**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record the review, it was determined, the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 18 sampled residents, a resident that was observed and verbally expressed their pain was not provided pain medication. In addition, there was a delay in the facility Medical Doctor (MD) responding to the nurses message regarding resident 33's pain. Resident identifier: 33. Findings included: On 9/10/23 at 11:43 AM, an observation of resident 33 was conducted. Resident 33 was observed in a wheelchair at the nurses station and stated to the Licensed Practical Nurse (LPN) that something needed to happen with his pain because he could not stand it anymore and he was not getting any sleep. Resident 33 also stated that he had ascites. The LPN was observed to palpate resident 33's stomach. Resident 33's stomach was observed to be tight and distended. The LPN and resident 33 were observed to go to resident 33's room. [Note: There were no progress notes regarding the event. Resident 33 did not receive any pain medication. Resident 33 was transported to the hospital on 9/10/23 at 9:45 PM, related to pain.] Resident 33 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, cirrhosis of liver, hepatic encephalopathy, schizotypal disorder, polyneuropathy, secondary hypertension, post-traumatic stress disorder, and major depressive disorder. Resident 33's medical record was reviewed on 9/11/23. A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 33 had a Brief Interview for Mental Status (BIMS) score of 9. A BIMS score of 8 to 12 indicated moderately impaired cognition. In addition, the MDS assessment documented that resident 33 had received scheduled, as need (PRN) pain medications, and non-medication interventions. A pain assessment interview was conducted. The Pain Assessment Interview documented that resident 33 had pain and the frequency was almost constantly. The pain made it hard for resident 33 to sleep at night and resident 33's day to day activities were limited due to pain. Resident 33's pain intensity on a numeric rating scale of 00 to 10 was documented as a 6. A care plan Focus initiated on 7/25/23, documented [Resident 33] has acute pain r/t [related to] polyneuropathy, cirrhosis of the liver, generalized weakness, limited mobility. A care plan Goal documented The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. The Interventions included: a. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. b. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. c. Notify physician if interventions were unsuccessful or if current complaint was a significant change from residents past experience of pain. The July 2023 Medication Administration Record (MAR) was reviewed. A physician's order dated 7/13/23, documented Tylenol Extra Strength Oral Tablet 500 MG [milligrams] (Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for pain. a. On 7/16/23, Tylenol was administered, pain score was 5. b. On 7/20/23, Tylenol was administered, pain score was 5. The August 2023 MAR was reviewed. a. A physician's order dated 8/16/23, documented oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth every 4 hours as needed for pain. Discontinued on 8/16/23. On 8/16/23, oxycodone was administered, pain score was 9. b. A physician's order dated 8/19/23, documented oxyCODONE HCl [hydrochloride] Oral Tablet 5 MG (Oxycodone HCl) Give 5 mg by mouth every 8 hours as needed for Pain for 5 Days. Discontinued on 8/24/23. i. On 8/19/23 at 4:15 PM, oxycodone was administered, pain score was 8. ii. On 8/20/23 at 12:21 AM, oxycodone was administered, pain score was 8. iii. On 8/20/23 at 8:48 AM, oxycodone was administered, pain score was 2. iv. On 8/20/23 at 5:40 PM, oxycodone was administered, pain score was 4. v. On 8/21/23 at 1:51 AM, oxycodone was administered, pain score was 8. vi. On 8/21/23 at 10:42 AM, oxycodone was administered, pain score was 7. vii. On 8/21/23 at 9:17 PM, oxycodone was administered, pain score was 5. viii. On 8/22/23 at 5:42 AM, oxycodone was administered, pain score was 5. ix. On 8/22/23 at 3:38 PM, oxycodone was administered, pain score was 7. x. On 8/23/23 at 4:30 AM, oxycodone was administered, pain score was 3. xi. On 8/24/23 at 7:08 AM,oxycodone was administered, pain score was 7. c. A physician's order dated 8/29/23, documented oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl) Give 5 mg by mouth every 6 hours as needed for Pain for 1 Day. Discontinued on 8/30/23. i. On 8/29/23 at 11:45 AM, oxycodone was administered, pain score was 8. ii. On 8/29/23 at 7:13 PM, oxycodone was administered, pain score was 8. iii. On 8/30/23 at 7:09 AM, oxycodone was administered, pain score was 6. iv. On 8/30/23 at 3:18 PM, oxycodone was administered, pain score was 8. The September 2023 MAR was reviewed. a. A physician's order dated 7/13/23, documented Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for pain. [Note: There were no administrations documented in September 2023.] b. A physician's order dated 7/13/23, documented Monitor pain level q [every] shift using (0-10 or FLACC [Face, Legs, Activity, Cry, Consolability] scale). Acceptable pain level: 4. Document ALL interventions being utilized for pain management: 0) No intervention indicated d/t [due to] no pain 1) Scheduled pain medication 2) PRN pain medication 3) PRN pain medication offered and refused 4) Repositioning 5) Rest 6) Ice/Heat 7) Other (specify in progress notes) 8) Resident refused all non-pharmacological interventions every shift. i. On 9/1/23 between 6:00 PM to 6:00 AM, pain score 8. ii. On 9/3/23 between 6:00 PM to 6:00 AM, pain score 8. iii. On 9/4/23 between 6:00 AM to 6:00 PM, pain score 7. iv. On 9/6/23 between 6:00 PM to 6:00 AM, pain score 10. v. On 9/9/23 between 6:00 AM to 6:00 PM, pain score 7. vi. On 9/10/23 between 6:00 AM to 6:00 PM, pain score 6. Interventions provided to resident 33 included scheduled pain medication, repositioning, and rest. vii. On 9/10/23 between 6:00 PM to 6:00 AM, pain score 8. Interventions provided to resident 33 included scheduled pain medication, repositioning, and rest. On 7/13/23, a Pain Assessment documented that resident 33 complains of severe constant pain. Resident 33's acceptable level of pain using the 0-10 pain scale was a 5. On 7/20/23 at 9:39 PM, an Orders - Administration Note documented Note Text: Tylenol Extra Strength Oral Tablet 500 MG Give 1 tablet by mouth every 6 hours as needed for pain pain to mid-right abdominal area. On 7/27/23 at 9:30 PM, an Orders - Administration Note documented Note Text: Monitor pain level q shift using (0-10 or FLACC scale). Acceptable pain level: 4. Document ALL interventions being utilized for pain management: 0) No intervention indicated d/t no pain 1) Scheduled pain medication 2) PRN pain medication 3) PRN pain medication offered and refused 4) Repositioning 5) Rest 6) Ice/Heat 7) Other (specify in progress notes) 8) Resident refused all non-pharmacological interventions every shift. The notes section documented right side of abdomen. On 8/5/23 at 9:01 PM, an Orders - Administration Note documented Note Text: Monitor pain level q shift using (0-10 or FLACC scale). Acceptable pain level: 4. Document ALL interventions being utilized for pain management: 0) No intervention indicated d/t no pain 1) Scheduled pain medication 2) PRN pain medication 3) PRN pain medication offered and refused 4) Repositioning 5) Rest 6) Ice/Heat 7) Other (specify in progress notes) 8) Resident refused all non-pharmacological interventions every shift. The notes section documented resident complains of chronic low abdominal pain. On 8/16/23, a physician's order documented oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth every 4 hours as needed for pain. The order had a discontinue date of 8/16/23 at 7:22 PM. The facility MD documented a reason for discontinue was Not needed at this time. On 8/17/23 at 3:21 PM, a Health Status Note documented Note Text: DON [Director of Nursing] spoke to [name removed] NP [Nurse Practitioner] with [name of clinic removed] to clarify abx [antibiotic] orders. DON also asked if [name removed] NP would escribe resident's pain medication (Oxycodone 5mg po [by mouth] Q4h [hours] PRN) to [name of pharmacy removed] so they could deliver medication to facility. DON spoke to [name of pharmacy removed] to confirm receipt of escribed order, pharmacy confirmed. Both medications should be sent out with the medication delivery tonight. Provider is aware. On 8/17/23, a physician's order from the local clinic documented oxycodone 5 mg tablet every four hours PRN for pain. [Note: The physician's order was not initiated.] On 8/17/23 at 9:13 PM, an Orders - Administration Note documented Note Text: Monitor pain level q shift using (0-10 or FLACC scale). Acceptable pain level: 4. Document ALL interventions being utilized for pain management: 0) No intervention indicated d/t no pain 1) Scheduled pain medication 2) PRN pain medication 3) PRN pain medication offered and refused 4) Repositioning 5) Rest 6) Ice/Heat 7) Other (specify in progress notes) 8) Resident refused all non-pharmacological interventions every shift. The notes section documented complains of achy chronic pain with right leg. On 8/19/23 at 4:09 PM, a Health Status Note documented Note Text: Resident reported pain 9/10 related to his TheraSphere treatment, MD have been notified and received order to start Oxycodone 5 mg TID [three times a day] PRN x 5 days, resident has been notified and first dose have been administered. On 8/19/23 at 4:11 PM, a physician's order documented oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl) Give 5 mg by mouth every 8 hours as needed for Pain for 5 Days. On 8/21/23 at 2:20 AM, a Health Status Note documented Note Text: Patient compliant with oral ABX, and pain medication q 8 hrs [hours]. Understanding that it is PRN and only available every 8 hrs when requested . No evidence of infection. Patient states a lot of pain, No evidence FLACC to back it up. Teach patient that the pain medication is only available for 5 days. He understands. Kept waking up and asking for the pain med [medication]. Kept reminding him when it was available. On 8/26/23 at 10:51 PM, an Alert Note documented Note Text: Resident states he is still having extreme pain to abdomen (rubbing his upper abdomen from sided to side) d/t his recent theraspere procedure. No S/S [signs or symptoms] of facial grimacing, guarding, difficulty repositioning or ambulating. Notified management and [name of facility MD removed]. On 8/29/23 at 11:25 AM, a Health Status Note documented Note Text: Patient reported still having pain rated 8/10 from the TheraSphere treatment, [name of facility MD removed] was notified, received order from her to contact Radiology at [name of clinic removed] to follow-up with patient's pain concern. Nurse talked to [name removed], NP who believes patient's pain should be improving by now and believes his pain might be due to something else other than theraspere, she ordered one day of oxycodone 5 mg PO x q6h PRN and recommends for patient to discuss his pain with the hepatic team on tomorrow's appointment, House MD and resident have been notified and nurse also discuss with patient NP's recommendation of discussing this concern with the hepatic team, patient stated understanding and is aware of tomorrow's appointment. On 8/29/23 at 11:33 AM, a physician's order documented oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl) Give 5 mg by mouth every 6 hours as needed for Pain for 1 Day. On 8/30/23 at 4:24 PM, a Health Status Note documented Note Text: Pt [Patient] had appointment w/ [with] [name of doctor removed] for a liver follow-up. Ultrasound ordered and scheduled d/t resident's abd [abdomen] pain. New prescription sent to pharmacy for Rifaximin. Provider recommends protein shakes TID in addition to small, frequent meals. Resident referred to pain specialist d/t frequent pain. Orders entered for endoscopy/colonoscopy pre-procedure protocol and ultrasound. Protocol discussed with staff and resident to ensure compliance. [Name of facility MD removed] notified. On 8/30/23 at 8:39 PM, an Orders - Administration Note documented Note Text: Monitor pain level q shift using (0-10 or FLACC scale). Acceptable pain level: 4. Document ALL interventions being utilized for pain management: 0) No intervention indicated d/t no pain 1) Scheduled pain medication 2) PRN pain medication 3) PRN pain medication offered and refused 4) Repositioning 5) Rest 6) Ice/Heat 7) Other (specify in progress notes) 8) Resident refused all non-pharmacological interventions every shift. The notes section documented Unable to get a response on pain at this time. Resident is asked to be left alone and responded with vulgar language. On 9/3/23 at 8:09 PM, an Orders - Administration Note documented Note Text: Monitor pain level q shift using (0-10 or FLACC scale). Acceptable pain level: 4. Document ALL interventions being utilized for pain management: 0) No intervention indicated d/t no pain 1) Scheduled pain medication 2) PRN pain medication 3) PRN pain medication offered and refused 4) Repositioning 5) Rest 6) Ice/Heat 7) Other (specify in progress notes) 8) Resident refused all non-pharmacological interventions every shift. The notes section documented pt refused Tylenol that was offered. suggested sleep and move positions. On 9/6/23 at 9:40 PM, an Alert Note documented Note Text: 2140 [9:40 PM] Patient complains of pain 10/10 to right abdominal area as he points to several areas on the right side of his abdomen. Patient states he can not handle the pain anymore and does not want to spend another night at [name of facility removed] without getting something for his pain. Vitals- 117/78 BP [blood pressure], 99 P [pulse], 16 R [respirations], O2 [oxygen] Sats [saturations] 99% RA [room air] Patient said he would go to [name of hospital removed] or [name of hospital removed]. Notified [name of facility MD] and DON. On 9/7/23, a Referral To Physicians And Clinics Form documented, Resident returned from ER [Emergency Room] on 9/7/2023 @ 0650 [6:50 AM]. No paperwork was sent back to our facility from Hospital ER. Resident reports to nurse that 'they drained fluid from my stomach' but is unsure of how much. Provider was notified. On 9/10/23 at 9:30 PM, a Health Status Note documented Note Text: Resident reported to day shift nurse that he was having severe abdominal pain that could not be relieved. Day shift nurse reported resident's concern to provider. Night shift reported to provider that resident wanted to go to the ER. Provider approved this request. On 9/10/23 at 9:45 PM, a Transfer/Discharge Report documented Pt is showing increased s/s of Jaundice. Resident has increased abdominal pain. Bowel sounds WNL [within normal limits]. Abdomen more rigid, tender. Pain 9/10 reported by resident. On 9/12/23 at 10:38 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 33 went to the hospital Sunday evening, 9/10/23, mostly for pain. RN 1 stated she spoke with the hospital yesterday and the hospital stated that resident 33 was admitted for observation. RN 1 stated the hospital did a paracentesis on resident 33 and RN 1 thought they had removed a half liter of fluid and resident 33's pain did not improve. RN 1 stated that she spoke to the hospital today and they were going to do another paracentesis and resident 33 would be coming back to the facility. On 9/13/23 at 12:27 PM, an interview was conducted with RN 2. RN 2 stated that communication with the facility MD was done through an app called WhatsApp. RN 2 referred to the WhatsApp messages and stated on 9/10/23 at 12:23 AM, the LPN had messaged the facility MD regarding resident 33 complaining of abdomen pain, tenderness right lower quadrant, active bowel sounds times four, complains of stabbing pain, nausea vomiting, and loss of appetite. On 9/10/23 at 3:04 PM, the facility MD responded was [resident 33] okay. [Note: The response from the facility MD was two hours and 41 minutes after the LPN sent the initial message.] On 9/10/23 at 6:43 PM, the LPN responded that no resident 33 was still feeling awful consistent complaints. [Note: The LPN responded three hours and 22 minutes after the facility MD responded.] On 9/10/23 at 7:18 PM, the facility MD responded did resident 33 feel bad enough to need to go to the ER again. [Note: Resident 33 was sent to the ER at 9:45 PM, nine hours and 36 minutes after the initial message to the facility MD.] RN 2 stated that he had sent resident 33 to the ER at that time. RN 2 stated that resident 33 had Tylenol and gababentin available for pain. RN 2 stated resident 33 had oxycodone after a procedure and the oxycodone was discontinued per the order. RN 2 stated there was another order that was given for the oxycodone by resident 33's doctor but the order was only for a certain amount of days. RN 2 stated that the oxycodone did help resident 33's pain per the resident. RN 2 stated that resident 33 had complained about pain but not in the areas that he did on Sunday, 9/10/23. RN 2 stated that resident 33 was given Tylenol and nonpharmalogical interventions for pain. RN 2 stated on Sunday, 9/10/23, resident 33 was very verbal and grimacing and RN 2 knew something was bad. RN 2 stated that an initial order for oxycodone was created but it was post procedure and the facility MD reached out wanting to know if resident 33 still needed the oxycodone. RN 2 referred to the WhatsApp message and stated on 8/18/23, the facility MD responded Don't put on order unless he needs that. RN 2 further stated that around 8/18/23, resident 22 was definitely not in the pain he was in on Sunday. On 9/13/23 at 12:52 PM, an interview was conducted with the DON. The DON stated the oxycodone order was for the therasphere procedure that resident 33 had due to post procedure pain. The DON stated a short term order for the oxycodone was for four days and the oxycodone was not scheduled. The DON stated that the Hepatology clinic sent the referral out for the pain specialist. The DON stated that she was not sure where the paperwork was sent for the pain specialist referral and she had not heard anything. The DON stated that she had spoke to the therasphere provider and they stated it would be unusual to have pain past the four days for the therasphere. On 9/13/23 at 1:03 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated if a resident had pain and there were not orders or sufficient orders to address pain the staff were to contact the provider. The RNC stated the WhatsApp was for nonurgent issues. The RNC stated if the provider did not respond the staff should reach out again or call the provider in order to get a response. The facility Pain Assessment and Management policy was reviewed. Purpose The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident ' s goals and needs and that address the underlying causes of pain. Steps in the Procedure Recognizing Pain 1. Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. 2. Possible Behavioral Signs of Pain: a. Verbal expressions such as groaning, crying, screaming; b. Facial expressions such as grimacing, frowning, clenching of the jaw, etc.; c. Changes in gait, skin color and vital signs; d. Behavior such as resisting care, irritability, depression, decreased participation in usual activities; e. Limitations in his or her level of activity due to the presence of pain; f. Guarding, rubbing or favoring a particular part of the body; g. Difficulty eating or loss of appetite; h. Insomnia; and i. Evidence of depression, anxiety, fear or hopelessness. 3. Possible Physiological Signs of Pain: a. Increased blood pressure; b. Tachycardia; c. Increased respirations; and d. Diaphoresis. 4. Ask the resident if he/she is experiencing pain. Be aware that the resident may avoid the term pain and use other descriptors such as throbbing, aching, hurting, cramping, numbness or tingling. 5. Review the medication administration record to determine how often the individual requests and receives pain medication, and to what extent the administered medications relieve the resident ' s pain. Assessing Pain: 1. During the comprehensive pain assessment gather the following information as indicated from the resident (or legal representative): a. History of pain and its treatment, including pharmacological and non-pharmacological interventions; b. Characteristics of pain: (1) Intensity of pain (as measured on a standardized pain scale); (2) Descriptors of pain; (3) Pattern of pain (e.g., constant or intermittent); (4) Location and radiation of pain; and (5) Frequency, timing and duration of pain. c. Impact of pain on quality of life; d. Factors that precipitate or exacerbate pain; e. Factors and strategies that reduce pain; and 2. Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident ' s cognitive level. 3. Discuss with the resident (or legal representative) his or her goals for pain management and satisfaction with the current level of pain control. Implementing Pain Management Strategies: 1. Non-pharmacological interventions may be appropriate alone or in conjunction with medications. Some non-pharmacological interventions include: a. Environmental - adjusting the room temperature, smoothing the linens, providing a pressure-reducing mattress, repositioning, etc.; b. Physical - ice packs, cool or warm compresses, baths, transcutaneous electrical nerve stimulation (TENS [transcutaneous electrical nerve stimulation]), massage, acupuncture, etc.; c. Exercise - range of motion exercises to prevent muscle stiffness and contractures; and d. Cognitive or Behavioral - relaxation, music, diversions, activities, etc. 2. Pharmacological interventions (i.e., analgesics) may be prescribed to manage pain, however they do not usually address the cause of pain and can have adverse effects on the resident (e.g., drowsiness, increased risk of falling; loss of appetite). 3. Addiction to narcotic analgesics is not likely if used appropriately for moderate to severe pain. 4. The physician and staff will establish a treatment regimen based on consideration of the following: a. The resident's medical condition; b. Current medication regimen; c. Nature, severity and cause of the pain; d. Course of the illness; and e. Treatment goals. 5. Strategies that may be employed when establishing the medication regimen include: a. Starting with lower doses and titrating upward as necessary; b. Administering medications around the clock rather than PRN; c. Combining long-acting medications with PRNs for breakthrough pain; d. Combining several analgesics or analgesics with other drug classes; and e. Reducing or preventing anticipated adverse consequences of medications (e.g., bowel regimen to preventing constipation related to opioid analgesics). 6. Implement the medication regimen as ordered, carefully documenting the results of the interventions. Reporting Report the following information to the physician or practitioner: 1. Significant changes in the level of the resident ' s pain; 2. Adverse effects from pain medications, such as gastrointestinal bleeding from nonsteroidal antiinflammatory drugs (NSAIDs [Non-steroidal anti-inflammatory drugs]), anorexia, confusion, lethargy, severe constipation, or ileus related to opioids; and/or 3. Prolonged, unrelieved pain despite care plan interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Sexual Abuse 1. Resident 11 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included of cirrhosis of liver, disorder of urea cycle metabolism, schizoaffective disorder, dementia, alcohol dependence, stimulant dependence, viral hepatitis C and benign prostatic hyperplasia. Review of the facility final abuse investigation report documented that an incident occurred on 8/18/21 at 7:45 AM. The description of the incident was Certified Nurse Assistant (CNA) 1 walked into resident 11's room and saw resident 20 touching resident 11's bare buttocks. Resident 11 had his underwear around his knees. Resident 11 reported that before the CNA walked into his room, resident 20 was touching himself and pressed himself against resident 11. The two residents were immediately separated and monitored by staff. The report documented the pertinent resident history for resident 11 was that resident 11 was a [AGE] year-old male resident with diagnoses including, but not limited to: schizoaffective disorder (bipolar type), unspecified dementia with behavioral disturbance and Chronic Obstructive Pulmonary Disease (COPD). Resident 11 was originally admitted on [DATE], with a recent readmission on [DATE] after a hospital stay. Resident 11 was cognitively impaired and ambulated on foot. Resident 11 was set-up or clean-up assistance with most Activities of Daily Living (ADLs). The report documented resident 20 was a [AGE] year-old male resident with diagnoses including, but not limited to: mental disorder (not otherwise specified), unspecified psychosis not due to a substance or known physiological condition, and type 2 diabetes mellitus. Resident 20 was admitted on [DATE]. Resident 20 was cognitively impaired and ambulated on foot. Resident 20's ADL needs ranged from set-up or clean-up assistance to dependent. The report documented the action taken to investigate the incident was to inform the local police department, State Survey Agency, Adult Protective Services (APS), the Ombudsman, resident 11's guardian, and the physician. The report documented that an officer with the local PD responded to investigate the incident. Upon questioning resident 11, resident 11 told the police officer that everything that happened was consensual. Resident 11 stated that he became nervous when staff questioned him because he did not want to go back to the hospital, which caused him to falsely report being the victim. The findings of the facility investigation was that the allegation of sexual abuse was not substantiated. On 8/18/21 at 11:39 AM, the APS report documented an incident of sexual abuse. The report documented that under safety concerns Called Reporter. It was stated that initially when nurse talked to [resident 11], he said he felt he was touched inappropriately. He told perp (perpetrator) to stop and to leave. He has been on his baseline this morning. As of now he hasn't had any acute change. [Resident 20] has a history of this. [Resident 20] is a registered sex offender. He has unspecified mental disorder and psychosis. He is cognitively impaired as well. He has a lower IQ level. He has schizoaffective disorder and unspecified dementia. [Resident 11] has had some behaviors stating that he would like to be a woman and that he is bisexual. It seems like it could have been consensual that he is now stating that it was not willful since they were caught. Resident 11's medical records were reviewed. Review of resident 11's physician orders revealed the following: a. Lithium Carbonate Tablet, give 600 milligrams (mg) by mouth at bedtime related to schizoaffective disorder, bipolar type. b. Clozapine Tablet, give 225 mg by mouth at bedtime related to schizoaffective disorder, bipolar type. c. Olanzapine Tablet, give 25 mg by mouth at bedtime related to schizoaffective disorder, bipolar type. d. L-Carnitine Tablet, give 1500 mg by mouth two times a day for Organic Brain Syndrome. e. Lactulose, give 60 milliliter (ml) by mouth two times a day. The order was initiated on 2/22/17 and discontinued on 7/7/21. Review of resident 11's Treatment Administration Record (TAR) for August 2021 documented behavior monitoring for number of delusions every shift. Prior to the incident on 8/18/21, resident 11 had 53 episodes of delusions documented from 8/5/21 to 8/17/21. Resident 11 had 54 episode of delusions documented from 8/18/21 to 8/31/21. The Hospital History and Physical dated 6/24/21 documented Altered Mental Status in setting of significant psychiatric medication changes with underlying schizophrenia leading diagnosis was psychosis, questionable delirium, minor contributions from electrolyte derangements, potential pneumonia and underlying liver disease. Clozapine was continued at 125 mg with a goal of 350. Resident 11 was admitted on an involuntary basis to a locked secure unit due to safety concerns and the plan was to continue with medication management. The Hospital Discharge orders on 8/4/21 stated to change Lactulose 10 gram/15 ml solution, give 15 mls by mouth daily for 30 days for constipation, liver cirrhosis. The order was not initiated upon re-admission to the facility. Review of resident 11's laboratory results revealed that on 5/21/21 the ammonia level was 145, with a reference range of 40-200. On 3/10/21 the Annual MDS Assessment documented under Section C for Cognitive Patterns that resident 11's Brief Interview for Mental Status (BIMS) score was a 7 which indicated severely cognitively impaired. The assessment documented under Section E for Behavior that resident 11 had Delusions which were defined as misconceptions or beliefs that were firmly held, contrary to reality. Resident 11 was also documented to have verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others). The frequency of these symptoms were scored at a 2 which indicated that the behavior of that type occurred 4 to 6 days, but less than daily during the look back period. Resident 11 was also documented to have other behavioral symptoms (E0200C) not directed towards others (e.g., physical symptoms such as hitting, or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbally vocal symptoms like screaming, disruptive sounds). Resident 11 was assessed as rejecting evaluation or care such as blood work, taking medications, and ADL assistance. This behavior occurred daily during the look back period. On 8/17/21 the admission MDS Assessment did not assess the resident 11's BIMS under Section C for Cognitive Patterns. The assessment documented under Section E for Behavior that resident 11 had Delusions which were defined as misconceptions or beliefs that were firmly held, contrary to reality. On 8/4/21 at 2:55 PM, a BIMS Assessment in progress was documented by the Director of Nursing (DON) under the standard assessments with a score of 12, moderately cognitively impaired. On 7/30/21 a Preadmission Screen Resident Review (PASRR) Level II for Mental Illness documented under Section 2: Medical Justification and Intensity of Services Needed in Nursing Facility the following: Resident 11 had a history of cognitive deficits and scored a 19/30 on the Montreal Cognitive Assessment (MoCA) in the past (2016), which would indicate mild cognitive impairment. He had an extended stay (15 months) at the state psychiatric hospital due to a severe exacerbation of symptoms of schizophrenia. He was prescribed Clozaril to treat schizophrenia but had a gradual dose reduction to 25 mg since January 2021 and eventually was discontinued in May 2021 due to concerns for increased ammonia levels and liver function. On 6/1/21 pt (patient) was noted to have pressured/garbled speech which got increasingly worse. Risperdal was started on 6/2/21. On 6/5/21 he had new onset incontinence, was unable to ambulate up stairs and was disoriented. He became increasingly delusional and perseverative; he thought he was married to one of the staff members. Due to both worsening medical and psychiatric function he was taken to the ER at [local hospital] on 6/5/21 for evaluation. He was admitted to the medical floor due to concerns for community-acquired pneumonia, AMS (altered mental status), and electrolyte imbalance. He was restarted on Clozaril on 6/5/21 at 25 mg and was titrated up to 125 mg as he remained on the medical floor until 6/24/21 due to ongoing medical issues. He was then transferred to [name omitted] for continued Clozaril titration (currently at 225 mg/day) and for management of severe manic and psychotic sxs (symptoms). Upon arrival at [name omitted] he was notably disorganized, psychotic, and grandiose. He was having persistent problems with incontinence and being unable to care for himself. He was defecating in inappropriate places for a time until his psychiatric sxs were more well managed. He continues to demonstrate a short attention span and poor concentration. He has a history of cognitive deficits felt to be d/t (due to) hepatic encephalopathy and substance use/abuse. His prior PASRR evaluation indicate pt underwent neuropsychological testing while in the [state psychiatric hospital] which indicated 'slowed processing speed, executive functioning impairment with difficulty with sequencing, shifting attention mental flexibility, abstraction, and maintaining two trains of thought simultaneously. He became agitated and quickly fatigued when presented with complex or lengthy materials/tasks. He had mild difficulty with perceptual discrimination, fluid reasoning, and memory'. The current psychiatric functioning documented a telephone interview was conducted with resident 11. When asked what happened that led to his hospitalization he stated the following: 'I was in a base camp and got caught in a snow slide, it was a bad experience. My daughter told me to get up, I was passing out, it was like 80 below zero. I've had a tough time getting over it'. It is unclear as to why he reported this, as none of it is accurate. Review of resident 11's Letter of Guardianship on 1/21/16 documented that guardianship was appointed to the petitioner who was resident 11's family member. The findings of the facts for the court determination were that resident 11 suffered from paranoid schizophrenia and was not capable of managing his own affairs. Resident 11 had been placed in a psychiatric ward at the local hospital and was transferred to the State Psychiatric Hospital and was not expected to become mentally stable such that he could manage his own affairs. Legal grounds for guardianship existed because resident 11 was incapable of managing his own financial affairs or care physically for himself and was deemed a protected person as defined by state law. The Conclusion of Law was that the petitioner was appointed as Guardian over resident 11 until he was mentally capable of managing his own affairs or such other time as was deemed appropriate by the court. Review of the resident 11's progress notes revealed the following: a. On 1/5/21 the note documented received order to decrease Clozapine to 25 mg by mouth two times a day. b. On 1/9/21 at 6:00 AM to 6:00 PM weekly, the note documented that resident 11 was alert and oriented times 3 (person, place, time); continent of bowel and bladder; medication and treatment compliant; pleasant, cooperative, friendly, interacts with other residents. c. On 1/16/21 the note documented that resident 11 was alert and oriented times 2-3. d. On 5/29/21 the note documented that resident 11 was alert and oriented times 3. Resident 11 was continent of bowel and bladder, socialized well with others, and talked to his family often. e. On 6/1/21 the note documented that resident 11 had increased restlessness, euphoric behaviors, loud and exaggerated mood. The physician was notified and an order was received to start Risperdal 0.5 mg by mouth two times a day. f. On 6/4/21 the note documented that resident 11 had increased restlessness; loud and exaggerated mood; delusional thoughts noted; resident 11 stated he was marrying a staff member and listed other staff to be in the wedding; resident 11 was speaking rapid and mumbled. g. On 6/5/21 at 7:10 AM, the note documented that resident 11 went to another resident's room, yelled and threatened to steal a ring because he needed it to get married; staff intervened, removing from room with much encouragement; resident 11 did not want to take medication and started swinging and punched a staff member; resident 11 was separated from others to calm down. h. On 6/5/21 at 10:15 AM, the note documented that resident 11's guardian called and stated he called me at 4 in the morning, rambling and making no sense. The guardian requested to speak to the physician about the medication change when resident 11 was stable. i. On 6/5/21 at 10:30 AM, the note documented received order to start Clozapine 25 mg by mouth every day. j. On 6/5/21 at 4:15 PM, the note documented resident 11 continued to be restless and agitated; will ask staff for assistance, and when staff attempts to assist resident 11 shouts, was verbally aggressive while swinging at staff. k. On 6/5/21 the weekly note documented patient in decline, aggressive and restless, unsteady on feet, speech slurred, and long term memory loss. m. On 6/6/21 at 4:45 AM, the note documented that the guardian was called, the patient was in decline, guardian wants full treatment. Patient was sent by ambulance service. n. On 8/6/2021 at 3:44 AM, the note documented that resident 11 was restless with some confusion noted. o. On 8/7/2021 at 2:41 PM, the note documented that resident 11 was alert and oriented to person, place and time. p. On 8/9/2021 at 3:25 PM, the physician note documented that resident 11 was a [AGE] year old male with schizoaffective disorder bipolar type who was admitted to the hospital with worsening psychosis. He was initially on the medical floor where he was treated for electrolyte imbalance and pneumonia and then transferred to the psych unit 6/24 where he stayed until his recent return to [name of facility]. He underwent medication adjustments. He is currently on zyprexa, lithium and clozaril. Staff report he is still not at his normal baseline but behaviors are currently manageable. Physical Exam documented alert, older male, clear delusional - tells me he is [NAME] and Elvis [NAME] and Lady Gaga. q. On 8/10/2021 at 10:15 PM, the note documented that the Registered Nurse (RN) attempted to give the resident his bedtime medicine. The RN knocked on the door, pt said wait a second, then the RN heard a lot of urine spraying on the floor. Upon opening the door the RN discovered a large urine puddle on the floor. The RN educated the resident on using the toilet that was near by and that the bedroom was not a toilet. The resident agreed. r. On 8/11/2021 at 4:14 PM, the note documented that the resident defecated on the bathroom floor. s. On 8/18/2021 at 11:54 AM, the note documented that the nurse received report from the CNA, I went to answer the call light in Res. (resident) room. When I entered the room Res. was reaching over to where his call light was and had his underwear down by his knees. Another res. was behind him touching his butt and Res. was trying to push him away and asking him not to do that. When I walked in I asked other res. to leave the room. The RN continued to document Res. states that other res. entered his room and was playing with himself, Res. reports he asked other res. to stop and reports that other res. pressed himself against Res; MD (medical doctor), DON and guardian notified. It should be noted that the note was located at the top of the progress notes out of sequential order with a view draft notation at the side. t. On 8/18/2021 at 10:23 AM, the note documented that the guardian was notified of the incident. The guardian asked if the other resident would be removed from the facility. The guardian was informed that the physician and administration were notified of the incident. u. On 8/18/2021 at 1:52 PM, the note documented that the local police department responded to investigate the resident to resident incident. The officer questioned the resident and the resident told him that everything that happened was consensual. Resident 11 stated that he became nervous when staff questioned him because he did not want to go back to the hospital, which caused him to falsely report being the victim. v. On 9/8/2021 at 6:54 PM, the note documented that resident 11 requested to be placed in the same room as another resident. Resident 11 stated he and the other resident would like a 2 bed room. Spoke to resident 11's guardian about request and permission for the room change was given. w. On 9/30/2021 at 5:47 PM, the note documented pt has had 4 physical contacts on day shift . AT BREAKFAST pt charged at CNA from the back pushed the CNA that was assisting another resident. Ten min (minutes) later he came back to the same CNA. Pt attacked the same CNA from behind again and reached around and hit the CNA in the lips. RN asked pt what was going on. he states states 'I did it because he don't believe in god'. On a bus ride around lunch he threw a sprite on the back of the activities director. During evening meal Pt attached (sic) another resident that was peacefully eating his dinner. He kicked the bed side table that was holding his food and yelled at him. RN and CNAs held back both residents from fighting. pt was sent to his room to eat his dinner. Pt has had several verbal issues today with hallucinations and has attention seeking behavior. pt has slammed his room door 6 [times] on day shift. x. On 10/1/2021 at 6:28 PM, the note documented Spoke with resident regarding behaviors and verbal/physical aggression. Educated resident about facility policy regarding inappropriate behaviors. Resident stated he would not physically touch or speak in an aggressive manor towards staff and residents. I let resident know that if this behavior happens again that he would not be able to stay at the facility. y. On 10/2/2021 at 10:00 AM, the note documented Patient was standing in the dining room at snack time when all of sudden he put a staff member into an arm choke, patient redirected and let aide go, after a couple minutes resident was holding a soda can and smashed the can into a resident's mouth, both patients started yelling and swearing at each other, patient redirected to his room, followed by staff to monitor him for safety, patient slamming door continuously, MD, DON, administrator and guardian have been notified of incident. Received order from MD to transfer patient to the ER at the [name of local hospital]. Ambulance have been notified to come pick up resident. On 8/18/21 at 10:07 AM, resident 11's incident report documented that the CNA entered this resident's room to bring him sugar that he had requested earlier. CNA observed [resident 20] standing behind [resident 11], touching [resident 11's] bare buttocks. [Resident 11's] pants were down by his knees. Upon being questioned by CNA about what was going on, [resident 11] reported that [resident 20] had been touching himself before the CNA came into the room and pressed himself against [resident 11]. None of this was observed by the CNA and the CNA did not hear anything being said by either resident prior to entering the room. The immediate action taken was that the CNA removed resident 20 from the room and alerted the nurse. Review of resident 11's care plan revealed a focus area for expressed/demonstrated a desire to participate in sexual activity with a certain resident that was initiated on 8/18/21. A goal was that he would not experience adverse outcomes related to the sexual activity e.g. sexual abuse, sexually transmitted diseases (STD), and unintentional pregnancy. It should be noted that the goal of unintentional pregnancy was not person centered or realistic as both parties involved were male. Interventions identified were to explain that the sexual activity should occur in a private setting to honor the rights of other residents and provide a private setting for sexual activity as needed. The intervention was initiated on 10/25/21. It should be noted that the resident was discharged from the facility on 10/2/21. Review of resident 11's Sexual Activity Capacity for Consent assessment that was conducted on 8/18/21 at 3:28 PM, documented that capacity was defined at the ability to make desires known and the ability to alert others when not wanting to participate in an activity. The assessment stated that capacity was not dependent upon competency. The assessment documented under interaction patterns, Resident interacts with other residents on a daily basis. He is friendly and social with others at baseline and able to choose when and with whom he interacts. Resident only notified staff today of his desire to engage in an intimate relationship with another resident. He has not been observed by staff to interact with others in a romantic way previously. Resident did not appear distressed during the interaction. His witnessed interaction with the other resident with whom he expressed a desire to be intimate did not appear that he was unwilling and he did not seek out or ask for help during the interaction. The resident's body language was documented as calm/happy/relaxed facial expressions and body posture, friendly/cooperative behavior, and interacts as usual with others. The resident was documented as able to demonstrate the ability to answer yes/no questions appropriately, able to mobilize without assistance, and able to alert others when wishing to stop an activity. Resident expressed that he is bisexual and desires to engage in an intimate relationship w/ (with) another. He is independently ambulatory, capable of expressing his thought content and asking for help if desired/needed. IDT (interdisciplinary team) believes this all affirms resident's capacity w/ decision making in this matter. The assessment documented that the resident had the capacity to make decisions to engage in sexual intimacy with others. The assessment was completed and signed by the facility DON. Review of the facility abuse policy defined sexual abuse as non-consensual sexual contact of any type with a resident. The facility policy and procedure on abuse did not address how the facility would identify all the details of how capacity to consent to a sexual contact would be determined, by whom and when. On 11/09/21 at 11:25 AM, an interview was conducted with RN 1. RN 1 stated that she recalled that resident 20 had a sexual behavior with resident 11 but that it was with consent. RN 1 stated that resident 11 consented to the sexual encounter, but that she was not sure how that was determined. RN 1 stated that it was reported to her on shift report that it was a consensual sexual interaction. RN 1 stated that she had never witnessed any incidents between resident 11 and resident 20. On 11/09/21 at 12:42 PM, a telephone interview was conducted with resident 11's guardian. The guardian was asked about the incident between resident 11 and resident 20 on 8/18/21 with the sexual contact. The guardian stated that the behavior was out of character for resident 11. The guardian stated that resident 11 was not doing well mentally and had just had a recent hospitalization at the psychiatric hospital before the incident occurred. The guardian attributed the hospitalization due to the dose reduction of Clozapine. The guardian stated that the medication was changed and resident 11 was mentally struggling after that medication change. The guardian expressed frustration and anger at not being involved in the decision to reduce the antipsychotic medication, and stated that resident 11 had been on it for a long time and had been doing well. The guardian stated that resident 11 was released from the psychiatric hospital prematurely, but they had started him back on the Clozapine. The guardian stated that resident 11 was currently back at the psychiatric hospital receiving treatment. The guardian stated that on the date of the incident he was informed by the facility that resident 11 had been violated, then management called a week later and said it was consensual. The guardian stated that it was either the facility Administrator or the DON that called him, but he can not recall who. The guardian again stated that resident 11, mentally he was not doing well and was struggling after the medication change. The guardian stated that when resident 11 was re-admitted to the facility in August 2021 he was not capable of making rationale judgements. The guardian stated that he did not think that resident 11 had the ability to consent to the sexual contact. The guardian stated that at the time resident 11 was having delusions of being the [NAME] and was not aware of who the guardian was. He was not thinking straight then. The guardian stated that resident 11 was a paranoid schizophrenic since he was [AGE] years old and that he had spent over a year at the state mental hospital for treatment. The guardian stated that the facility reported that it was consensual sexual contact. The guardian stated that was not consistent with resident 11's behavior. The guardian stated that resident 11 was not gay, had never been with another man ever, had never had a homosexual encounter ever, has wanted to dress up as a woman, but that he was not gay. The guardian stated that at the time of the incident resident 11's room was located next to the nurse's station and directly next to the community restroom. The guardian stated that everybody went to the bathroom and sometimes walked into resident 11 room, which was a private room. The guardian stated that he was not aware of the police being involved in the incident. The guardian stated that resident 11's manic behaviors continued to escalate and he was violent to staff, and having grandiose behavior. The guardian stated that resident 11 was eventually sent to the hospital again. On 11/09/21 at 1:56 PM, an interview was conducted with the facility Administrator. The Administrator stated that he was not present at the time of the incident, but was transferred to the facility the following day. The Administrator stated that the previous Administrator conducted the facility investigation into the incident between resident 11 and resident 20. The Administrator stated that APS came to the facility the following week after the incident. The Administrator stated that APS concluded that their investigation coincided with the report that he was scared and wanted to come out as being bisexual. It should be noted that the APS report dated 8/18/21 at 11:39 AM documented that the facility was contacted by telephone and reported [Resident 11] has had some behaviors stating that he would like to be a woman and that he is bisexual. It seems like it could have been consensual that he is now stating that it was not willful since they were caught. The Administrator stated that they contacted the guardian and notified him of the incident and the guardian did not want to pursue it further. The Administrator stated that the police made the determination that the resident had the ability to consent to the sexual contact, but that the police officer did not have access to the resident's medical records and was not able to determine if resident 11 was capable of giving consent. The Administrator stated that the process for determining the resident's capacity to consent was to look at the medical diagnoses, look at the ability to make decisions, look at the resident's ability, obtain a MoCA score, obtain a BIMS score, and obtain the guardian consent as well. The Administrator stated that they currently were looking for a Social Service Worker (SSW) and the Administrator was filling that responsibility for now. The Administrator stated that the previous SSW was actually a Resident Advocate and was not licensed at all. The Administrator stated that she left the facility when the new company acquired the building in July 2021. The Administrator stated that their Licensed Clinical Social Worker (LCSW) consultant started last week and they did not have one at the time of the incident. The Administrator stated that resident 11 was not evaluated by social services prior to discharge from the facility. On 11/09/21 at 2:23 PM, an interview was conducted with the DON. The DON stated that she conducted the consent assessment at the time of the sexual activity between the resident 11 and resident 20. The DON stated that resident 11 and resident 20 had said that they had relations before when they were roommates upstairs. The DON clarified relations in the sense of sexual relations when they were roommates. The DON stated that resident 11 and resident 20 were roommates a couple of years ago. The DON stated that the police officer had come into the facility to investigate the incident and resident 11 stated that it was consensual. The DON stated that she interviewed resident 11 and he reported that they had a relationship. The DON stated that it was news to them from the police report. The DON stated that at first it was not the same report that was given from CNA 1. The DON stated that CNA 1 initially stated that she went into the room and saw resident 11 with his pants down and resident 20 was reaching towards resident 11's buttocks and resident 11 was say to go. The DON stated that she was working the day of the incident. The DON stated that resident 11 was not informed that the police were being called that it was automatic and part of their procedure. The DON stated that if she wanted to determine consent she would determine if the resident was cognitively able to make decisions on their own. Resident 11 had a guardian, the guardian was surprised. The DON stated that later the guardian was okay with it. The DON stated if they were able to make those decisions if they were competent. The DON stated that resident 11 was competent to make decisions. The DON stated resident 11 was impulsive, but he could tell you what he wanted to eat, if he needed to use the bathroom, and what he wanted to wear. The DON stated that resident 11 had previously been at the psychiatric hospital for some medication changes due to having more outburst, agitation and [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 4 was admitted to the facility on [DATE] with diagnoses which included anoxic brain damage, drug induced subacute dyskinesia, insomnia, and unspecified psychosis not due to a substance or known physiological condition. On 11/8/21 at 12:18 PM, resident 4 was observed outside smoking independently. Resident 4 stated that he did not want to be around anyone. On 11/8/21 at 1:11 PM, resident 4 was observed resting in bed in one of the two upstairs rooms in the facility. On 11/10/21, resident 4's electronic medical record review was completed. Nursing notes revealed the following: a. On 8/24/21 at 3:07 AM, revealed that at 2:18 AM, resident 4 was coming down the stairs then crash. He is collapsed on the stairs, not responsive or aware, half way up. Protect head, assist him to the floor pillow for head. He's breathing fast and steady and loud, not responsive . Seizure He's awake now, sits, up, states no pain when asked, responding normal . walks up the stairs, closely followed by aide in case he collapses again. Aide assists him to bed . opens the top door again stop him, have him sit on top step, he does Ask [resident 4] to go back to bed for a little while to recover. He does 245 [AM]. [resident 4] insists on a smoke, assist him down the stairs and aide assists him, also watches him, no further seizure activity. Monitor him walking up the stairs to bed. Encourage him to sleep for a while. vitals normalize. Acting like usual. Upstairs sleeping now. b. On 8/24/21 at 9:46 AM, resident 4 complained of pain to left shoulder and left ankle. The nurse noted new discoloration and some swelling on his left ankle, no deformities noted. c. On 8/24/21 at 4:04 PM, resident 4 returned from the Emergency Department. d. On 8/24/21 at 10:50 PM, resident 4 had a diagnosis of a fracture of the left humeral head. Resident 4 remained downstairs while recovering. e. On 8/26/21 at 7:33 PM, resident 4 was walking safely alone, and up the stairs, shadowed . The Emergency Department discharge paperwork from 8/24/21, page 3, revealed that Follow-up care consisted of Follow up with your healthcare provider, or as advised. A shoulder joint will become stiff if left in a sling for too long. Ask your doctor when it is safe to start range-of-motion exercises. Resident 4's care plan was reviewed and revealed the following: a. On 6/15/2020, resident 4 had a fall due to an unsteady gate. The interventions were to monitor and provide activities that promoted exercise and strength building. These were resolved on 11/7/21. b. On 11/6/21, a risk for falls focus was initiated for resident 4. c. On 11/6/21, a focus was added for behavior problem (verbal/physical aggression/resisting cares) r/t (related to) delusions, hallucinations, mental health problems associated with behavioral disturbances, fatigue, delirium, dementia. The goal was The resident will have fewer episodes of verbal and physical aggression weekly by review date. Resident 4's care plan was not updated after his seizure, though resident 4 had no previous seizure activity. No interventions were initiated to provide goals or interventions related to seizures. Resident 4's care plan was not updated after his fall on 8/24/21 with new interventions. Resident 4 had no assessments after the fall to determine his safety with climbing and descending stairs. Minimum Data Set (MDS) Assessments for resident 4 revealed the following: a. On 4/15/21, a quarterly MDS revealed that resident 4 required limited assistance with transfers, walking, dressing, eating, toilet use, personal hygiene, and bathing. b. On 9/27/21, a quarterly MDS revealed that resident 4 did not self-transfer, required supervision for walking, that resident 4 did not move off the unit location, required assistance with eating, physical assistance with personal hygiene, and was dependent for bathing. For walking, turning and transferring, resident 4 was not steady, but able to stabilize without staff assistance. c. On 11/2/21, a quarterly MDS revealed that resident 4 required supervision for bed mobility, was unable to transfer, required supervision when walking, had only left the unit once or twice with physical assistance, required set up help with dressing that only occurred once or twice, required two person physical assistance with eating that only occurred once or twice, supervision with toilet use, and set up for personal hygiene. Bathing did not occur. For walking, turning and transferring, resident 4 was not steady, but able to stabilize without staff assistance. A physical therapy progress note dated 6/29/21 revealed that resident 4 required assistance with standing, was able to walk sixty feet with support, and resident 4's lower extremities were weak with decreased gait and balance. Resident 4 had reached max rehab. A physician's order on 9/15/21 revealed that resident 4 required physical therapy after his injury. On 11/9/21 at 10:23 AM, CNA 3 was interviewed. CNA 3 stated that resident 4 seemed to walk fine and did not require supervision or assistance. CNA 3 stated that she did not know resident 4 had a seizure diagnosis. On 11/9/21 at 10:55 AM, CNA 4 was interviewed. CNA 4 stated that she received information about the residents' needs from the other CNAs. CNA 4 stated that she did not know of any special requirements for resident 4. On 11/9/21 at 10:31 AM, CNA 5 was interviewed with a translator application. CNA 5 stated that she did not know resident 4 had a seizure. CNA 5 stated that resident 4 had a room upstairs because he can walk. CNA 5 stated that resident 4 was not provided supervision or assistance with ambulating. On 11/10/21 at 8:07 AM, Registered Nurse (RN) 2 was interviewed. RN 2 stated that the orthopedic physician's report revealed that resident 4 would not return to full range of motion in his left arm. RN 2 stated that resident 4 had weakness when walking at times and had emotional and behavioral issues. RN 2 stated that resident 4 often came downstairs at night and asked for items, because he did not sleep well. On 11/10/21 at 3:45 PM, an interview was conducted with the Director of Nursing (DON) and Regional Nurse Consultant (RNC). The RNC stated that resident 4 had no seizure history before 8/24/21, but resident 4 had been taking Lamictal for mood stabilization. The RNC stated that resident 4 remained on the ground level of the facility until he was on Lamictal for one month. The RNC stated that the physician was informed after resident 4 moved back upstairs, and stated that the physician was not consulted about room changes. The RNC stated that she did not know if resident 4 had full range of motion. The CRN stated that the care plan was not updated to ensure the safety of resident 4 sleeping upstairs. The Director of Nursing (DON) stated that resident 4 wanted to return to sleeping upstairs, because he really wanted to be upstairs and liked his roommate. The DON stated that there was no assessment to determine if resident 4 was safe to sleep upstairs. The DON stated that resident 4's insurance would not pay for additional therapy. Based on observation, interview and record review it was determined, for 2 out of 28 sampled residents, that the facility did not ensure that the resident's environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance to prevent accidents. Specifically, a resident sustained multiple falls which resulted in facial lacerations. The incident will be cited at a harm level. The same resident had a successful elopement from the facility and sustained a fall. In addition, an another resident sustained a fall after a seizure which resulted in a fracture. Resident identifiers 4 and 15. Findings included: 1. Resident 15 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included epilepsy, contracture, brachial plexus disorder, mood disorder, neuralgic amyotrophy, and dementia. On 11/8/21 at 9:30 AM, resident 15 was observed sleeping in bed with the blankets pulled up over the head. On 11/8/21 at 10:00 AM, resident 15 was observed sleeping in bed with the blankets pulled up over the head. On 11/8/21 at approximately 12:30 PM, resident 15 was observed seated in their room on the bed eating lunch. On 11/08/21 at 12:53 PM, resident 15 was observed ambulating independently in the main dining area while returning from the smoking patio. A strong odor of cigarette smoke was noted on the resident. Resident 15 was greeted and replied with hello. Resident 15 did not answer any questions asked by this surveyor. Resident 15 was observed wearing a brace on the right wrist. The resident demonstrated that he could open and close both hands. Resident 15's hands were observed without any burns, cigarette ash or stains. No cigarette stains or burns were observed on the resident 15's clothing. Resident 15 ambulated back to his bedroom. A. Falls Resident 15's medical records were reviewed. Resident 15's physician orders revealed the following: a. Valproic Acid Solution 250 milligram (mg)/5 milliliter (ml), Give 500 mg by mouth at bedtime related to UNSPECIFIED CONVULSIONS. The order was initiated on 11/11/21. b. Donepezil Tablet, Give 5 mg by mouth at bedtime related to UNSPECIFIED DEMENTIA WITH BEHAVIORAL DISTURBANCE. The order was initiated on 11/11/21. c. WANDERGUARD: To be used at all times due to elopement risk. Device located on left ankle. Verify placement of wanderguard every shift. The order was initiated on 9/1/21. d. WANDERGUARD: Check function of device daily every day shift for elopement risk. The order was initiated on 9/2/21. e. Keppra Tablet 1000 mg, Give 2 tablet by mouth one time a day for Seizures. The order was initiated on 9/2/21. f. Valproic Acid Solution 250 mg/5 ml, Give 750 mg by mouth two times a day related to UNSPECIFIED CONVULSIONS. The order was initiated on 9/2/21. g. Topamax Tablet (Topiramate), Give 50 mg by mouth two times a day for Seizures. The order was initiated on 9/2/21. h. Lamictal Tablet (lamotrigine), Give 50 mg by mouth two times a day related to UNSPECIFIED CONVULSIONS. The order was initiated on 9/2/21. i. Keppra Tablet 1000 MG (levetiracetam), Give 1 tablet by mouth one time a day for Seizures. The order was initiated on 9/2/21. j. Citalopram Hydrobromide Tablet, Give 20 mg by mouth one time a day related to MOOD DISORDER. The order was initiated on 9/2/21. Review of the facility incident reports for resident 15 revealed the following: a. On 1/31/21 at 1:30 PM, the resident stood up from a chair after smoking and lost balance falling backwards and hit the back of head. No injuries were noted. The resident was educated on standing up slowly and the aide was educated on assisting the resident with standing. b. On 2/26/21 at 9:00 AM, the aide in a nearby room heard a thud, exited and found resident 15 face down with the right cheek on the ground. Injuries noted were an abrasion below the left eye, sheering with swelling to the right posterior wrist and ring finger, and a small laceration to the tongue with minor bleeding. Resident 15 was re-educated on calling for assistance when preparing to ambulate, and to make sure proper footwear/attire was worn. c. On 3/7/21 at 4:10 PM, the nurse heard a loud crashing sound. Resident 15 was found on the bathtub casing with his face against wall. Resident 15 had excessive blood dripping from the head due to a shattered window. Resident 15 stated he fell and hit his face on the glass. The resident was transferred to the emergency room for treatment. No new interventions were documented. d. On 4/3/21 at 6:00 AM, resident 15 attempted to stand from the wheelchair and fell over the wheelchair. No injuries were noted. No new interventions were documented. e. On 4/4/21 at 12:15 PM, resident 15 was using the toilet, stood, turned to flush and fell against the door and slid to ground. No injuries documented. Resident 15 was reminded to use staff to assist with standing and using the restroom. f. On 4/15/21 at 11:00 PM, resident 15 fell out of bed. Resident 15 was educated to keep alarm tab on at all times, and to call for assistance. Staff were educated to make sure tab alarm was on resident. Review of resident 15's hospital History and Physical on 3/7/21 documented that the resident presented after an unwitnessed fall through a pane of glass. It was possible that it was a seizure or syncopal event. Procedures performed were laceration repair of 3 separate lacerations on the face. The first measured 3 centimeters (cm) on the right cheek. The second measured 2 cm on the right upper eyelid. The third measured 2 cm on the left upper eyelid. The wounds were anesthetized with 1% lidocaine. The wounds were explored to the base and no evidence of neurovascular injury, no evidence of retained glass or foreign body, and no evidence of tarsal plate involvement was noted. The wounds were irrigated with saline and repaired using 5-0 Ethilon with simple interrupted sutures. Review of resident 15's progress notes revealed the following: a. On 2/20/21 at 6 AM to 6 PM, weekly note documented that the resident was alert and oriented times 2, expressed basic needs and wants. Ambulated with a slow gait. Would ask for extra cigarettes during the day and could be anxious about smoking between scheduled times. b. On 2/26/21 at 9:30 AM, the aide heard a sound outside the resident room, opened door to find the resident face down on the ground. The resident stated he tripped and fell over his own foot. Abrasion to left cheekbone and right wrist with swelling. X-ray to right wrist ordered. c. On 2/26/21 at 10:45 AM, x-ray results to right writs received, no fracture noted. d. On 3/1/21 at 6 PM to 6 AM, the weekly note documented that the resident ambulated independently. e. On 3/7/21 at 4:40 PM, at 4:10 the nurse heard a loud crashing noise and found resident 15 laying awkwardly on tub surround enclosure with head against east wall with a large amount of blood dripping down wall and off head. The window above was broken. The nurse called for the aide to assist with positioning resident 15 to a sitting position. Resident 15 stated that he tripped and fell, no other explanation was offered. Injuries observed were small laceration to posterior ringer finger below 2nd knuckle with scant blood. A 2-3 inch laceration to the right temple above the cheekbone, a laceration to the bridge of the nose, one right brow, and a 3-4 inch laceration to left eyelid. The resident was sent to the emergency department for treatment. f. On 3/9/21 the note documented a bed alarm in place. g. On 3/15/21 the note documented that resident 15 was alert and oriented (A & O) times 3. He ambulated with assistance from staff and used a tab alarm for fall prevention. h. On 3/22/21 the note documented A & O times 2-3. Able to communicate wants and needs. Usually ambulated ad lib. This week resident 15 was instructed to use the wheelchair for ambulation with a personal alarm to keep him safe. The resident wanted to walk, but was still a little weak. i. On 4/3/21 the note documented that the patient was unsteady on feet, stood up and fell out of wheelchair. Resident 15 keeps removing his personal alarm, kept trying to get to wheelchair independently, sometimes not able to make it, sits on floor. Resident 15 was a one person assist to stand and back to bed with alarm attached. j. On 4/4/21 at 12:15 PM, the note documented that resident 15 was using the toilet, stood and turned to flush the toilet, fell against the door and slid to the floor. The aide and nurse assisted him to stand. Slight redness to left cheekbone with minimal swelling noted. Reminded resident to let staff assist with standing and using restroom. k. On 4/4/21 at 6 PM to 6 AM, the note documented that resident 15 continued to remove the personal alarm and tried to walk independently. Resident 15 was not steady. l. On 4/8/21 at 6 PM to 6 AM, the note documented that resident 15 had some weakness, and had difficulty going to the toilet. m. On 4/15/21 the note documented that the resident fell out of bed and was pulling at alarms. No injuries were noted. n. On 4/26/21 the weekly 6 PM to 6 AM note documented that the resident wore a personal alarm to notify staff if he tried to stand up. Resident 15 was resistant to the alarm and was able to turn it off and put it in his pocket. Resident 15 stumbles, slipped out of wheelchair, and jumped up and walked to restroom, removed alarm to do this. o. On 5/21/21 the note documented that the tab alarm was discontinued due to steady gait. p. On 6/7/21 the note documented that the resident ambulated independently. Review of resident 15's Minimum Data Set (MDS) Assessments revealed the following: a. On 11/22/20 the Annual MDS assessed resident 15's Functional Status under Section G for bed mobility as Supervision with set up help; Limited 1 person assist for transfer, walk in room, walk in corridor, and off the unit; Total dependence 1 person assist for dressing and toilet use; and Limited 1 person assist for eating. The assessment did not conduct a Brief Interview for Mental Status (BIMS) under Section C due to resident was rarely/never understood. The Care Area Assessment (CAA) Summary triggered a care plan for falls and identified it was existing. b. On 2/22/21 the Quarterly MDS assessed resident 15's Functional Status under Section G for bed mobility as Supervision with set up help; Limited 1 person assist for transfer, walk in room, walk in corridor, and off the unit; Total dependence 1 person assist for dressing and toilet use; and Limited 1 person assist for eating. The assessment did not conduct a BIMS under Section C due to resident was rarely/never understood. The CAA was not applicable for a quarterly assessment. c. On 9/15/21 the admission MDS assessed resident 15's Functional Status for bed mobility as Supervision with set up help; Supervision with set up help for transfer, walk in room, and walk in corridor; Independent with no help from staff on locomotion on unit and off unit; Extensive 1 person assist for dressing; and Supervision set up help only for eating and toileting. The assessment did not conduct a BIMS score under Section C and was documented as Not assessed. The CAA Summary triggered a care plan for falls and identified it was modified. Review of resident 15's Care Plan revealed the following: a. A RESOLVED care plan: The resident has had an actual fall with minor injury above right and left eye brow due to unsteady gait. The care plan was initiated on 10/22/21. A RESOLVED goal was: The resident's left eyebrow laceration will resolve without complication by review date and the Left eye abrasion will resolve without complication by review date. The goal was initiated on 10/22/21. The RESOLVED interventions were: Bed will be in lowest position for patient's safety and fall precaution; For no apparent acute injury, determine and address causative factors of the fall. Resident would sit for a few minutes before standing; Monitor/document /report as needed for 72 hrs (hours) to physician for signs and symptoms of: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. It should be noted that the care plan was initiated nearly 7 months after the incident occurred. b. A RESOLVED care plan: The resident has had an actual fall with minor injury above right and left eye brow due to unsteady gait. The care plan was initiated on 10/22/21. A RESOLVED goal was: The resident will resume usual activities without further incident through the review date. The RESOLVED interventions were: Neuro (neurological)-checks [times] 72 hrs; Provide activities that promote exercise and strength building where possible; and Provide 1:1 activities if bedbound. It should be noted that the care plan was initiated nearly 7 months after the incident occurred. c. The resident had a seizure disorder. The care plan was initiated on 10/22/21. A goal of the resident was to be/remain free of seizure activity through review date and was initiated. The interventions identified were: Ask resident about presence/absence of aura prior to seizure; Give medications as ordered; Monitor/document for effectiveness and side effects; Obtain and monitor lab (laboratory)/diagnostic work as ordered; Report results to the physician and follow up as indicated; and SEIZURE PRECAUTIONS: Do not leave resident alone during a seizure, Protect from injury, If resident was out of bed, help to the floor to prevent injury, Remove or loosen tight clothing, do not attempt to restrain resident during a seizure as this could make the convulsions more severe, Protect from onlookers, draw curtain etc. It should be noted that there was no current care plan for at risk for falls for resident 15. On 11/15/21 at 9:20 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 15 was able to ambulate independently and right now he was safe. RN 1 stated that in the past he had periods of unsteadiness, but that he had no recent falls. RN 1 stated that resident 15 was discharged and readmitted and had no falls since readmission. RN 1 stated that she was not sure what had changed with resident 15's functional mobility to improve it. RN 1 stated that resident 15 had no recent medication changes and it was hard to tell what contributed to the improvement. RN 1 stated that resident 15 was moved to the front of the building to keep a closer eye on him. RN 1 stated resident 15 previously had a tab alarm, but at some point he refused it. RN 1 stated resident 15 kept taking it off and saying no to it. RN 1 stated that during resident 15's periods of unsteadiness they assisted with ambulation and transfers. RN 1 stated that currently resident 15 was steady on his feet. RN 1 stated that resident 15 required no assistance with toileting, and he was continent of bowel and bladder. RN 1 stated that she was not present during resident 15's elopement. RN 1 stated that she only knew that he went outside and jumped the fence. RN 1 stated that resident 15 had no previous attempts at elopement that she recalled. RN 1 stated that when resident 15 started declining and was unsteady on his feet the physician referred him to a neurologist. RN 1 stated that she made an appointment for resident 15 with the neurologist and the soonest appointment she could get was on November 2, 2021. RN 1 stated that documentation of all her attempts at earlier appointments were in the progress notes. On 11/09/21 at 9:57 AM, an interview was conducted with Certified Nurse Assistant (CNA) 3. CNA 3 stated that she had worked at the facility for 4 years. CNA 3 stated that anything new that happened with a resident was reported to her by the supervisor. CNA 3 stated that if a resident had a behavior or change in condition it would be passed off to her in report. On 11/15/21 at 10:10 AM, an interview was conducted with CNA 4 and CNA 5 utilizing the English/Spanish Translator application. CNA 4 stated that resident 15 ambulated independently, was sometimes unsteady, and came out of his room for cigarettes and coffee. CNA 5 stated that resident 15 did not utilize a walker or wheelchair for ambulation. CNA 4 stated that resident 15 did not need assistance with toileting. CNA 5 stated that resident 15 had not had any falls since she had worked at the facility for the last month. CNA 4 stated that to her knowledge resident 15 had never left the building, and had not eloped prior to the placement of the wander guard. CNA 5 stated that resident 15 currently had a wander guard in place. On 11/09/21 at 10:25 AM, an interview was conducted with CNA 2. CNA 2 stated that she utilized a communication application to communicate information to the CNAs for each resident behavior or change in condition and changed the written report to pass off information to the next shift to read. CNA 2 stated the written report was for information on incidents that had occurred that day. CNA 2 stated that for new CNAs she explained each resident's care needs, and then they could look in the computer on what the resident history was and what their needs were. On 11/15/21 at 1:47 PM, an interview was conducted with the Director of Nursing (DON) and the Regional Nurse Consultant (RNC). The RNC stated that the previous Administrator prior to the acquisition by the new company was doing the care plans. The RNC stated that they were not updating the care plans with new interventions. The RNC stated that the process now was that the IDT reviewed the incident, tried to determine the root cause, the care plans were updated, the comprehensive care plans were updated, and the new MDS Coordinator did that process Annually and Quarterly also. The RNC stated that with resident 15's history they typically have an at risk for falls care plan initiated. B. Elopement Review of the facility initial entity report documented, On 7/10/2021 at 10:44 AM, the facility reported that, on 7/10/2021 at 8:45 AM, the resident was found to have eloped from the facility. The resident was last seen at 8 AM during a scheduled smoking time. Other facility residents notified the staff that there was 'a guy that had fallen down near the road in front of the building'. The nurse went outside to assess the situation and see if she could give any medical assistance. At that time, the nurse noticed that the 'guy' was the resident of the facility who had eloped. The nursing staff did a head to toe assessment and assisted the resident back to the building. APS (Adult Protective Services) was notified. The family and physician were notified. The facility will contact the resident's guardian and seek receive approval to temporarily transfer the resident to a sister facility with a wander guard system while [name of facility] can assess and install a wander guard system of their own. Review of resident 15's progress notes revealed the following: a. On 7/10/21 at 8:45 AM, the note documented, Nurse at med (medication) cart; residents sitting at window in dayroom notified nurse of a man laying in middle of road; nurse looked and saw man laying on side with 3 men around him; nurse notified staff they'd be stepping out to see if they needed help; nurse approached scene asking men if EMS (emergency medical services) had been notified, they said EMS not notified; nurse looked a man to assess, recognized res. (resident); nurse then asked if incident had been witnessed; one of the men states it appeared that he had tripped and they went to him to ensure his safety, nurse asked if res. hit head, bystander stated he didn't hit head; witnesses and nurse slowly assisted res. to sitting position, res. denied light headed/dizziness; assisted to standing, again res. denied being light headed or dizzy; assisted res. back to facility; assessment performed; PERRLA (pupils, equal, round, reactive to light and accommodation), grips at baseline, skin tear to R (right) lateral wrist (2.5 cm), abrasions to L (left) pinky (1 x 3 cm) and abrasion to R shin (2 x 7 cm); cleansed areas with wound cleanser, applied bacitracin, wrapped with Kerlex and secured with coban; VS (vital signs) signs (sic) BP (blood pressure): 105/69 HR (heart rate): 75 RR (respiratory rate): 16 O2 (oxygen): 96% RA (room air) T (temperature): 98.0 denies pain with exception of abrasions, reports pain 'better' after tx (treatment); staff checked exterior doors/exits for point of egress, step ladder found next to fence in front courtyard, ladder secured b. On 7/10/2021 at 4:00 PM, the note documented, resident 15 required immediate transfer to due to resident's imminent risk for elopement as evidenced by successful elopement today. Resident has cognitive deficits associated with mental illness, such as impaired safety awareness, impulsivity, and impaired judgment. Less restrictive measures such as indirect supervision, distraction, redirection, orientation and re-orientation to facility routines and practices were not effective in mitigating elopement risk. [Name of facility] can no longer manage resident s elopement risk as no wander guard system is in place and staffing at a 1:1 is not feasible. [Name of sister facility] has a wander guard system as well as a door monitor and the IDT (Interdisciplinary team) believes that resident's elopement risk can more safely and effectively be managed at this receiving facility. c. On 9/7/2021 at 11:43, the physician note documented that resident 15 was readmitted for care. He had been transferred to another facility because he needed a more secure environment due to wander risk. The current facility had a wander guard system so he had been readmitted per the guardian's request. Review of resident 15's Care Plan revealed the following: a. The resident was an elopement risk related to impaired safety awareness. The care plan was initiated on 10/22/21. Interventions identified were to distract the resident from wandering by offering pleasant diversions, structured act[TRUNCATED]