accidents/supervision (Resident #28) in that: Facility failed to ensure a resident environment as free of accidents/hazards as possible due to not ensuring the locks were engaged on the secure unit and not ensuring that the alarm was functioning on the emergency door on secure unit. Resident #28 eloped from the facility on 6/23/23 and was discovered by a local citizen approximately 2 blocks from the facility. The non-compliance was identified as past non-compliance. The IJ began on 6/23/23 and ended on 6/23/23. The facility had corrected the noncompliance before survey began. This failure could place all residents at risk of eloping which could lead to severe injuries or death. Findings included: During an observation on 8/10/23 at 9:35 am on female secure unit, 2 aides were present. Resident #28 observed wandering aimlessly, ambulating independently, resident did not speak, would only make facial expressions and occasionally grunt. Record review of a facility face sheet dated 8/8/23 for Resident #28 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease, repeated falls, and history of traumatic brain injury. Record review of a quarterly MDS dated [DATE] for Resident #28 indicated that resident was unable to complete interview for BIMS score and had severely impaired cognitive status. Question E0900 indicated that resident exhibited wandering behavior 4-6 times per week. Record review of comprehensive care plan for Resident #28 dated 12/20/22 indicated that she was an elopement risk/wanderer as evidenced by impaired safety awareness, resident wanders aimlessly. Interventions included .distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . Record review of an elopement nurses note for Resident #28 dated 6/23/23 at 5:45 pm and signed by DON, indicated that resident was missing for 18 minutes. Record review of a behavior nurses note for Resident #28 dated 6/23/23 at 8:22 pm and signed by LVN H indicated that resident eloped from building in rain and was walking on 2nd street towards the highway. Record review of a progress noted for Resident #28 dated 6/23/23 at 8:12 pm indicated .CMA notified nurse of receiving a phone call from a lady stating y'all have a resident with a pink helmet on over on second street walking I then proceeded to exit building in attempt to locate resident which I did, and she was walking on second street with a male that lived near the nursing home. Upon reaching resident redirected her into care and back to the nursing home. Head to toe assessment done, no injuries noted, removed damp clothes from the rain and placed dry clean clothes onto her . signed LVN H. During an interview on 8/7/23 at 9:37 am, CNA D said that she was not here when Resident #28 eloped. She said that Resident #28 does not speak, she will only grunt at times. During an observation and interview on 8/7/23 at 10:20 am, Administrator said that on the day Resident #28 eloped, the facility received a phone call from a lady saying that there was a resident with a pink helmet on walking down 2nd street toward the highway. Staff immediately went and got her and brought her back. She said that the emergency switch (this was a light switch on the wall that turned the locks on the doors off and on) had somehow gotten flipped off, so the doors were unlocked. Administrator demonstrated that there was a clear plastic cover over the switch now that was locked and could no longer be accidentally or purposefully switched off unless it was unlocked with a key. Administrator said that she has the key. She said they do not know how long it had been off or who turned it off, but the emergency switch controls the locks on the unit doors and the end door. The alarm on the end door did not go off. The resident got out of the end door and out of the gate (which did not have a lock on it at that time). Resident walked down the sidewalk with several steps and got to the roadway near the front of the facility. Administrator said that the alarm did not go off when end door was opened. Administrator said that after the incident, a cover was placed over the emergency switch, which cannot be opened without a key. All staff were in serviced on elopements, a new door alarm was placed on end door and outside gate [NAME] lock placed on it. During an interview on 8/7/23 at 3:20 pm, LVN H said that she was on the men's unit doing finger sticks on 6/23/23 when someone yelled we need you. She said she immediately went to help. She said that a first responder picked her up and they went toward the resident in the vehicle. She said that she got the resident in the car, and they brought her back to the facility and changed her out of her wet clothes, did a head-to-toe assessment and notified everyone of the incident. She does not remember which aides were working that day. She said that the resident was able to get out of the door because the emergency switch had been flipped off. She said that everyone was in-serviced on elopements immediately after the incident and they monitored the alarm switches hourly to ensure they were not turned off again. During an interview on 8/7/23 at 3:00 pm, LVN E said that he has been working here since October of this year. He was working on 6/23/23 and said that someone had turned the switch off to the release switch which powers the doors. He said Resident #28 was able to get out and walked to the intersection. He said he was the one who answered the phone when the lady told him there was a resident walking down the road, he immediately went out to get Resident #28. He said she had made it to the intersection of 2nd street and [NAME] Street, which was 2 blocks from exit point of facility. He said that they got her back in and they had to change her out of her wet clothes because it was raining, and she had gotten wet. He said that they did a head-to-toe assessment to make sure she didn't have any injuries. He said she was not injured. He said the lady that called apparently lives in one of the houses across the street and that a male first responder was following closely behind the resident to help ensure that she did not get into the road. He said that in-services were done the day the incident occurred on elopements and emergency procedures. He said they also did a head count of all residents in the facility and alarms were monitored hourly until all new systems were put into place. During an interview on 8/10/23 at 10:00 am, the DON said after the elopement, they secured both units doors immediately by turning the switch back on and placing a temporary cover over the switch until a new permanent one could be delivered and installed. She said there was also a striker alarm placed on the end emergency door until a new alarm could be delivered and installed. DON said that they no longer allow staff members to go out the emergency end doors. She said that they always do a head count when the door alarms go off. She said that elopements put residents at risk of falls and injury because they are close to a highway and also at risk of heat exposure. She said that she expected her staff to not allow it to happen again. Record review of a QAPI Committee Report dated 6/23/23 indicated that there was a meeting held on 6/23/23 at 6:00 pm consisting of Administrator, DON, ADON, Dietary Supervisor, Activity Director, MDS nurse, Maintenance Supervisor, Social Worker, Rehabilitation Director, and Medical Director. The following interventions were put in place: In-services: Elopements, Emergency Procedure - Missing Resident, Reporting Maintenance Tasks. Door Alarms - Monitor door alarms every shift, and monitor that cover is over the door alarm and is intact Maintenance will be notified of any non-working equipment. Alarm and door check will be checked off by nursing staff every shift. Record review of sign in sheet for in-service on Emergency Procedure - Missing Resident, dated 6/23/23, indicated that 59 staff members signed the in-service. Record review of sign in sheet for in-service on Elopements, dated 6/23/23, indicated that 59 staff members signed the in-service. Record review of in-service dated 6/23/23 for Maintenance indicated that the following education was provided to staff: .all maintenance tasks must be reported to the maintenance supervisor. This can be reported in the maintenance log located at the nurse's station. When reporting maintenance tasks you must put the date, what the task is and where the maintenance task is located. The maintenance supervisor and/or designee will update the maintenance binder once a maintenance task has been completed. If you find any maintenance tasks that need immediate attention, then you must report to the Administrator immediately. Examples of tasks that need to be reported immediately: Alarms not working, doors not locking, broken equipment, etc .If you are ever in doubt, report it . Record review of a Secure Unit Door and Alarm Check form dated 6/23/23 -6/28/23 indicated that door alarms and unit doors were monitored hourly by nursing staff beginning immediately after incident on 6/23/23 until new door alarms were placed on 6/26/23 and for 48 hours after new alarm placed. Record review of Elopement Risk assessments dated 6/19/23 indicate that assessments were done on all residents in facility on 6/19/23. Record review of Inservice for Maintenance Supervisor (who is no longer employed) dated 6/26/23 to test door alarms and ensure they are working properly. Return demonstration done and signed by Administrator and Maintenance Supervisor. Record review of alarm monitoring form indicated that new alarm for emergency end door arrived and was placed on 6/26/23 and that permanent cover was installed on 7/3/23. Daily monitoring for functioning was documented daily until 8/4/23. Record review of Work History Report dated 8/7/23 indicated that outside gate had lock placed and was checked for proper functioning on 6/30/23. Record review of a facility policy titled Emergency Procedure - Missing Resident dated 2001 with revision date of August 2018 indicated .Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety . On 8/8/23 at 10:25 am Administrator, DON and Corporate staff were informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 6/23/23 and ended on 6/23/23. The facility had corrected the noncompliance before survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free from abuse for 1 of 22 residents (Resident #1) reviewed for Resident Abuse. CNA A hit Resident #1 in the face resulting in redness and bleeding from his right nostril. The noncompliance was identified as PNC. The immediate jeopardy (IJ) began and ended on 6/15/23. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of physical harm, mental anguish, emotional distress, or death. Findings included: Review of a face-sheet dated 06/17/23 showed Resident #1 was a [AGE] year-old male first admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease with late onsite, Dementia with other behavioral disturbances, Psychotic disorder with delusions due to known physiological condition, major depression, diabetes, and anxiety. Review of MDS dated [DATE] showed Resident #1 had a BIMS score of 7, which indicated he was alert to person but had severe to moderate cognition deficit. He required one-person assistance with bed mobility, personal hygiene, and toileting. Resident #1 was always incontinent to bladder. Review of a care plan dated 03/09/23 showed Resident #1 was a moderate risk for falling due to confusion. Resident #1 was having adjustment issues since admission. CNAs were to provide Resident #1 with as many situations as possible which would give him control over his environment and care delivery. Resident #1 resided on the secure unit and had a history of exit seeking behaviors. Resident #1 had cognitive dementia, impaired thought process and impaired decision-making skills. CNAs were to provide Resident with necessary cues-stop and return if agitated. When conflict arises, CNAs were to remove Resident #1 to a calm environment and allow to vent and share feelings. Resident #1 had communication problems due to language barrier. Resident #1 speaks Spanish and understands English. Staff were to encourage Resident #1 to continue stating thoughts even if Resident #1 was having difficulty. Staff were to focus on a word or phrase that makes sense or respond to the feeling resident was trying to express. Resident #1 had a history of physical aggression toward staff. Staff were to provide ADL and incontinent care as needed. During an interview on 06/17/23 at 11:30 a.m. and review of a video surveillance tape provided by the administrator dated 06/15/23, showed on 06/15/23 at 2:14 AM, Resident #1 (Identified by the administrator) was in the hallway on the secure unit. Resident #1 and CNA A (Identified by the administrator) had a physical altercation involving physically hitting. It was not clear as to which one hit who because of the distance away from the camera, but later in the video, CNA A was seen near the exit door when Resident #1 approached CNA A. CNA A was observed pushing Resident #1 in the face with her hand and pushing Resident #1 away. CNA A was observed attempting to run away from Resident #1 by quickly moving around Resident #1 and running down the hallway. During an interview on 06/19/23 at 9:21 a.m. with assistance from RTA A, who served as Spanish/English interpreter, Resident #1 said he remembered the incident with CNA A. Resident #1 said he was standing in the hallway talking to CNA A when she kicked him two times. Resident #1 said CNA A did not kick or hit him in his room. Resident #1 said CNA A scratched him on his nose. Resident #1 said the bleeding on his nose was from the scratch, but he did not know if it was from fingernails or jewelry. Resident #1 said the nurse took him to the nurse's station. Resident #1 said he was not in pain when he was at the nurse's station, but he was upset because he wanted to hit CNA A and couldn't. Resident #1 said he felt safe when he was at the nurse's station, but he did not know if other staff working at the facility would hurt him. During an interview on 06/18/23 at 1:49 p.m., CNA A said she was working on A-Hall, (Men's secure unit) on 06/15/23 on the night shift. CNA A said around 2:30 a.m., she heard Resident #1 yelling and went to see what he needed. CNA A said she had changed Resident # earlier that evening with no issue. CNA A said when she attempted to provide incontinent care to Resident #1, he became combative and started hitting her and pulling her hair. CNA A said Resident #1's nose may have been scratched by her jewelry at this time she attempted to get away from him, but she was not sure. CNA A said she did not hit Resident #1. CNA A said she left the room and went into the hallway. CNA A said she attempted to return to the room to provide care, but Resident #1 would not let her in the room. CNA A said she was standing in the hallway outside Resident #1's room when Resident #1 came out and started attaching her. CNA A said Resident #1 hit her on the left side of her head. CNA A said she went to the exit door and knocked to get the nurse's attention who was sitting at the nurse's station just outside the exit door. CNA A said when she turned around, she saw Resident #1, walking towards her in an aggressive manner. She said she held her hand out and told Resident #1 to go on. CNA A said she skited around Resident #1 and ran down the hall. CNA A said she did not remember pushing Resident #1 in the face. CNA A said LVN A opened the door. CNA A said LVN A came in the unit and took Resident #1 to the nurse's station. CNA A said the nurse asked her to make a written statement about what happened and asked her to clock out. CNA A said she clocked out and left the facility about 2:40 a.m. CNA A said when she started her shift on 06/14/23 at 10:00 p.m. the CNA who had been working the 2-10 shift told her Resident #1 was a fall risk and to keep an eye on him. CNA A said the CNA also told her that Resident #1 yells out in the night and to try to keep him calm and quit so he will not disturb the other residents. CNA A said this was the second time she had worked at the facility and had no problems the first time. During an interview on 06/19/23 at 12:03 p.m. LVN A said she was working on 06/15/23 on the night shift. LVN A said she was not assigned to A-hall (Men's secure unit) but was sitting at the nurse's desk just outside the unit, when she heard knocking at the exit door. LVN A said she opened the door and when she entered the unit, she saw CNA A. LVN A said CNA said Resident #1 was coming at her and she had to knock him out. LVN A said she escorted Resident #1 outside the unit to the nurse's station and observed blood on the right side of his nose. LVN A said she called the Administrator and DON to report the incident but did not get an answer. LVN A said she then call the Regional Nurse Consultant and received instructions to have CNA A write a statement, clock out and leave the facility. LVN A said she called the police to report the incident. LVN A said she contacted another CNA working at the time to cover A-hall. LVN A said while she was making phone calls and dealing with CNA A, LVN B cleaned the blood off Resident #1's nose and offered emotional support to Resident #1. LVN A said Resident #1 was visibly upset at the time and crying. LVN A said her assessment of Resident #1 at the time showed no other injuries other than the skin tear on his nose. During an interview on 06/19/23 at 9:41 a.m. the DON said she had been the DON at the facility since March 2023. The DON said on 06/15/23 at 2:30 a.m. she missed a call from the facility because the ringer on her phone was off. The DON said at 5:30 a.m. she noticed the missed call and called the facility. The DON said LVN A told her about the incident and said she had contacted the Regional Nurse Consultant. The DON said LVN A had already contacted the police. The DON said she arrived at the facility around 8:00 a.m. and the Medical Director was also at the facility. The DON said the Medical Director ordered x-rays for Resident #1, but Resident #1 said his hip was hurting so it was decided to discontinue the orders for x-rays and send Resident #1 to the hospital for evaluation and treatment to be on the safe side. The DON said CNA A was immediately asked to clock out and leave the facility. The DON said CNA A worked for an agency and the agency was contacted and told CNA A could not longer work at the facility. The DON said In-service training on preventing, identifying, and reporting resident abuse and neglect. The DON said staff also received training on resident rights and dealing with residents with aggressive behaviors. The DON said staff will be trained prior to working their next shift. The DON said the QAPI plan for intervention included that only employees of the facility will work in the secure units and agency staff will not work in the units unless there is no other alternative. The DON said she and the Administrator are responsible to ensure all staff are trained and they are to monitor to ensure compliance with the QAPI plan. During an interview on 06/17/23 at 2:55 p.m. Administrator said CNA A was an agency staff and first worked for the facility on 05/30/23 for one shift. Administrator said on 06/15/23 CNA A was working the night shift on the men's secure unit. Administrator said this was the second time CNA A had worked at the facility. Administrator said she was notified of the incident and reported the incident to the medical director, agency employer, the local police, Resident #1's family (RP), and the state agency as required. Administrator said after the incident staff received training on abuse prohibition, resident rights and dealing with residents with aggressive behaviors. Administrator said notification was given to the employment agency that CNA A is not longer eligible to work at the facility due to physically abusing Resident #1. Administrator said on 06/15/23 the QAPI had a meeting to discuss interventions to ensure residents were safe from abuse. Review of QAPI notes dated 06/15/23 showed a meeting was held to discuss the incident with Resident #1 and CNA A on 06/15/23. Members present included the administrator, DON, Medical Director, MDS Coordinator, Charge Nurse, Social Worker, and Dietary Supervisor. The interventions and plan for correction included o Agency Staff was removed immediately o Notified Agency Staff Employer of incident o Made a police Report o Sent resident to hospital for eval and treatment o DON completed skin assessment on all residents on a hall emotional assessment completed on Resident #1 o Abuse/neglect training to be completed with all staff o Staff working on the secure units will be employees of the facility and not agency staff. Review of nurse progress notes written by LVN A for Resident #1 dated 06/15/23 at 2:30 a.m. showed CNA banged on door to get someone's attention from outside the unit. LVN A, walked to the A hall unit to see what was going on. After arriving the CNA said, I had to lay him out because he tried to jump on me, he tried to fight on me, and I had to lay him out LVN asked who? Resident began walking out of his room and CNA pointed at resident and said, Him, him right there. CNA said, I tried to change him, and he refused and charged at me and does he do that all the time. LVN A replied, yes, he does sometimes. Resident began speaking in Spanish and said in English, Someone call the police. LVN A immediately removed resident off the unit to separate both parties. LVN A and LVN B immediately began calling Administrator, DON and ADON. LVN B performed care to Resident #1 was active bleeding on the right side of his nose. LVN B clean up his nose. LVN A called the sheriff's office and was given direct time of 7:30 AM, when sheriff office will come to the facility. Review of nurse progress notes Resident #1 dated 06/15/23 at 10:42 a.m. the DON recorded Due to resident's progressive pain to hip and abrasion to face, decided to send resident to ER for further evaluation. Review of nurse progress notes written by LVN C for Resident #1 dated 06/15/23 at 10:49 a.m. showed Ambulance arrived at this time to transfer resident to ER. Awake and alert at time of leaving this facility. Review of nurse progress notes written by the administrator for Resident #1 dated 06/15/23 at 12:17 PM, Administrator spoke with RP regarding altercation this morning. A police report had been filed and the case number is OR-06152301. Review of hospital records for Resident #1 dated 06/15/23 showed: Resident #1 arrived at ER. Complaint: Fall injury to [AGE] year-old- male .presented to emergency department .from home with complaints of hip pain. The patient reports that he had a fall last night landing on his left side injuring his hip. Patient notes that he was assaulted by a medical aide at the nursing home and would like a CT scan. (A scan combines a series of X-ray images taken from different angles around your body and uses computer) Patient has had Tylenol .is not on blood thinner .also complained of chest pain. Review of X-ray report for Resident #1 dated 06/15/23 at 12:58 PM, showed no fractures to pelvis. Review of CT scan of Resident #1's head dated 06/15/23 at 2:27 PM showed Clinical indication: Assault. Findings included: No Acute intracranial hemorrhage (No bleeding), No acute infarction (obstruction of the blood supply). No acute intracranial abnormalities (nothing abnormal found). Review of nurse progress notes written by LVN C for Resident #1 dated 06/15/23 at 4:20 PM, Resident returned to facility at 3:40 PM. MD notified. Recommendation from NP to monitor per nursing protocol and to notify them of any increase in anxiety or unusual behavior. On 06/19/2023, the surveyor confirmed the facility implemented appropriate measures to ensure the safety of residents after the incident on 06/15/23 involving Resident #1 and CNA A by: 4 LVN's (on all shifts) 6 CNA's (on all shifts) said they received training regarding resident abuse, neglect, rights and dealing with residents with aggressive behaviors. The nursing staff verbalized understanding of the trainings and said they were to follow resident's plan of care dealing with behaviors. Review of facility policy showed Residents have the right to be free from abuse . 1. Protect residents from abuse .by anyone including, a. facility staff, .c. staff from other agencies .j. any other individual. 7. Implement measures to address factors that may lead to abusive situation, for example: a. adequately prepare staff for caregiving responsibilities; . c. instruct staff regarding appropriate ways to address interpersonal conflicts, and help staff understand how cultural religious and ethnic differences can lead to misunderstanding and conflict. 8. Identify and investigate all possible incidents of abuse . 9 report any allegations within timeframe required by federal requirements. 10. Protect residents from any further harm during investigation. 11. Establish and implement a QAPI review and analysis of reports, allegations, or findings of abuse .