**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. Specifically, for 1 out of 27 sampled residents, a resident was not given an oral antibiotic that was susceptible to treat her urinary tract infection (UTI) and then required intravenous (IV) antibiotics. Resident identifier: 15. Findings included: Resident 15 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included obstructive and reflex uropathy, type 2 diabetes mellitus, and dementia. On 4/1/25 at 8:23 AM, an interview was attempted with resident 15. Resident 15 was unable to answer any questions. Resident 15's medical record was reviewed. A quarterly Minimum Data Set assessment dated [DATE], documented that resident 15 had a Brief Interview for Mental Status (BIMS) score of 15. A BIMS score of 13 to 15 indicated intact cognitive function. On 3/6/25 at 3:37 PM, a nurse practitioner note documented, . Pt [patient] was in the activities room participating in the activities, the dark urine flowing the [sic] the urinary bag, pt C/o [complaining of] feeling extremely tired and says, 'I always feel very tired'. C/o urinary mild dysuria and suprapubic tenderness.New order today Iron sulfate 325mg [milligrams] PO [by mouth] daily with Vitamin C 500mg after meals UA [urinalysis], C&S [culture and sensitivity] staff to notify provider when the lab result is available Staff to monitor pt closely, including vitals and notify provider if any concerns. On 3/7/25 at 3:58 PM, an electronic Medication Administration Record (eMAR) note documented, Changed foley catheter and drain bag using SILICONE 18 french catheter r/t [related to] latex allergy. as needed Foley catheter changed to obtain UA with C/S, sent to [name redacted] lab. On 3/10/25 at 2:41 PM, a laboratory result note documented, Pt had UA with C&S collected and sent to lab on 3/7/25. Abnormal findings (preliminary): Appearance SL [slightly] cloudy, Blood 1+, Protein 2+, Nitrite positive, LK [leukocyte] Esterase 1+, WCB [sic] [White blood cells] 30-5-0, Bacteria 2+, Renal cells 2-5. Organism 1: Gram negative Bacillus. Per NP [Nurse Practitioner], N.O. [new order] to start Ciprofloxacin 500mg BID [twice daily] x [for] 5 days and await for final culture. Pt updated. On 3/13/25 at 11:35 AM, a nurse practitioner note documented, Late Entry: [AGE] years old female resides at [name redacted] who was seen today for F/u [follow up] visit of UTI. Pt had c/o dysuria, flank pain and suprapubic tender. UA with C&S showed on 3/10 [25]; (preliminary): Appearance SL cloudy, Blood 1+, Protein 2+, Nitrite positive, LK Esterase 1+, WCB [sic] 30-5-0, Bacteria 2+, Renal cells 2-5. Organism 1: Gram negative Bacillus Ne [sic] order given to [sic] Ciprofloxacin 500mg BID x 5 days and await for final culture. In today visit, pt says she continues to be tired, AXO [alert and oriented] as her norm [normal], denies flank pain, suprapubic tenderness, dysuria. NAD [no abnormality detected], Vitals WNL [within normal limits]. Continue to Cipro to complete 5 days course. Waiting for final c&S result. It should be noted that the urine culture from 3/7/25, was resistant to Ciprofloxacin which was administered to the resident on 3/10/25 through 3/15/25. The facility received the urine culture results on 3/17/25. On 3/28/25 at 1:04 PM, an eMAR note documented, Meropenem Intravenous Solution Reconstituted 1 GM [gram] Use 1 gram intravenously STAT [immediately] for Rule out UTI. On 3/28/25 at 7:39 PM, a nurse practitioner note documented, Late Entry: pt has history of feeling tired and sleeping whole morning and waking up late as her baseline, however, the floor nurse was a little concerns [sic] that pt might be more tired and sleeping more than usual 3/27/25, Vitals WNL, NAD. However, pt seems more lethargic to NP. ordered some stat lab 3/27/25.Chest WBC [white blood cell] and Neutrophil looks normal though. IV fluid and other orders were ordered by Oncall provider 3/27 [25], night. Per staff, she continues to be really lethargic, extremely tired, mild tachycardia (102), other vitals look WNL. She has not eaten breakfast/ lunch, urine was not collected until this morning, pthas [sic] history of urosepsis, has foley catheter. IV fluid was running. Called family member and left message, has not called me back yet. Working dx [diagnosis]: UTI/ dehydration, AKI [acute kidney injury]. New orders today: Meropenem 1 gram IV Q [every] 12 hr [hours] X [for] 3 days (the lab takes about a week for urine culture, Meropenem according to the last urine C&S, She has resistant to many ABX [antibiotics] last time) . please monitor fluid input and urine output, notify provider if any concerns Vitals every 6 hr Stat CMP [comprehensive metabolic panel] tomorrow morning UA, C&S Contingency Plan: send pt to ER [emergency room] if she requires higher care continue with IV fluid NS [normal saline] 75ml [milliliters]/hr (according to CMP result) Adjust ABX according to UA, C&S result. On 3/29/25 at 2:09 PM, a laboratory note documented, . Preliminary UA faxed back and will call NP with these results. UA abnormals as follows: Appearance: Cloudy, UA Blood- 1+, UA Protein- 2+, UA nitrite- Positive, UA Esterase- 3+, UA WBC- 30-50, UA Bacteria- 4+, UA Renal Cells- 5-10. On 4/2/25 at 9:07 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 15 had completed IV antibiotics for a UTI on 3/31/25. RN 1 stated that resident 15 had a change in condition and the NP ordered a urinalysis because resident 15 was not waking up. RN 1 stated that over the past week resident 15 had a flat affect and seemed off. On 4/2/25 at 9:46 AM, an interview was conducted with the Infection Preventionist (IP). The IP stated that resident 15 got UTI's quite often. The IP stated that it took a while for the urine culture to come back from the UA that was done on 3/7/25. The IP stated that resident 15 was given Ciprofloxacin for the UTI at the beginning of March and the urine culture showed that it was resistant to Ciprofloxacin. The IP stated that she did not chart when she called the lab requesting results from the urine culture. The IP stated that resident 15 had completed the Ciprofloxacin when the urine culture results came back and did not think she needed to follow up on that because resident 15 stopped complaining of painful urination. The IP stated she believed that resident 15's UTI never went away as she just completed IV antibiotics for another UTI. The IP stated they gave resident 15 IV antibiotics that were susceptible from the urine culture from the beginning of March as they were still waiting on culture results from the other day. On 4/3/25 at 8:56 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she expected nursing staff to call the lab the next day to see if there was any growth and if not then they would call intermittently. The DON stated that it should be charted in the chart every time the lab was called. The DON stated that resident 15 had a history of chronic UTI's. The DON stated that if a resident was prescribed a resistant antibiotic then staff should contact the physician with the results and get new orders for a different antibiotic. The DON stated that resident 15 was acting differently with the night nurse and the provider was notified and the provider ordered a UA and labs. The DON stated that the provider should have been contacted by nursing staff when results of the urine culture for resident 15 showed that Ciprofloxacin was resistant. On 4/3/25 at 9:01 AM, a follow up interview was conducted with the IP. The IP stated the Physician saw the urine culture results. The IP stated that resident 15 was put on an antibiotic that the urine culture from 3/7/25, was susceptible to.

Based on record review, interviews, and facility document and policy review, the facility failed to protect the resident's right to be free from sexual abuse by another resident for 1 (Resident #4) of 6 residents reviewed for abuse prohibition. Resident #189 touched Resident #4, a severely cognitively impaired resident, inappropriately on the breast on 10/23/2022 and the facility failed to implement adequate interventions to address Resident #189's behavior. This failure resulted in Resident #189 touching Resident #4 inappropriately on the legs, private area, and breast area on 12/26/2022. It was determined that the reasonable person in Resident #1's position would have experienced psychosocial harm as a result of sexual abuse. Findings included: The facility policy titled, Freedom from Abuse, Neglect and Exploitation, dated November 2017 and last revised 09/13/2022, revealed, The facility will provide a safe resident environment and protect residents from abuse. The facility will keep residents free from abuse, neglect, misappropriation of resident property, and exploitation. This includes freedom from verbal, mental, sexual, or physical abuse, corporal punishment, involuntary seclusion and physical or chemical restraint not required to treat the resident's medical symptoms. The policy indicated under the Guidelines section, 3. When the facility has identified abuse, the facility should take appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. This includes but is not limited to: a. Take steps to prevent further potential abuse. b. Report the allegation to appropriate authorities within required timeframes. c. Conduct a thorough investigation of the allegation. d. Document and report the result of the investigation of the allegation. e. Take appropriate corrective action. f. Revise the resident care plan if indicated, to reflect changes to needs or preferences related to an abuse incident. The policy further indicated under the Guidelines section, 5. Resident to resident abuse: a. Cognitive impairment or mental disorder does not preclude a resident from being abusive. b. In determining abuse, willful (deliberate) action (not inadvertent or accidental) will be considered regardless of whether the individual intended to inflict injury or harm. c. Facility will assess the resident and care plan interventions to address resident behaviors that may indicate a risk for abuse, aggressive interactions (e.g. physical, sexual, or verbal aggression; taking, touching, or rummaging through another's property; wandering into another's rooms/space). The policy indicated sexual abuse was, a. Non-consensual sexual contact of any type with a resident who appears to want the contact to occur but lacks the cognitive ability to consent or a resident who does not want the contact to occur. A review of Resident #4's admission Record revealed the facility admitted the resident on 11/01/2018 with diagnoses that included Alzheimer's disease with early onset, major depressive disorder, moderate intellectual disabilities, and generalized anxiety disorder. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/17/2023, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 0, indicating the resident had severe cognitive impairment. The MDS indicated the resident required limited assistance from staff with most activities of daily living but required extensive assistance from staff for dressing and personal hygiene. A review of Resident #4's comprehensive care plans revealed a Focus, initiated on 11/06/2018, that indicated the resident had impaired thought processes related to Alzheimer's disease and unspecified dementia without behavioral disturbance. The care plan Focus indicated Resident #4 experienced frequent confusion and forgetfulness and had significant difficulty with recall. A review of Resident #189's admission Record revealed the facility most recently admitted the resident on 07/08/2022 with diagnoses that included metabolic encephalopathy, schizoaffective disorder - depressive type, major depressive disorder - recurrent severe without psychotic features, dementia - unspecified severity with other behavioral disturbance, and schizoaffective disorder - bipolar type. A review of a significant change in status MDS, with an ARD of 10/06/2022, revealed a Staff Assessment for Mental Status (SAMS) that indicated Resident #189 had short- and long-term memory problems and severely impaired cognitive skills for daily decision making. The MDS also indicated the resident had physical behavioral symptoms directed towards others (such as hitting, kicking, pushing, scratching, grabbing, or abusing others sexually), other behavioral symptoms not directed toward others (such as hitting or scratching self, pacing rummaging, public sexual acts, etc), and wandered one to three days of the seven-day assessment period. These behaviors significantly interfered with the resident's care and participation in activities or social interaction and significantly intruded on the privacy or activity of others and disrupted care or the living environment of others. The MDS indicated the behaviors had worsened since the previous MDS. A review of Progress Notes, dated 10/11/2022 and completed by Registered Nurse (RN) #9, indicated nurses and certified nursing assistants (CNAs) reported Resident #189 was having increased sexual behaviors. In an interview on 08/23/2023 at 9:17 AM, RN #9 stated Resident #189 became very sexual and was masturbating and asking females to get into bed with them. There had to be two staff present when providing care for Resident #189 to protect the staff. RN #9 said Resident #189 was difficult to redirect and very handsy. A review of Progress Notes for Resident #189, dated 10/12/2022 and completed by the Social Worker (SW), indicated a call was received from the nurse practitioner (NP) related to Resident #189's increased sexual behaviors. The note indicated the NP increased the resident's sertraline (an antidepressant medication). A review of Progress Notes for Resident #189, dated 10/22/2022 at 6:20 PM, indicated the resident was sexually inappropriate with staff and other residents. The note indicated Resident #189 was redirected several times during the shift. A review of Progress Notes for Resident #189, dated 10/22/2022 at 6:30 PM, indicated Resident #189 was found in the lobby with another resident and had the resident cornered in the phone booth and was staring at their private areas. The note indicated no physical contact was made, but the cornered resident appeared to be no [sic] a fan of the situation. A review of an incident report, dated 10/23/2022 and prepared by Licensed Practical Nurse (LPN) #11, revealed Resident #4 was in the dining room sitting at a table with Resident #189 when Resident #189 grabbed Resident #4's breast. Resident #4 slapped Resident #189's hand. The incident report indicated the residents were separated and a nurse stayed in the dining room with Resident #189 until they finished breakfast. According to the incident report, Resident #4 stated I want to get away from [Resident #189]. There were no injuries noted to Resident #4. A review of Progress Notes for Resident #189, dated 10/23/2022 at 8:30 AM and completed by LPN #11, revealed Resident #189 was in the dining room sitting at a table with Resident #4 when Resident #189 grabbed Resident #4's breast. Resident #4 slapped Resident #189's hand. The note indicated the residents were separated and a nurse stayed with Resident #189 until they finished breakfast. In an interview on 08/23/2023 at 12:20 PM, LPN #11 stated on 10/23/2022 someone reported to her that they saw Resident #189 grab Resident #4's breast. LPN #11 stated she did a report, a progress note, and contacted the Director of Nursing (DON) and Administrator right away. LPN #11 said she separated the two residents and monitored them closely. She said staff were to check both residents frequently and report any issues to the DON. LPN #11 stated staff were notified at the meetings during shift change by the DON and the Administrator to keep an eye on Resident #189 to prevent that kind of incident and how to report abuse. LPN #11 said Resident #189 was masturbating a lot prior to this incident and was somewhat redirectable. LPN #11 stated after the investigation, abuse was not substantiated because both residents had dementia. A review of Resident #189's comprehensive care plan revealed a Focus, initiated on 02/11/2019, that addressed behaviors and indicated the resident had a history of delusions and hallucinations and was often nervous they had done something wrong and would be arrested. On 10/27/2022, the care plan Focus was updated to indicate Resident #189 had recently had an increase in socially inappropriate sexual behaviors. Interventions directed staff to educate Resident #189 and staff on successful coping and interaction strategies such as one to one visit/interventions, activities, deep breathing, reading, redirect with suggestions of working with maintenance, watching favorite movies, exercise etc., redirect inappropriate gestures/behaviors, encourage to keep hands clasped on head or knees during care. On 10/23/2022 an intervention was added that instructed staff to redirect away from female residents. A review of Progress Notes for Resident #189, dated 10/25/2022, indicated the resident touched or grabbed multiple staff today. The note indicated Resident #189 grabbed one resident's side and was trying to force them closer to them. The note indicated Resident #189 removed their clothing and grabbed their genitalia and was trying to force the CNA's face towards their genitalia. The note indicated a nurse and the CNA spoke with the SW about Resident #189's behavior and indicated the interdisciplinary team (IDT) was discussing the situation with the physician and NP to find possible medication changes. A review of Progress Notes for Resident #189, dated 10/27/2022, indicated Resident #189 put their hands down their pants and grabbed a CNA's buttocks when the CNA was placing water on the resident's bedside table. The note indicated the resident was redirected and told the behavior was inappropriate. A review of Progress Notes for Resident #189, dated 11/08/2022, indicated the resident continued to have sexual behaviors and was very difficult or unsuccessful with redirection. A review of Progress Notes for Resident #189, dated 11/12/2022, indicated the resident continued to have sexual behaviors with improvement with redirection. The note indicated Resident #189 continued to stare at females and make sexual sounds. A review of Progress Notes for Resident #189, dated 11/14/2022, indicated the resident was in another resident's room with their pants down. The note indicated Resident #189 was taken to their room and tried three times to touch the nurse inappropriately. The note indicated Resident #189 was reminded of proper behavior towards others and was brought to the front lobby area to be monitored. A review of Progress Notes for Resident #189, dated 11/17/2022, indicated the resident continued to have sexual behaviors towards female staff. The note indicated the resident refused to keep their brief and pants in place while in bed. A review of Progress Notes for Resident #189, dated 11/22/2022, indicated the resident was awake all night and was continuously attempting to go into other resident's rooms. The note indicated the resident repeatedly attempted to go into the hallway without pants. The note indicated Resident #189 continued into the day yelling repetitive words and laughing loudly and needed to be checked every five minutes. A review of Progress Notes for Resident #189, dated 11/26/2022 indicated the resident was difficult to direct. The note indicated the resident was propositioning staff for sex. A review of Progress Notes for Resident #189, dated 12/08/2022, indicated the resident was found in another resident's room pouring water on their comforter. A review of Progress Notes for Resident #189, dated 12/11/2022, indicated the resident needed frequent intervention and redirection to stay in their room, stay out of other resident's rooms and to not touch staff. The note indicated Resident #189 did not adhere to staff request for long and would stay in their room and keep their clothes on for approximately two to five minutes and would then come back out undressed and walking around the hall and into other resident's rooms. The note indicated Resident #189 either forgot or disregarded staff direction. A review of Progress Notes for Resident #189, dated 12/11/2022, indicated the resident required multiple staff interventions and redirection to stay in their room, keep their clothes on, keep out of other resident's rooms and to not touch staff. The note indicated the resident either forgot or disregarded staff direction within minutes of being reminded. A review of Progress Notes, dated 12/16/2022, indicated Resident #189's sexual behavior continued, and they required redirection and cueing. A review of Progress Notes, dated 12/17/2022, indicated Resident #189's sexual behavior towards staff and residents continued. A review of Progress Notes, dated 12/21/2022, indicated Resident #189 needed cueing for sexually inappropriate behaviors and required frequent reorientation to be appropriate and refrain from wandering to other resident rooms. A review of Progress Notes, dated 12/26/2022 at 3:28 PM, indicated Resident #189 continued to stare at female residents, but the nurse had not heard any sexual comments on this day. The note indicated Resident #189 told the CNA during a shower that they wanted sex so bad but did not ask the CNA for sex. A review of an incident report, dated 12/26/2022, revealed staff and residents witnessed Resident #189 in front of Resident #4 in the activity room. Resident #189 was seen massaging Resident #4's foot, and then stroked their hand up Resident #4's leg. Resident #4 was yelling for Resident #189 to go away and was swatting at Resident #189's hands with their hands. Resident #189's hands continued up Resident #4's leg to their private area, over the clothing, and then attempted to pull up Resident #4's shirt. The incident report indicated the kitchen staff (Cook #10) yelled at Resident #189 to stop and Resident #189 stepped back. In an interview on 08/23/2023 at 8:47 AM, [NAME] #10, who witnessed the 12/26/2022 incident, stated the incident occurred after dinner around 7:00 PM. Resident #4 was sitting in a chair. [NAME] #10 said she witnessed Resident #189 rubbing Resident #4's legs. She told Resident #189 to stop but Resident #189 kept touching Resident #4 and began touching Resident #4's breast over Resident #4's shirt. [NAME] #10 stated she knew it was not right. Resident #4 kept telling Resident #189 to stop and was slapping Resident #189's hands away. [NAME] #10 stated she left the two residents alone while she left to get a nurse to help. [NAME] #10 stated she was not aware of any previous incidents between Resident #4 and Resident #189 and had not been told about any interventions related to Resident #189. [NAME] #10 stated she did not receive any training or in-services after the incident on 12/26/2022. A review of Progress Notes for Resident #189, dated 12/26/2022 at 7:01 PM, revealed Resident #189 was seen trying to pull up Resident #4's shirt. The note revealed Resident #189 had been more mobile and was walking better so Resident #189 was able to leave their room sometimes and go to the activity and day room independently without staff seeing them. A nursing staff member was called into the room immediately by another resident. A review of Progress Notes for Resident #189, dated 12/26/2022, revealed staff and resident questioning determined that Resident #189 was witnessed stroking their hand up Resident #4's leg and private area over Resident #4's clothes. A review of Progress Notes, dated 12/27/2022 at 8:34 AM, indicated the Administrator interviewed Resident #189 about the incident and the resident did not recall the incident or know details about it. The note indicated the Administrator made Resident #189 aware the details of the allegation were inappropriate and unacceptable. The note indicted the Administrator used simple language that the resident could understand to explain how to avoid those types of situations in the future. A review of Progress Notes, dated 12/27/2022 at 1:22 PM, indicated Resident #189 required frequent reorientation and redirection to their room on this day. A review of a Progress Note, dated 12/28/2022, indicated Resident #189 was discharged from the facility. In an interview on 08/23/2023 at 11:19 AM, CNA #21 stated staff were told to take another staff member in with them to Resident #189's room, to report any sexual inappropriate behavior, and keep a watchful eye. The intervention seemed to work because there were fewer reports of incidents related to staff. After the incident with Resident #4, staff were told to keep an eye on Resident #189 if they were going to be out of their room. The amount of redirecting depended on the day; sometimes they would have to redirect Resident #189 multiple times but other times Resident #189 would be agreeable after the first redirection. She did not recall a one to one supervision intervention but whoever was on the resident's hall or in the dining room would be responsible to watch over Resident #189. In an interview on 08/23/2023 at 11:41 AM, RN #2 stated Resident #189 had some serious mental illness issues. She recalled Resident #189 began having increased sexual activity such as masturbating, grabbing at staff, and making comments to staff that they were going to marry them. She said Resident #189 was basically always under supervision when out of their room and ate at an individual table with a supervising staff person in the dining room. The interventions seemed to be more of a preventative measure rather than a solution and Resident #189 was only redirectable for a short time and then they would have to redirect them continually. In an interview on 08/23/2023 at 9:17 AM, RN #9 stated Resident #189 was initially in a wheelchair but as time went on, Resident #189 was able to walk independently. She said Resident #189 could sometimes be redirected but most of the time Resident #189 would keep doing whatever inappropriate thing they were doing, and it would take several attempts to redirect. RN #9 stated staff tried to keep Resident #189 in their room. RN #9 stated Resident #189 was very active at night and went into other residents' rooms. She said at times staff would have to physically move Resident #189 in their wheelchair back to their room. RN #9 said redirection would only work some of the time and one to one supervision became necessary for a short time. She stated one to one supervision was not for days or weeks straight. RN #9 stated Resident #4 was sitting in a chair in the activity room and Resident #189 started groping Resident #4. The two residents were separated, and she asked Resident #4 if they were okay and Resident #4 said yes. She assessed Resident #4 for any injury or bruising and none were noted. She recalled Resident #189 had started touching Resident #4 at their legs and had gone up their legs (near their private area) and then maybe the chest area. In an interview on 08/24/2023 at 12:33 PM, the DON stated for resident-to-resident abuse, the expectation was that staff provided a safe environment to the resident and then notified their direct supervisor. The DON stated a resident touching another resident would be considered abuse and she would expect that to be reported immediately or as soon as possible. The DON stated she would expect staff to implement the care plan interventions related to supervision of residents and keeping the residents separated. The DON indicated it would be a breach in facility policy if two residents were left unsupervised in an altercation/incident. The DON stated redirection was an appropriate intervention after Resident #189 touched Resident #4's breast in the dining room on 10/23/2022. The DON stated she felt like Resident #189 could be redirected and would respond but it probably depended on the time of day and who the staff person was who was working with Resident #189. The DON stated she would consider inappropriate touching as abuse. In an interview on 08/24/2023 at 12:59 PM, the Administrator stated he would expect staff to report a resident-to-resident incident to the Administrator and separate the two residents. The Administrator stated care staff were expected to follow care plan interventions.