**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 3 sampled residents, a resident that was a quadriplegic received second degree burns on his body after being served hot water by a Certified Nursing Assistant (CNA) and the resident was not supervised while drinking the hot water. Resident identifier: 1. Findings included: Resident 1 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, quadriplegia, type 1 diabetes mellitus, neuromuscular dysfunction of bladder, anxiety disorder, and burn of unspecified body region. Resident's medical record was reviewed on 11/8/23. On 11/18/22, a Hot Beverage Evaluation documented that resident 1 DOES NOT demonstrate the ability to self serve hot liquids, but wishes to have hot liquids and can do so with interventions. The interventions included, Staff will assist to serve hot liquids and assist with proper positioning during hot beverage consumption. A quarterly Minimum Data Set assessment dated [DATE], documented a brief interview for mental status (BIMS) score of 15. A BIMS score of 13 to 15 would suggest cognitive intactness. On 11/3/23 at 11:58 PM, a Nursing Progress Note documented Date 11/3/2023 reported at 2300 [11:00 PM]: [Resident 1] sustained burns to right upper chest, right inner arm, right posterior lateral back, left groin, left hip and abdomen. CNA on PM shift reported to nurse at 2300 that [resident 1] had blisters and would I look at them. I spoke with [resident 1], he stated, his CNA filled his mug with water at approx [approximately]. 10 PM. [Resident 1] states as he was drinking his water, it was so hot that he pushed the straw from his mouth so that it would not burn him. [Resident 1] explained that when taking a drink out of his personal straw set up for his water, it is like siphoning gas, only stops when he puts his tongue back on the straw to stop it from flowing. [Resident 1] said due to it being so hot, he was not able to put his tongue on the straw to stop it. That's when the water poured out of the mug it went all over his chest & body. [Resident 1] could not feel the water as he has not [sic] feeling from the neck down. CNA's and nurse removed clothing and linens and changed to new gown and linens. Body check was completed. NP [Nurse Practitioner] [name removed] was notified; orders were given to clean burns with NS [normal saline], and apply Bacitracin, keep wounds clean and dry. Monitor patient closely for any changes or concerns. [Resident 1] denies pain at this time. temperature 98.1 [degrees Fahrenheit (F)], refused any additional vital signs. Education given, verbalizes understanding. Call light within reach. Hydration encouraged-CNA's informed to keep [resident 1] with fluids, no hot water. Staff education provided. On 11/4/23 at 12:10 AM, a Nursing Progress Note documented [Resident 1] sustained burns from hot water-order for Clean with NS, pat dry, apply bacitracin cream and protect with gauze. Monitor for infection. Do not apply cover [sic] blisters. This has been completed, nursing will continue to monitor patient condition-vital signs refused per patient, temp [temperature] 98.1 [degrees F]-No pain r/t [related to] quadriplegic-staff will be vigilant to monitor through the night-Linens, gown C/D [clean and dry]. [Resident 1] is aware of the situation, drinking well at this time. On 11/4/23 at 2:07 AM, a Nursing Progress Note documented Patient during bs [blood sugar] check dressings changed per order. Patient drinking well and urine output is good. Mucous membranes moist. VSS [vital signs stable] at this time patient is afebrile 98.4 [degrees F]. Patient pulse 88 bp [blood pressure] 103/71. Patient offered at this time to be evaluated at hospital related to surface area. Patient content with POC [plan of care]. Hydration and nutritional needs reinforced. Patient spent whole time telling pirate jokes. WCTM [will continue to monitor]. On 11/4/23 at 4:10 AM, a Nursing Progress Note documented Patient mugged [sic] filled with tap water per his request. Patient dressing changed and reinforced per order. Patient has had serous drainage from distal and posterior chest. Patient dressings otherwise intact and without irritation. Patient resting at this time. WCTM. On 11/4/23 at 6:13 AM, a Nursing Progress Note documented Patient bs 114 temp 98.5 [degrees F]. Mucous membranes moist. Patient urine is clear yellow. Patient has had no further drainage thus far. Patient dressing are intact without s/s [signs and symptoms] of irritation. Patient educated on need to continue fluids and to increase protein to promote healing. Patient educated on s/s to report. Discussed ways patient his [sic] body expresses infection ie increased bs, inability to maintain body temp, decreased intake and output. Patient content with care and progress thus far. Patient demonstrated ability to push call light. WCTM. On 11/4/23 at 9:29 AM, a Hot Beverage Evaluation documented that resident 1 was able to drink lukewarm beverages with straw. DOES NOT demonstrate the ability to self serve hot liquids, but wishes to have hot liquids and can do so with interventions. The interventions included, Staff will assist to serve hot liquids and assist with proper positioning during hot beverage consumption. Provide cups with lids, Use only mugs appropriate for hot liquids, DO NOT refill resident's cup while they are holding it, Educated on safe handling techniques, and Other - only lukewarm beverages, per pt [patient]. On 11/4/23 at 10:37 AM, a Nursing Progress Note documented new order per NP to Clean burns with chlorohexidine (NO ALCHOLOL [sic]), Apply silvadene to red and blistered areas BID [twice daily], Cover with Adaptic or xeroform, then place non adherent pad on top and wrap with kerlix, and secure with dry dressing on the unable to wrap areas of the body BID and PRN [as needed] and to have wound team evaluate for further treatment and monitoring. Res [Resident] aware. On 11/4/23 at 11:04 AM, a Nursing Progress Note documented Skin assessment done with wound nurse. Resident with second degree burns d/t [due to] scalding from hot liquid R [right] inner arm measurements 14x7 [centimeters (cm)] R back side posterior lateral measurements 22x18 [cm] Chest measurements 20x20 [cm] Abdomen 20x32 [cm] with a large blister on R side measuring 8.0x7.0 [cm] L [left] groin multiple small blisters measuring 3.0x13.0 [cm] L hip blister 1.0x1.5 [cm] All scaled areas are red with some denuded areas, and multiple blisters. Wound team and NP notified. New orders in place. On 11/4/23 at 11:49 AM, a Nursing Progress Note documented Resident in good mood this morning. Temperature check this morning 98.0 [degrees F]. Resident denies any pain. Repositioned for comfort. Offered prn pain medications resident refused. Skin treatment done. Continue monitoring for any changes. Continue staff education about hot beverages to be mindful and careful of the temperature when assisting a resident with food or drinks. For [resident 1] serve only lukewater per [resident 1] request. On 11/4/23 at 12:06 PM, a Nursing Progress Note documented Follow up with resident related to burns sustained from warm water and ask resident if he wants to go to the hospital. Resident refused, stating he wants to be treated here in facility, agrees with skin treatment order. Resident stated that he feel [sic] safe in facility, and that nobody hurt or abuse him, and complimented staff for prompt action and providing exceptional care. On 11/4/23 at 12:41 PM, a Nursing Progress Note documented New order received from NP to monitor and encourage hydration, monitor vitals and notify provider with any concerns. Resident notified. Fluids encouraged as tolerated. On 11/4/23 at 4:46 PM, a Nursing Progress Note documented [Resident 1] burn wounds changed per order/[resident 1] states he feels a little weak/Midodrine given prn as ordered to elevate BP of 60's-next BP 79 systolic-after second dosing of Midodrine, BP > [greater than] 130. [Resident 1] is increasing his fluids. Tylenol for general well being-no temp at this time/call light within reach. On 11/4/23 at 9:10 PM, a Nursing Progress Note documented [Resident 1] states he is a little cold-some mild shivering-no temperature,vss. NP [name removed] notified of BP improving with Midodrine and increaseing [sic] fluids as well as his overal [sic] fatigue. Dressings to burns C/D/I [clean, dry, and intact] call light within reach-repositioned as requested. On 11/5/23 at 3:15 PM, a Nursing Progress Note documented Resident received Tx [treatment] for burn on torso, front/inner lateral, right arm, right posterior lateral back, left groin and L hip per order BID wound care. Not [sic] c/o [complaints of] pain or discomfort noted. Fluids intake as tolerated. Recorded as Late Entry on 11/5/23 at 9:17 PM. On 11/5/23 at 9:00 PM, a Nursing Progress Note documented Resident's burn dressing change BID. Not [sic] c/o pain at this time. Resident is encourage to drinks fluids. Reposition done. assist with feeding, appetite is fair to good. Not [sic] fever noted. WCM [will continue monitor]. Recorded as Late Entry on 11/6/23 at 6:02 PM. On 11/6/23 at 5:03 PM, a Nursing Progress Note documented Resident received partial bed bath. Burn dressing changed. Not [sic] s/s of infection. Not [sic] c/o pain noted. Fluids [sic] intakes is tolerated well. Supra Foley in place DD [down drain] well. Resident participated in therapy session . Appetite is good. WCM. Recorded as Late Entry on 11/6/23 at 6:06 PM. On 11/6/23 at 9:55 PM, a Nursing Progress Note documented Dressings changed to burns this evening. Tolerated well. No s/s of infection noted. All needs met at this time. Call light within reach. On 11/7/23 at 12:15 PM, a Nursing Progress Note documented New order received from wound team and approved by NP: Silvadene (silver sulfadiazine) cream; 1 %; amt [amount]: 1 application; topical Special Instructions: Clean burns with chlorohexidine (NO ALCHOLOL), Apply silvadene to red and blistered areas daily, Cover with Adaptic, then place non adherent pad on top and wrap with kerlix, and secure with dry dressing on the unable to wrap areas of the body daily and PRN. Avoid areas drying out. Resident made aware. Wound burn dressing done by wound team. Resident tolerated dressing change well. Recorded as Late Entry on 11/8/23 at 9:16 AM. On 11/7/23 at 4:37 PM, a Nursing Progress Note documented Resident remain in bed. Wound burn dressing changed. Not [sic] c/o pain at this time. Resident is encourage to drink fluids. Foley Cath [catheter] in place DD well. Encourage to use call light within to reach. WCM. Recorded as Late Entry on 11/7/23 at 6:38 PM. On 11/7/23 at 11:43 PM, a Nursing Progress Note documented Resident resting in bed this shift. He is A&O [alert and oriented] at his baseline. Compliant with medication administration and cares offered. Dressing in place, CDI. He has no c/o pain. Resident encouraged to use call light. Within reach. Will continue with current plan of care. On 11/8/23 at 9:16 AM, a Nursing Progress Note documented Spoke with resident this morning. Resident is in good spirit and making jokes and laughing. Wound burn dressing in place, intact. Resident denies any pain or discomfort. Encouraged fluids as tolerated. Educated resident to use call light and ask for help if needed. On 11/8/23 at 10:35 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 1 asked for the hot water and not thinking any thing of it CNA 1 gave resident 1 the hot water and the straw. CNA 1 stated that she came back later and resident 1 stated that the water was to hot. CNA 1 stated that she had noticed the blisters on resident 1 and told the nurse. CNA 1 stated that she was doing cares for resident 1 when she noticed the blisters. CNA 1 stated the Creamery was where she usually got the hot water for residents. CNA 1 stated there was a tap by the hot chocolate machine labeled Hot Water. CNA 1 stated that she had put the hot water in resident 1's water mug and could not remember if there was a lid for the mug. CNA 1 stated that resident 1 had a personal drinking straw that was hooked up to suction. CNA 1 stated the suction helped resident 1 to drink from the straw. CNA 1 stated that she had given resident 1 hot water in the past. CNA 1 stated she did not know if the protocol was to temp the water prior to giving the hot water to a resident. CNA 1 stated she did not temp the hot water prior to giving the mug to resident 1. On 11/8/23 at 10:47 AM, an interview was conducted with resident 1. Resident 1 stated that suction had nothing to do with the drinking straw. An observation was conducted of resident 1's water mug. A long straw that appeared to be suction tubing came out of the water mug and was attached to a arm device that resident 1 could reach with his mouth. The suction canister tubing was observed to be attached to the same arm device but separate from the drinking straw. Resident 1 stated that he would request warm water when he was cold. Resident 1 stated that he was a quadriplegic and when he got cold the warm water would warm him up. Resident 1 stated the other CNAs would get the hot water from the nurses station and would fill his water mug with half hot water and half cold water. Resident 1 stated that CNA 1 was his CNA the night he got burned. Resident 1 stated he did not specify on the water and when he got a drink it was burning hot water. Resident 1 stated that he tried to blow the water back in the straw but the water was to hot and it came out of the straw and he felt the hot water on his chest. Resident 1 stated that he thought the water was only on the blanket but it had poured onto his skin. Resident 1 stated the water had burned under the side of his right arm, right side of his genitals, and along side the right of his hip. Resident 1 stated that he had blistered and the blisters bursted for two nights. Resident 1 stated the NP which was the wound nurse seen him once a week. Resident 1 stated he had a racking headache over the weekend after the incident. Resident 1 stated that he was not sure if the headache was a response to the pain. Resident 1 stated by Monday he was feeling better and yesterday the NP described the wound areas were looking much better. Resident 1 stated the NP had prescribed saline and silvadene cream for the burns and to cover the burns with protective pads. Resident 1 stated that yesterday the NP changed the dressing order to once a day. Resident 1 stated that he has not had a headache for two days. Resident 1 stated that he had received compassionate and effective care from the facility since the hot water incident. Resident 1 stated that CNA 1 had not brought him hot water before. Resident 1 stated that though it was a mistake it was out of ignorance or lack of communication. Resident 1 stated that the hot water was not out of negligence. On 11/8/23 at 11:24 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 1 was a quadriplegic. RN 1 stated that resident 1 had been at the facility for four years. RN 1 stated that resident 1 was respectful but sarcastic and very specific with cares. RN 1 stated that resident 1 did not like ice water and the CNAs have told RN 1 that resident 1 would ask for hot water. RN 1 stated that the CNAs have told RN 1 that they would mix hot and cold water so the water was warm. RN 1 stated that resident 1's suction was for congestion and respiratory would see resident 1 twice a day and empty the canister if needed. On 11/8/23 at 11:29 AM, resident 1's wound dressing change was observed with RN 2. RN 2 was observed to remove the dressings from the right lower back and right side. RN 2 stated she would clean the wounds in sections. The edges of the burns were observed to be bright red and the center was a creamy off-white color. RN 2 cleansed the burn areas with Hibiclens. A silver dollar sized area of skin came off near the lower back during the cleaning. RN 2 applied silvadene, covered the area with oil emulsion dressings, abdomen pads, and tapped the pads to resident 1's skin. Resident 1's right arm was observed to have some drainage on the bandage. The burn on resident 1's right side was observed to cover half way down the right side to the hip area and angled towards the middle of resident 1's back. RN 2 was observed to remove the dressings from the chest area and abdomen. The burn was observed to cover resident 1's chest and down toward resident 1's left side around the colostomy site. The burn was observed in the left hip crease area and towards the top of the pelvic area. The edges of the burns were observed to be bright red and the centers were a creamy off-white color. Blisters were observed on resident 1's left side near resident 1's ostomy. Resident 1's belly button was observed to be red. RN 2 was observed to remove the dressings from resident 1's right arm. The burn area covered under the bicep from the elbow to half way up the arm. RN 2 stated that the skin was starting to come off. On 11/8/23 at 12:50 PM, an observation of the hot water was conducted. In the Creamery the hot water tap was observed to be connected to the coffee machine. A resident coffee mug was filled with hot water. The temperature was obtained with a digital thermometer and read 158.7 F. On 11/8/23 at 12:54 PM, an interview was conducted with CNA 2. CNA 2 stated if a resident requested hot water she could get the hot water at the nurses station or the Creamery. CNA 2 stated that she would get the resident a new cup and a new straw. CNA 2 stated that she never used the hot water in the Creamery. CNA 2 stated if the resident was coherent she would remind them that the water was hot. CNA 2 stated if the resident was not coherent or oriented she would dilute the hot water. On 11/8/23 at 1:00 PM, an interview was conducted with CNA 3. CNA 3 was observed in the main dining area near the Creamery. CNA 3 stated that when dining was finished there was a chain that was put up so the residents were not able to access the Creamery. CNA 3 stated that during dining a staff member would be present and the residents would ask for what they needed. A resident was observed to wander into the Creamery and filled her water mug with ice. CNA 3 was observed to assist the resident and escorted her out of the Creamery. On 11/8/23 at 1:12 PM, an interview was conducted with the Administrator (Admin). The Admin stated that he had tested the hot water on Saturday and it was coming out at 176 F. The Admin stated the company that owns the coffee machine came to the facility on Monday and the coffee machine was set at 196 F. The Admin stated he was told by the company that the coffee machine needed to be set in the 180's to be able to make coffee. The Admin stated the company made adjustments on the coffee machine for 180 F. The Admin stated the kitchen staff were temping the coffee mugs before the mugs went to the residents and monitoring was conducted once a day. On 11/8/23 at 1:39 PM, an interview was conducted with the Director of Nursing (DON). The DON stated there had not been any other burns in the facility. The DON stated the residents usually rarely ask for hot water, but the residents would usually ask for tea or coffee. The DON stated the staff were to pour the water and if the water was hot the staff would put cold water or ice in the cup. The DON stated the staff should make sure the temperature was good and the water was in a proper cup with a lid. The DON stated when the staff bring the warm water to the resident room the staff need to reposition the residents and ask the resident how they would like to drink. The DON stated the staff need to supervise the resident. The DON stated that resident 1 was the only resident that would ask for hot water. The DON stated she did education for the entire facility regarding hot water. The DON stated that resident 1 at this moment has requested luke warm water and the care plan had been updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 3 of 6 sampled residents, that the facility did not ensure each resident was free from verbal, mental, sexual, or physical abuse. Specifically, a male resident entered female resident rooms without their permission. One female resident was touched by the male resident during the night and another female resident expressed to staff she would use [NAME] on the male resident if he entered her room again. The female resident later maced the male resident when he tried to enter her room. This resulted in the finding of harm for two residents. Resident identifiers: 1, 2 and 3. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction due to unspecified occlusion or stenosis of right posterior cerebral artery, hemiplegia and hemiparesis, dysarthria and dysphagia follow cerebral infarction, and sexual dysfunction not due to a substance or known physiological condition. Resident 1's medical record was reviewed on 3/2/23. A Pre-admission Screening Applicant/Resident Review (PASRR) dated 7/2/22 revealed that resident 1 had hypersexual behaviors. The comment and notes section revealed New medication started on 9/17/2022 for hypersexuality. Resident 1 was screened out for a level II because the diagnosis was not considered to be a serious mental illness. A quarterly Minimum Data Set (MDS) dated [DATE] revealed resident 1 had a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS further revealed resident 1 was not steady but able to stabilized without human assistance when moving from seated to standing, walking, turning around and facing the opposite direction while walking and transferring from surface to surface. A care plan dated 9/9/22 and edited on 12/7/22 revealed behavioral symptoms because resident 1 made sexually inappropriate comments/actions toward staff and others. The goal was that resident 1 would not exhibit inappropriate comments/actions. An approach dated 9/9/22 revealed Remind [resident 1] that his comments can make others uncomfortable, but do not alienate him. Two approaches with start dates of 10/28/22 revealed to Let resident know those types of comments are unwelcome, and to please stop. Make sure he is being appropriate around other residents. Praise resident for appropriate behaviors and [Resident 1] stated he will go to his room if he has an urge. An approach dated 12/5/22 was one on one supervision related to an incident on 12/5/22. A care plan dated 12/5/22 with a created date of 12/6/22 revealed that resident 1 had behavioral symptoms of making other residents feel unsafe by entering their rooms. The goal was to make other residents in the building feel safer and the approach was one on one care in place. Resident 1's progress notes were reviewed and revealed the following: a. On 9/4/22 at 5:43 AM, [Resident 1] had been trying all night to entice [name removed] the CNA [Certified Nursing Assistant] into his room. [Name removed] said he asked her if she can undress and do the 'nasty'. [Name removed] had refused to go into his room after which he got into his wheelchair and was wheeling himself in the hallway. [Resident 1] also approached me and asked me if [name removed] is allowed to go into his room. I said she is if there is a need for [name removed] to perform CNA duties. He asked if [name removed] is allowed to do sex I emphatically said NO. b. On 9/9/22 at 2:20 AM, CNA on 400 hall reported patient asked for sex, patient was assessed He agreed to ask staff member for sex [sic] and he apologized. An intervention was taken as to have a different CNA check on him for the rest of the night if he heeds help. c. On 9/12/22 at 7:28 AM, recorded as a late entry on 9/13/22 at 7:28 AM, the Nurse Practitioner (NP) documented .He has been more sexually inappropriate with staff and have more behaviors over the weekend. Treatment plan: .Add paroxetine and monitor behaviors. d. On 10/14/22 at 12:30 AM, Patient had incident of inappropriate behavior with CNA this evening. He asked CNA if she 'wanted to play nasty with him.' Resident was told this behavior is inappropriate and he is not to speak like this to the staff who are here to assist him. e. On 10/19/22 at 5:10 AM, '[Resident 1] has had multiple inappropriate behaviors with both nursing staff and residents stating he is 'looking for sex' Patient has been advised numerous times that his behavior will not be tolerated and continues to roam the hallways making sexual comments to CNA's and nurse and making multiple attempts to go into several patients rooms. f. On 10/19/22 at 3:45 PM, recorded as late entry on 10/20/22 at 1:47 AM revealed, Spoke with patient about inappropriate behaviors toward staff, explained that he was making staff and visitors uncomfortable. Patient verbalized understanding and agreed to stop behavior, MD [Medical Doctor] was notified. Social services to follow up. g. On 10/19/22 at 7:47 PM, SS [Social Services] spoke with resident this evening in regards to his recent sexual comments to staff, he says that 'he is sorry, and will stop'. Resident was also notified of a room change that will take place tomorrow. h. On 10/20/22 at 10:30 AM, Resident found in another residents room showing her his penis. SS reached out to his daughter [name removed], she sats [sic] that he has been a very sexual person his whole life. She is unsure what to do at this time. She states that she will come in and speak to him. SS has contacted police, they are on the way. Daughter is planning on coming by as well, she is questioning his mental state at this point and would like us to send him out for a psyche [psychological] eval [evaluation]. She states that he has been trying to leave the facility, and since his stroke she feels that he is not in his normal mental state. i. On 10/20/22 at 10:47 AM, Resident is on 1:1 care right now. k. On 10/20/22 at 11:51 AM, .She [daughter] had a conversation with her father today about his behavior and she says that he has agreed to stop, but she feels that he is not 'with it.' l. On 10/20/22 at 7:15 PM, Dipped urine that was collected and all values are within normal limits.Patient continues one on one but has made inappropriate comments to her. He stated to her that, he was waiting for a [NAME]. m. On 10/24/22 at 12:21 PM, Staff reports that resident continues to make inappropriate/sexual comments and advances towards them, and offers them money for sex. He is still 1:1 with staff. n. On 10/24/22 at 2:05 PM, resident was sent to local hospital for a psych evaluation. o. On 10/24/22 at 3:40 PM, was recorded as a late entry on 10/27/22 at 3:41 PM, Resident was offered a counseling referral, and refused it. He states that he doesn't need counseling. p. On 10/24/22 at 6:38 PM, resident returned from hospital. r. On 10/25/22 at 1:27 PM, resident was one on one. s. On 10/25/22 at 9:30 PM, Resident continues to have a one on one cna due to inappropriate sexual behaviors. Per CNA no inappropriate behaviors or comments made this shift. Resident currently in bed resting. t. On 10/26/22 at 5:09 PM, Psychotropic review.Per pharmacist recommendation and NP no changes at this time. u. On 10/26/22 at 6:24 PM, Resident continues to have one on one cna due to inappropriate sexual behaviors. Per CNA inappropriate behaviors or comments made this shift to staff started around 1800 (6:00 PM). Per CNA resident made comments such as 'Can you find a black [NAME]' and 'where are the chocolate girls at.' Educated [resident 1] on inappropriate comments and behaviors. Pt stated he understands. v. On 10/27/22 at 4:38 PM, MSW [Masters of Social Work] asked to consult on this [AGE] year old long term resident who has been making sexually inappropriate comments to staff and others. Pt was awake and alert when MSW entered room. Pt explained that he is a 'sex addict' and that he has been married 4 times. Pt states that he has been making sexually related comments in hopes of 'hooking up' with staff. MSW countered that would not occur in this building. Pt also stated that he enjoys making such comments because if [sic] makes people upset and gets 'a rise' out of them. MSW talked with pt about consequences of his behavior and how that could effect his long term placement. MSW reviewed with pt ways he could curb his behavior and the pt was able to come up by himself ways in which he could re-direct his sexual urges. The pt has had a change in his medication in hopes of reducing his urges. The staff have stated that they have seen minimal effects. w. On 11/2/22 at 1:12 PM and recorded as a late entry on 11/4/22 at 1:12 PM the NP documented, .Paxil helping with hypersexualy [sic] . x. On 11/10/22 at 6:45 AM, Aide answered patient's call light and he was partially undressed in his bed and his privates exposed. Patient asked aide to finish undressing him. Nurse reoriented patient and educated him on remaining as independent as possible, patient agreed he could undress himself and that he would alert nurse if he needed anything else. y. On 11/11/22 at 4:59 PM, Staff agency aide answered call light at 3AM [3:00 AM] and patient took off his blankets exposing himself and asked her to shower him. Nurse reoriented patient and reminded him that showers usually take place after 6am [6:00 AM] patient agreed with waiting until later in the morning and went back to bed. z. On 11/15/22 at 4:17 PM, SS went to talk with resident in regard to him continuing to offer staff money for sex, and trying to touch staffs bottoms. He was reminded that he cannot be doing that, and that if that type of harassment continues, we will be calling the police. aa. On 12/1/22 at 7:09 PM and was edited by the nurse on 12/13/22 at 10:34 AM revealed, Resident has been inappropriate all shift. Asking staff if 'anyone wants to hook up and if we can find someone to hook up with him he will be in room [ROOM NUMBER]'. Educated [resident 1] about inappropriate comments and behaviors. Staff will continue to monitor, documented, and educated [resident 1] on this behavior. No falls or injuries this shift. bb. On 12/1/22 at 9:39 PM and was edited by the nurse on 12/9/22 at 12:27 PM revealed, .Pt has been making inappropriate comments this shift. LN [Licensed Nurse] educated resident on making inappropriate comments. He verbalized understanding . cc. On 12/3/22 at 8:19 AM, Nurse went to patients room in 501 to administer medications to patient. Patient reports that [resident 1] was in here [sic] room pulling her covers off while she was asleep. Resident in 501 states she yelled 'get out of my room.' Nurse told patient in 501 she will talk to [resident 1] about the issue. After leaving 501 room, patient in 503 opened her door and reports that [resident 1] was in her room trying to mover [sic] her bedside table. Patient states she yelled at him to get out. Nurse told patient in 503 she will talk to patient. Administrator, DON, and MD notified. dd. On 12/5/22 at 7:17 AM, recorded as a late entry on 12/6/22 at 7:17 AM by the NP revealed, .Had pepper spray to eyes earlier today. He is resolved with eye wash. He continues to be inappropriate with other staff and residents requesting sex. ee. On 12/5/22 at 9:27 AM, LN was notified by another LN that resident was outside a room at the end of the hall with what appears to be orange colored substance on his glasses. LN went to assess and immediately started choking from something in the air. A nearby CNA informed LN that a [sic] this patient had attempted to enter the patients room uninvited and was sprayed with something. LN immediately knocked on the door and asked the patient what the substance was and was told it was pepper spray. This LN and another LN took him back to his room and started washing his face and eyes with saline. Patient recovered quickly. LN notified DON and administrator of event. The patient down the hall then called police. MD and daughter has been notified of event. Order to monitor for any side effects from pepper spray in the eyes for 3 days. Order carried out. ff. On 12/5/22 at 10:29 AM, SS called residents daughter and asked about a discharge plan, she is comfortable with her dad discharging home to her house today. Resident is a threat to other residents safety and well being here [name of facility]. gg. On 12/5/22 at 10:36 AM, the physician documented I was informed that [resident 1] entered a female patient's room uninvited and unwelcome. She warned him not to enter. The police were called and he is being charged with a misdemeanor trespassing. DHS [Department of Health Services], the ombudsman, and APS [Adult Protective Services] were also notified. It is my professional opinion that [resident 1] poses a threat to the patients at our facility and should be removed ASAP [as soon as possible]. hh. On 12/5/22 at 11:08 AM, Resident is currently on 1:1 supervision. ii. On 12/5/22 at 1:58 PM, SS has been working with daughter and his Utah Case management team, if he leaves today he will lose his New Choice Waiver. His daughter has teenage daughters, so him discharging to his daughters is not ideal. I then called mobile crisis unit and spoke to [name removed], they could not help either. jj. On 12/5/22 at 3:09 PM, SS and business office went down to issue resident discharge notice. he signed it and understood. 2. Resident 3 was admitted to the facility on [DATE] with diagnoses which included urinary tract infection, hypo-osmolality and hyponatremia, chronic pain, fibromyalgia, and personal history of a transient ischemic attack. Resident 3's medical record was reviewed on 3/2/23. Resident 3's progress notes revealed the following entries: a. On 11/3/22 at 1:45 PM, Patient arrived via stretcher . Oriented to place, time, place [sic] and situation. Patient can't hear on the right ear and able to on the left ear. Patient has on hearing aide with case and charger .Patient states she only lays on left side because it hurts her to lay on her right side and on her back . b. On 11/17/22 at 5:03 PM, Type of MDS Assessment: Admit.She has adequate hearing in right ear. She is deaf in lef [Sic] ear and has hearing aides. She has clear speech. She is understood and she understands others. Her cognition is intact aeb [as evidenced by] BIMS score of 15/15 .Pt requires extensive assist of staff for most ADLs . c. On 12/3/22 at 8:29 AM, Residents discharge was pushed out to the 10th due to Covid +, however resident wants to leave the 12/3/22 as originally planned. SS reached out to [name of assisted living], they are fine with taking her Covid + . d. On 12/3/22 at 6:31 PM, Resident discharged today. e. On 12/5/22 at 3:20 PM, DON and SS went to [name of assisted living] where [resident 3] discharged to from facility to follow up with resident's report of male resident entering room on 12/3/22 and pulling down covers while resident was sleeping. [Resident 3] reported to DON and SS that while [resident 3] was in bed facing window a male resident in wheelchair stroked her back twice. On the first time she could not see anyone after turning head to look back after the second time she turned around to the other side facing the door and saw male resident in wheelchair next to bed who proceeded to touch her leg inappropriately and up to her breast. She then yelled for him to get out of her room and resident left. Resident did not report extent of abuse to nurse on Saturday before discharging. [Local police department] was called to report abuse and SS is reporting to state agency. It should be noted that there was a no note regarding the incident on 12/3/22 in resident 3's medical record but there was a note in resident 1's medical record. 3. Resident 2 was admitted to the facility on [DATE] with diagnoses which included infection following a procedure, sepsis, fusion of spine, diabetes mellitus, generalized anxiety disorder and depression. Resident 2's medical record was reviewed on 3/2/23. Resident 2's progress notes revealed the following entries: a. On 11/4/22 at 8:30 AM, .Patient is alert and oriented to person, place, time and situation. Hear [sic] adequate ob [sic] both sides no hearing aides. Has glasses. b. On 11/21/22 at 3:27 PM, Type of MDS Assessment: Admit .Her cognition is intact aeb BIMS score of 15/15 . c. On 11/29/22 at 8:45 AM, SS reached out to [name of behavioral health company] to follow up on referral for a psyche eval, [name removed] was going to come and complete it last Friday, however she has been very ill. [Name removed] responded to me this morning stating that she is not a provider for [resident 2's] insurance, and said that it may be best to refer her somewhere when she discharges. In the meantime, SS has received no reports of resident having any behaviors in the past week or so. She seems to have settled in, and spends a lot of time working on the puzzle in the dining area. d. On 11/30/33 at 12:09 AM, .Rapid COVID test done, with positive results . e. On 12/5/22 at 8:19 AM, recorded as late entry on 12/9/22 at 12:24 PM, LN went in to administer morning medications and asked resident how she was feeling about the situation. Resident stated she was angry that it happened. LN notified resident that the other patient would have a 1:1 supervision aide and she stated she felt better about that. Resident said she just wanted to go back to sleep. f. On 12/5/22 at 10:53 AM, LN was notified of an incident involving another resident this morning. LN went in to talk to this resident about what happened. Resident stated that another resident opened her door and tried to come in her room so she sprayed him with pepper spray. She stated she was fearful of what he might do so she called the police. LN assured resident that we will do all we can to prevent the other resident from going into her room. g. On 12/5/22 at 2:46 PM, recorded as a late entry on 12/5/22 at 6:56 PM, SS went to speak with resident in regards to the incident that happened this morning. SS asked resident how she was feeling, she started telling me that nobody cares about how she is feeling. I reassured resident that I care, and that's why I am here. I asked her if she feels safe and secure, she stated that she hasn't felt safe or secure since she arrived. I asked what I could do to help her feel safe, and her response was 'nothing could be done or it would be done already'. I offered her a counseling referral and she argued with me about how she would be able to do it, said she did not have correct technology for virtual visits . h. On 12/6/22 at 11:12 AM, Spoke with daughter [name removed] about how we could help [resident 2] feel safe in our facility, daughter stated she feels the best option is to have resident transferred to another facility. Ensured daughter and resident that we are taking every step to ensure resident feels safe, multiple options were refused by resident, SS working on finding facility that resident will approve. i. On 12/6/22 at 1:38 PM, UM [Unit Manager] went to check in with patient on how she was feeling after yesterdays events. Expressed that we want to make sure that she feels safe here and address any emotional concerns she may have at this time. Her reply was 'I'm fine, I'm fine.' . j. On 12/7/22 at 6:10 AM, Referral to LCSW [Licensed Clinical Social Worker] sent, SS will assist resident with choosing a counseling place today. k. On 12/7/22 at 2:16 PM, Due to recent events it was discovered that residents daughter had brought her in pepper spray because resident reported to daughter that she did not feel safe. However, resident and daughter failed to report that pepper spray was [NAME] [sic] in, or that [resident 2] felt unsafe during her stay. SS had been in [resident 2's] room over the past couple of weeks, and she had not said anything to me. Staff have not reported to myself or any other management that resident has not felt safe. It should be noted that there was a no note regarding the incident on 12/3/22 in resident 2's medical record but there was a note in resident 1's medical record. l. On 12/16/22 at 1:33 PM, Patient discharged home today. A review of the facility reported incidents to the State Survey Agency revealed the facility reported on 12/5/22 at 10:39 AM, the following incident. The initial report revealed on 12/5/22 with no time indicated, resident 1 tried to enter resident 2's room. The report revealed resident 2 told him no and sprayed him with pepper spray. The follow-up investigation report revealed that resident 1 was interviewed. [Resident 1] admitts [sic] to atempting [sic] to enter [resident 2's] room where she warned him and told him to leave. When he did not leave [resident 2] sprayed him. Through the day [resident 1] was on a one on one with staff and did not report or display any psychological harm or disstress [sic] as a result. According to the summary of interviews, [Resident 2] was interviewed. [Resident 2] stated she warned [resident 1] not to go into her room when [resident 1] did not leave she sprayed him with pepper spray. This was done is [sic] self defense. [Resident 1] reports that her daughter brought in the pepper spray and the daughter verified she did bring in the pepper spray. Staff were not notified that pepper spray was brought into the facility. The Summary of interviews with other residents who have had contact with the alleged perpetrator revealed During the course of this investigation another allegation came to light. It was reported by [resident 2] that a recently discharged resident [resident 3] told [resident 2] that [resident 1] had entered [resident 3's] room and touched her inappropiately [sic]. This was reported as a separate allegation. The conclusion was that the allegation was verified, It is verified that [resident 2] did spray [resident 1] in the face with a pepper spray like substance, but it was done out of self defense. The form further revealed that abuse training and in-service with staff sine [sic] incident. A review of the facility reported incident to the State Survey Agency revealed on 12/5/22 at 4:59 PM, the following incident occurred. The initial report revealed that on 12/3/22 at an unknown time resident 3 reported that resident 1 had allegedly entered her room and pulled her covers off. The follow-up investigation report revealed [Resident 3] accused [resident 1] of touching her inappropriately. [Resident 3] says that she feels safe and secure in her new home . The form further revealed [Resident 1] confirms that he was in [resident 3's] room, and that she was 'teasing him.' He confirms that he did touch her, and that he won't do it again. The allegation was verified The allegation of innapropriate [sic] touching was verified as evidenced by [resident 1] admitting to the action. The form further revealed that resident 1 was given a discharge notice but then passed away. Resident 3 was offered counseling services but felt safe in her new home. The systemic actions were Reviewed and provided abuse inservice. The facility provided abuse training and reporting with staff signatures from 12/7/22, 12/20/22, 1/19/23, 1/30/23, 2/21/23, 2/23/23 and 2/28/23. There was no specific education information provided. On 3/2/23 at 2:11 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated resident 1 was alert and oriented to person, place, time and sometimes situation. RN 1 stated resident 1 did have times of confusion. RN 1 stated resident 1 was provided one on one supervision for being inappropriate with female staff. RN 1 stated resident 2 resided in room [ROOM NUMBER] and resident 3 resided in room [ROOM NUMBER]. RN 1 stated the first time she heard about any interactions, was on 12/3/22 when resident 2 told her that a man in an orange hat came into her room and moved her bedside table in the middle of the night. RN 1 stated resident 2 told her if he entered her room again she had [NAME]. RN 1 stated that resident 2 told her that her daughter brought her the [NAME]. RN 1 stated she reported what resident 2 had told her to the DON and Administrator (ADM). RN 1 stated that happened on 12/3/22. RN 1 stated resident 3 had told her that someone entered her room and tugged on her blanket in the middle of the night and she nudged him with her leg. RN 1 stated when she reported to the DON, she thought resident 1 was provided with one on one supervision after that incident but could not remember. RN 1 provided a text message sent to the DON on 12/3/22 with the nurses note from resident 1's medical record. The text message further revealed This is my note about [resident 1]. This was this morning. And awhile ago when I was discharging 501, I hear 503 [resident 2] yelling 'get out of here! I will [NAME] [sic] you if you come near my door or come in my room and call the cops after' While she was yelling at him, [resident 1] was holding his fist at her! I told [resident 1] to leave and while telling him to leave, [resident 3] 501 tells family members that, that was the guy I told was in my room this morning. Family member started to tell me you guys can't have him going into peoples room and that he shouldn't be here. Told them we are dealing with the issue. On 3/2/23 at 4:42 PM, a phone interview was conducted with RN 2. RN 2 stated resident 1 went into other resident rooms. RN 2 stated resident 1 lost his cell phone and went into everyone's room looking for it. RN 2 stated around 12/1/22 several residents told resident 1 to get out of their rooms. RN 2 stated resident 2 was aware that resident 1 was entering resident rooms. RN 2 stated she was working the morning that resident 1 was maced by resident 2. RN 2 stated he opened resident 2's door and she was ready and sprayed resident 1 in the doorway. RN 2 stated prior to resident 1 being maced resident 2 had complained that he had gone into her room because the information had been passed onto her in report by other nurses. RN 2 stated resident 1 was maced between 6:00 AM and 6:45 AM. On 3/2/23 at 2:42 PM, an interview was conducted with the Resident Advocate (RA) and the DON. The RA stated resident 1 had some behaviors/incidents. The RA stated resident 1 went into female rooms. The RA stated that he had entered 3 different female resident rooms including resident 2 and resident 3. The RA stated resident 1 exposed himself to a female resident in October 2022. The RA stated that resident 1 attempted to touch the female residents when he went into their rooms. The RA stated resident 2 and resident 3 were in rooms next to each other. The RA stated they found out resident 1 had entered resident 3's room and touched her from resident 2. The RA stated resident 1 entered resident 3's room and touched her leg or back and pulled the blankets off. The DON stated that she remembered the pepper spray happened on Monday 12/5/22 before their 9:00 AM meeting. The DON stated that the Saturday (12/2/22) before, Registered Nurse (RN) 1 reached out to her about resident 2 having [NAME] and was going to [NAME] resident 1 if he entered her room. The DON stated she was not sure why resident 2 needed [NAME]. The DON stated she instructed RN 1 to report it to the Administrator (ADM) who was the abuse coordinator. The DON stated resident 1 was moved to his own room and his behaviors calmed down a lot. The DON stated then his behaviors started again and he was put on one on one supervision. The DON stated resident 1 was placed on one on one on 10/20/22 after he exposed himself to a resident and did not come off of one one one supervision until he went to the hospital on [DATE]. The DON was asked how resident 1 had been maced if he was provided one on one supervision. The DON stated if it was during shift change, a CNA might be late and the nurses should have kept an eye on him. The DON stated she did not know how long resident 1 was without a one on one on 12/5/22. The DON stated after resident 1 was maced, staff washed his eyes out and one on one supervision was continued. The RA stated she talked to resident 2 on 12/5/22 and resident 2 reported that resident 1 tried to go in and touch her beside table and she threw him out. The RA stated that resident 2 stated resident 1 tried to enter her room on 12/3/22 and told resident 1 she would pepper spray him if he entered her room again. The RA stated that resident 1 had been removed from one on one supervision at one point from the ADM. The DON stated there should have been a physician's order for residents to receive one on one supervision. The DON stated according to resident 1's medical record he received one one one supervision from 10/20/22 until 11/4/22. The DON stated resident 1's daughter reported that resident 1 had always been a sexual person. The DON stated that resident 1 had an increase in his medication Paxil on 10/14/22 because of hypersexual behaviors. On 3/2/23 at 3:55 PM, an interview was conducted with the ADM. The ADM stated he was the facility abuse coordinator. The ADM stated resident 1 had issues and was provided one on one supervision until his behavior improved and was taken off. The ADM stated there was another incident and resident 1 was put back on one on one supervision. The ADM stated resident 1's daughter informed staff that resident 1 had a history of being sexually inappropriate. The ADM stated he was notified that resident 1 tried to go into resident 2's room but resident 2 did not say anything prior to spraying resident 1 with [NAME]. The ADM stated police came to the facility and did not press charges against resident 2 because resident 1 was in her doorway, and she acted in self defense. The ADM stated after resident 1 was maced he was provided one on one supervision. The ADM stated that resident 2 told staff that resident 1 entered resident 3's room prior. The ADM stated he was not notified that resident 2 had [NAME] or that resident 1 had entered other residents' rooms prior to 12/5/22. The ADM stated even if he had been notified that resident 2 had [NAME], he would not have completed an abuse investigation but would probably have talked to resident 2 regarding why she needed it. On 3/6/23 at 12:28 PM, a follow up interview was conducted with the ADM. The ADM stated he was not aware of any events on 12/3/22 with resident 1 or that resident 2 had [NAME]. The ADM stated he was out to eat for his wife's birthday on 12/3/22. The ADM stated staff were probably not bugging him because of that. The ADM stated the DON did not know how to fill out the abuse reporting to the State Survey Agency. The ADM stated that the Social Service Director had completed abuse reporting and investigating in the past but he had taken that over so he was aware of issues in the facility. The ADM stated he looked back at his text messages and his tiger texts on 12/3/22 and there were no notification from RN 1 or the DON. On 3/7/23 at 2:33 PM, a phone interview was conducted with resident 2. Resident 2 stated that a few days after she was admitted , resident 1 came up to her in the dining room and asked her to have sex with him. Resident 2 stated she complained resident 1 was going in and out of her room for 2 weeks straight. Resident 2 stated he either entered her room or was knocking on the door between midnight and 2:00 AM most nights. Resident 2 stated he molested the resident i[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 3 of 6 sampled residents, that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility did not have evidence that all alleged violations were thoroughly investigated to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress. Specifically, allegations of abuse were not thoroughly investigated and staff did not prevent further abuse after a male resident entered female resident rooms without their permission. One female resident was touched by the male resident during the night and another female residents expressed to staff she would use [NAME] the male resident if he entered her room again. The female resident later maced the male resident when he tried to enter her room. This resulted in the finding of harm for two residents. Resident identifiers: 1, 2 and 3. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction due to unspecified occlusion or stenosis of right posterior cerebral artery, hemiplegia and hemiparesis, dysarthria and dysphagia follow cerebral infarction, and sexual dysfunction not due to a substance or known physiological condition. Resident 1's medical record was reviewed on 3/2/23. A Pre-admission Screening Applicant/Resident Review (PASRR) dated 7/2/22 revealed that resident 1 had hypersexual behaviors. The comment and notes section revealed New medication started on 9/17/2022 for hypersexuality. Resident 1 was screened out for a level II because the diagnosis was not considered to be a serious mental illness. A quarterly Minimum Data Set (MDS) dated [DATE] revealed resident 1 had a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS further revealed resident 1 was not steady but able to stabilized without human assistance when moving from seated to standing, walking, turning around and facing the opposite direction while walking and transferring from surface to surface. A care plan dated 9/9/22 and edited on 12/7/22 revealed behavioral symptoms because resident 1 made sexually inappropriate comments/actions toward staff and others. The goal was that resident 1 would not exhibit inappropriate comments/actions. An approach dated 9/9/22 revealed Remind [resident 1] that his comments can make others uncomfortable, but do not alienate him. Two approaches with start dates of 10/28/22 revealed to Let resident know those types of comments are unwelcome, and to please stop. Make sure he is being appropriate around other residents. Praise resident for appropriate behaviors and [Resident 1] stated he will go to his room if he has an urge. An approach dated 12/5/22 was one on one supervision related to an incident on 12/5/22. A care plan dated 12/5/22 with a created date of 12/6/22 revealed that resident 1 had behavioral symptoms of making other residents feel unsafe by entering their rooms. The goal was to make other residents in the building feel safer and the approach was one on one care in place. Resident 1's progress notes were reviewed and revealed the following: a. On 10/20/22 at 10:30 AM, Resident found in another residents room showing her his penis. SS reached out to his daughter [name removed], she sats [sic] that he has been a very sexual person his whole life. She is unsure what to do at this time. She states that she will come in and speak to him. SS has contacted police, they are on the way. Daughter is planning on coming by as well, she is questioning his mental state at this point and would like us to send him out for a psyche [psychological] eval [evaluation]. She states that he has been trying to leave the facility, and since his stroke she feels that he is not in his normal mental state. b. On 10/20/22 at 10:47 AM, Resident is on 1:1 care right now. c. On 12/1/22 at 7:09 PM and was edited by the nurse on 12/13/22 at 10:34 AM revealed, Resident has been inappropriate all shift. Asking staff if 'anyone wants to hook up and if we can find someone to hook up with him he will be in room [ROOM NUMBER]'. Educated [resident 1] about inappropriate comments and behaviors. Staff will continue to monitor, documented, and educated [resident 1] on this behavior. No falls or injuries this shift. d. On 12/1/22 at 9:39 PM and was edited by the nurse on 12/9/22 at 12:27 PM revealed, .Pt has been making inappropriate comments this shift. LN [Licensed Nurse] educated resident on making inappropriate comments. He verbalized understanding . e. On 12/3/22 at 8:19 AM, Nurse went to patients room in 501 to administer medications to patient. Patient reports that [resident 1] was in here [sic] room pulling her covers off while she was asleep. Resident in 501 states she yelled 'get out of my room.' Nurse told patient in 501 she will talk to [resident 1] about the issue. After leaving 501 room, patient in 503 opened her door and reports that [resident 1] was in her room trying to mover [sic] her bedside table. Patient states she yelled at him to get out. Nurse told patient in 503 she will talk to patient. Administrator, DON, and MD notified. f. On 12/5/22 at 7:17 AM, recorded as a late entry on 12/6/22 at 7:17 AM by the NP revealed, .Had pepper spray to eyes earlier today. He is resolved with eye wash. He continues to be inappropriate with other staff and residents requesting sex. g. On 12/5/22 at 9:27 AM, LN was notified by another LN that resident was outside a room at the end of the hall with what appears to be orange colored substance on his glasses. LN went to assess and immediately started choking from something in the air. A nearby CNA informed LN that a [sic] this patient had attempted to enter the patients room uninvited and was sprayed with something. LN immediately knocked on the door and asked the patient what the substance was and was told it was pepper spray. This LN and another LN took him back to his room and started washing his face and eyes with saline. Patient recovered quickly. LN notified DON and administrator of event. The patient down the hall then called police. MD and daughter has been notified of event. Order to monitor for any side effects from pepper spray in the eyes for 3 days. Order carried out. h. On 12/5/22 at 10:29 AM, SS called residents daughter and asked about a discharge plan, she is comfortable with her dad discharging home to her house today. Resident is a threat to other residents safety and well being here [name of facility]. i. On 12/5/22 at 10:36 AM, the physician documented I was informed that [resident 1] entered a female patient's room uninvited and unwelcome. She warned him not to enter. The police were called and he is being charged with a misdemeanor trespassing. DHS [Department of Health Services], the ombudsman, and APS [Adult Protective Services] were also notified. It is my professional opinion that [resident 1] poses a threat to the patients at our facility and should be removed ASAP [as soon as possible]. j. On 12/5/22 at 11:08 AM, Resident is currently on 1:1 supervision. k. On 12/5/22 at 1:58 PM, SS has been working with daughter and his Utah Case management team, if he leaves today he will lose his New Choice Waiver. His daughter has teenage daughters, so him discharging to his daughters is not ideal. I then called mobile crisis unit and spoke to [name removed], they could not help either. l. On 12/5/22 at 3:09 PM, SS and business office went down to issue resident discharge notice. he signed it and understood. 2. Resident 3 was admitted to the facility on [DATE] with diagnoses which included urinary tract infection, hypo-osmolality and hyponatremia, chronic pain, fibromyalgia, and personal history of a transient ischemic attack. Resident 3's medical record was reviewed on 3/2/23. Resident 3's progress notes revealed the following entries: a. On 11/3/22 at 1:45 PM, Patient arrived via stretcher . Oriented to place, time, place [sic] and situation. Patient can't hear on the right ear and able to on the left ear. Patient has on hearing aide with case and charger .Patient states she only lays on left side because it hurts her to lay on her right side and on her back . b. On 11/17/22 at 5:03 PM, Type of MDS Assessment: Admit.She has adequate hearing in right ear. She is deaf in lef [Sic] ear and has hearing aides. She has clear speech. She is understood and she understands others. Her cognition is intact aeb [as evidenced by] BIMS score of 15/15 .Pt requires extensive assist of staff for most ADLs . c. On 12/3/22 at 8:29 AM, Residents discharge was pushed out to the 10th due to Covid +, however resident wants to leave the 12/3/22 as originally planned. SS reached out to [name of assisted living], they are fine with taking her Covid + . d. On 12/3/22 at 6:31 PM, Resident discharged today. e. On 12/5/22 at 3:20 PM, DON and SS went to [name of assisted living] where [resident 3] discharged to from facility to follow up with resident's report of male resident entering room on 12/3/22 and pulling down covers while resident was sleeping. [Resident 3] reported to DON and SS that while [resident 3] was in bed facing window a male resident in wheelchair stroked her back twice. On the first time she could not see anyone after turning head to look back after the second time she turned around to the other side facing the door and saw male resident in wheelchair next to bed who proceeded to touch her leg inappropriately and up to her breast. She then yelled for him to get out of her room and resident left. Resident did not report extent of abuse to nurse on Saturday before discharging. [Local police department] was called to report abuse and SS is reporting to state agency. It should be noted that there was a no note regarding the incident on 12/3/22 in resident 3's medical record but there was a note in resident 1's medical record. 3. Resident 2 was admitted to the facility on [DATE] with diagnoses which included infection following a procedure, sepsis, fusion of spine, diabetes mellitus, generalized anxiety disorder and depression. Resident 2's medical record was reviewed on 3/2/23. Resident 2's progress notes revealed the following entries: a. On 11/4/22 at 8:30 AM, .Patient is alert and oriented to person, place, time and situation. Hear [sic] adequate ob [sic] both sides no hearing aides. Has glasses. b. On 11/21/22 at 3:27 PM, Type of MDS Assessment: Admit .Her cognition is intact aeb BIMS score of 15/15 . c. On 11/29/22 at 8:45 AM, SS reached out to [name of behavioral health company] to follow up on referral for a psyche eval, [name removed] was going to come and complete it last Friday, however she has been very ill. [Name removed] responded to me this morning stating that she is not a provider for [resident 2's] insurance, and said that it may be best to refer her somewhere when she discharges. In the meantime, SS has received no reports of resident having any behaviors in the past week or so. She seems to have settled in, and spends a lot of time working on the puzzle in the dining area. d. On 11/30/33 at 12:09 AM, .Rapid COVID test done, with positive results . e. On 12/5/22 at 8:19 AM, recorded as late entry on 12/9/22 at 12:24 PM, LN went in to administer morning medications and asked resident how she was feeling about the situation. Resident stated she was angry that it happened. LN notified resident that the other patient would have a 1:1 supervision aide and she stated she felt better about that. Resident said she just wanted to go back to sleep. f. On 12/5/22 at 10:53 AM, LN was notified of an incident involving another resident this morning. LN went in to talk to this resident about what happened. Resident stated that another resident opened her door and tried to come in her room so she sprayed him with pepper spray. She stated she was fearful of what he might do so she called the police. LN assured resident that we will do all we can to prevent the other resident from going into her room. g. On 12/5/22 at 2:46 PM, recorded as a late entry on 12/5/22 at 6:56 PM, SS went to speak with resident in regards to the incident that happened this morning. SS asked resident how she was feeling, she started telling me that nobody cares about how she is feeling. I reassured resident that I care, and that's why I am here. I asked her if she feels safe and secure, she stated that she hasn't felt safe or secure since she arrived. I asked what I could do to help her feel safe, and her response was 'nothing could be done or it would be done already'. I offered her a counseling referral and she argued with me about how she would be able to do it, said she did not have correct technology for virtual visits . h. On 12/6/22 at 11:12 AM, Spoke with daughter [name removed] about how we could help [resident 2] feel safe in our facility, daughter stated she feels the best option is to have resident transferred to another facility. Ensured daughter and resident that we are taking every step to ensure resident feels safe, multiple options were refused by resident, SS working on finding facility that resident will approve. i. On 12/6/22 at 1:38 PM, UM [Unit Manager] went to check in with patient on how she was feeling after yesterdays events. Expressed that we want to make sure that she feels safe here and address any emotional concerns she may have at this time. Her reply was 'I'm fine, I'm fine.' . j. On 12/7/22 at 6:10 AM, Referral to LCSW [Licensed Clinical Social Worker] sent, SS will assist resident with choosing a counseling place today. k. On 12/7/22 at 2:16 PM, Due to recent events it was discovered that residents daughter had brought her in pepper spray because resident reported to daughter that she did not feel safe. However, resident and daughter failed to report that pepper spray was [NAME] [sic] in, or that [resident 2] felt unsafe during her stay. SS had been in [resident 2's] room over the past couple of weeks, and she had not said anything to me. Staff have not reported to myself or any other management that resident has not felt safe. It should be noted that there was a no note regarding the incident on 12/3/22 in resident 2's medical record but there was a note in resident 1's medical record. l. On 12/16/22 at 1:33 PM, Patient discharged home today. A review of the facility reported incidents to the State Survey Agency revealed the facility reported on 12/5/22 at 10:39 AM, the following incident. The initial report revealed on 12/5/22 with no time indicated, resident 1 tried to enter resident 2's room. The report revealed resident 2 told him no and sprayed him with pepper spray. The follow-up investigation report revealed that resident 1 was interviewed. [Resident 1] admitts [sic] to atempting [sic] to enter [resident 2's] room where she warned him and told him to leave. When he did not leave [resident 2] sprayed him. Through the day [resident 1] was on a one on one with staff and did not report or display any psychological harm or disstress [sic] as a result. According to the summary of interviews, [Resident 2] was interviewed. [Resident 2] stated she warned [resident 1] not to go into her room when [resident 1] did not leave she sprayed him with pepper spray. This was done is [sic] self defense. [Resident 1] reports that her daughter brought in the pepper spray and the daughter verified she did bring in the pepper spray. Staff were not notified that pepper spray was brought into the facility. The Summary of interviews with other residents who have had contact with the alleged perpetrator revealed During the course of this investigation another allegation came to light. It was reported by [resident 2] that a recently discharged resident [resident 3] told [resident 2] that [resident 1] had entered [resident 3's] room and touched her inappropiately [sic]. This was reported as a separate allegation. The conclusion was that the allegation was verified, It is verified that [resident 2] did spray [resident 1] in the face with a pepper spray like substance, but it was done out of self defense. The form further revealed that abuse training and in-service with staff sine [sic] incident. A review of the facility reported incident to the State Survey Agency revealed on 12/5/22 at 4:59 PM, the following incident occurred. The initial report revealed that on 12/3/22 at an unknown time resident 3 reported that resident 1 had allegedly entered her room and pulled her covers off. The follow-up investigation report revealed [Resident 3] accused [resident 1] of touching her inappropriately. [Resident 3] says that she feels safe and secure in her new home . The form further revealed [Resident 1] confirms that he was in [resident 3's] room, and that she was 'teasing him.' He confirms that he did touch her, and that he won't do it again. The allegation was verified The allegation of innapropriate [sic] touching was verified as evidenced by [resident 1] admitting to the action. The form further revealed that resident 1 was given a discharge notice but then passed away. Resident 3 was offered counseling services but felt safe in her new home. The systemic actions were Reviewed and provided abuse inservice. The facility provided abuse training and reporting with staff signatures from 12/7/22, 12/20/22, 1/19/23, 1/30/23, 2/21/23, 2/23/23 and 2/28/23. There was no specific education information provided. It should be noted that resident 1 had a progress note on 12/3/22 regarding resident 1 going in and out of resident 2 and 3's room. There was no invesitgation until 12/5/22 after resident 1 had been maced. On 3/2/23 at 2:11 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated resident 1 was alert and oriented to person, place, time and sometimes situation. RN 1 stated resident 1 did have times of confusion. RN 1 stated resident 1 was provided one on one supervision for being inappropriate with female staff. RN 1 stated resident 2 resided in room [ROOM NUMBER] and resident 3 resided in room [ROOM NUMBER]. RN 1 stated the first time she heard about any interactions, was on 12/3/22 when resident 2 told her that a man in an orange hat came into her room and moved her bedside table in the middle of the night. RN 1 stated resident 2 told her if he entered her room again she had [NAME]. RN 1 stated that resident 2 told her that her daughter brought her the [NAME]. RN 1 stated she reported what resident 2 had told her to the DON and Administrator (ADM). RN 1 stated that happened on 12/3/22. RN 1 stated resident 3 had told her that someone entered her room and tugged on her blanket in the middle of the night and she nudged him with her leg. RN 1 stated when she reported to the DON, she thought resident 1 was provided with one on one supervision after that incident but could not remember. RN 1 provided a text message sent to the DON on 12/3/22 with the nurses note from resident 1's medical record. The text message further revealed This is my note about [resident 1]. This was this morning. And awhile ago when I was discharging 501, I hear 503 [resident 2] yelling 'get out of here! I will [NAME] [sic] you if you come near my door or come in my room and call the cops after' While she was yelling at him, [resident 1] was holding his fist at her! I told [resident 1] to leave and while telling him to leave, [resident 3] 501 tells family members that, that was the guy I told was in my room this morning. Family member started to tell me you guys can't have him going into peoples room and that he shouldn't be here. Told them we are dealing with the issue. On 3/2/23 at 4:42 PM, a phone interview was conducted with RN 2. RN 2 stated resident 1 went into other resident rooms. RN 2 stated resident 1 lost his cell phone and went into everyone's room looking for it. RN 2 stated around 12/1/22 several residents told resident 1 to get out of their rooms. RN 2 stated resident 2 was aware that resident 1 was entering resident rooms. RN 2 stated she was working the morning that resident 1 was maced by resident 2. RN 2 stated he opened resident 2's door and she was ready and sprayed resident 1 in the doorway. RN 2 stated prior to resident 1 being maced resident 2 had complained that he had gone into her room because the information had been passed onto her in report by other nurses. RN 2 stated resident 1 was maced between 6:00 AM and 6:45 AM. On 3/2/23 at 2:42 PM, an interview was conducted with the Resident Advocate (RA) and the DON. The RA stated resident 1 had some behaviors/incidents. The RA stated resident 1 went into female rooms. The RA stated that he had entered 3 different female resident rooms including resident 2 and resident 3. The RA stated resident 1 exposed himself to a female resident in October 2022. The RA stated that resident 1 attempted to touch the female residents when he went into their rooms. The RA stated resident 2 and resident 3 were in rooms next to each other. The RA stated they found out resident 1 had entered resident 3's room and touched her from resident 2. The RA stated resident 1 entered resident 3's room and touched her leg or back and pulled the blankets off. The DON stated that she remembered the pepper spray happened on Monday 12/5/22 before their 9:00 AM meeting. The DON stated that the Saturday (12/2/22) before, Registered Nurse (RN) 1 reached out to her about resident 2 having [NAME] and was going to [NAME] resident 1 if he entered her room. The DON stated she was not sure why resident 2 needed [NAME]. The DON stated she instructed RN 1 to report it to the Administrator (ADM) who was the abuse coordinator. The DON stated resident 1 was moved to his own room and his behaviors calmed down a lot. The DON stated then his behaviors started again and he was put on one on one supervision. The DON stated resident 1 was placed on one on one on 10/20/22 after he exposed himself to a resident and did not come off of one one one supervision until he went to the hospital on [DATE]. The DON was asked how resident 1 had been maced if he was provided one on one supervision. The DON stated if it was during shift change, a CNA might be late and the nurses should have kept an eye on him. The DON stated she did not know how long resident 1 was without a one on one on 12/5/22. The DON stated after resident 1 was maced, staff washed his eyes out and one on one supervision was continued. The RA stated she talked to resident 2 on 12/5/22 and resident 2 reported that resident 1 tried to go in and touch her beside table and she threw him out. The RA stated that resident 2 stated resident 1 tried to enter her room on 12/3/22 and told resident 1 she would pepper spray him if he entered her room again. The RA stated that resident 1 had been removed from one on one supervision at one point from the ADM. The DON stated there should have been a physician's order for residents to receive one on one supervision. The DON stated according to resident 1's medical record he received one one one supervision from 10/20/22 until 11/4/22. The DON stated resident 1's daughter reported that resident 1 had always been a sexual person. The DON stated that resident 1 had an increase in his medication Paxil on 10/14/22 because of hypersexual behaviors. On 3/2/23 at 3:55 PM, an interview was conducted with the ADM. The ADM stated he was the facility abuse coordinator. The ADM stated resident 1 had issues and was provided one on one supervision until his behavior improved and was taken off. The ADM stated there was another incident and resident 1 was put back on one on one supervision. The ADM stated resident 1's daughter informed staff that resident 1 had a history of being sexually inappropriate. The ADM stated he was notified that resident 1 tried to go into resident 2's room but resident 2 did not say anything prior to spraying resident 1 with [NAME]. The ADM stated police came to the facility and did not press charges against resident 2 because resident 1 was in her doorway, and she acted in self defense. The ADM stated after resident 1 was maced he was provided one on one supervision. The ADM stated that resident 2 told staff that resident 1 entered resident 3's room prior. The ADM stated he was not notified that resident 2 had [NAME] or that resident 1 had entered other residents' rooms prior to 12/5/22. The ADM stated even if he had been notified that resident 2 had [NAME], he would not have completed an abuse investigation but would probably have talked to resident 2 regarding why she needed it. On 3/6/23 at 12:28 PM, a follow up interview was conducted with the ADM. The ADM stated he was not aware of any events on 12/3/22 with resident 1 or that resident 2 had [NAME]. The ADM stated he was out to eat for his wife's birthday on 12/3/22. The ADM stated staff were probably not bugging him because of that. The ADM stated the DON did not know how to fill out the abuse reporting to the State Survey Agency. The ADM stated that the Social Service Director had completed abuse reporting and investigating in the past but he had taken that over so he was aware of issues in the facility. The ADM stated he looked back at his text messages and his tiger texts on 12/3/22 and there were no notification from RN 1 or the DON. On 3/7/23 at 2:33 PM, a phone interview was conducted with resident 2. Resident 2 stated that a few days after she was admitted , resident 1 came up to her in the dining room and asked her to have sex with him. Resident 2 stated she complained resident 1 was going in and out of her room for 2 weeks straight. Resident 2 stated he either entered her room or was knocking on the door between midnight and 2:00 AM most nights. Resident 2 stated he molested the resident in the room next to her who was resident 3. Resident 2 stated the nurses knew he was in and out of rooms. Resident 2 stated resident 3 told her that resident 1 entered resident 3's room in the middle of the night and put his hand on her leg and up her body to her breast. Resident 2 stated the next morning she was in her doorway and told resident 1 to stay away and resident 1 shook his fist at her. Resident 2 stated she had warned him that if he came in her room again she would [NAME] him. Resident 2 stated she was very worried he would enter her room and try to do something with her and she would hurt her back trying to get him away. Resident 2 stated she had recently had back surgery. Resident 2 stated she was concerned he would get into her bed when she was not awake. Resident 2 stated she slept during the day and had a note on her door to not disturb because that was the only time she could get rest. Resident 2 stated another resident reported to her that when the resident was at lunch, resident 1 went into her room, got naked, and was in her bed. Resident 2 stated she became a light sleeper and a couple of times he caught her sleeping, she woke up and told him to get out. Resident 2 stated that staff did not care and would come ask her if she was okay and she responded by saying I'm fine, I'm fine because they did not do anything. Resident 2 stated she asked to talk to a therapist and was told she was not there long term, so she could not have counseling. Resident 2 stated she told her daughter about resident 1 coming in her room, so her daughter brought her [NAME] to protect herself. Resident 2 stated resident 1 was in her doorway, opened her door and she sprayed him with [NAME] on 12/5/22 and called the police. On 3/7/23 at 3:13 PM, a phone interview was conducted with resident 3. Resident 3 stated she was at the facilty for about a month. Resident 3 stated there was a guy who went around in his wheelchair through the hallway. Resident 3 stated the last morning she was there at about 7:00 AM, after the nurse brought her medications in, she felt someone behind her scratching at her back. Resident 3 stated she asked what was going on and there was no response. Resident 3 stated she was unable to turn in bed or sleep on the right side because of back surgery. Resident 3 stated she had to sleep with her back to the door. Resident 3 stated she felt the scratching on her back again with a rub touch with the finger. Resident 3 stated she turned a little more and saw a man in a wheelchair behind her. Resident 3 stated he touched her leg and ran his hand all the way up to her breast. Resident 3 stated there was a lot of COVID-19 in the facility, so she yelled that she had COVID and he was going to get sick. Resident 3 stated he went to the doorway and just sat there and looked at her so she yelled it again. Resident 3 stated she told the nurse she had been assaulted and the nurse responded that was not the first time he was in another resident's rooms. Resident 3 stated he talked to the neighbor, who was resident 2, and the same man had come into her room and scared her. Resident 3 stated resident 2 was so terrified of him coming in again, she was sleeping during the day and her daughter brought in pepper spray. Resident 3 stated she discharged from the facility on 12/3/23. Resident 3 stated when she was leaving the facility, resident 1 was physically being stopped by staff because he was trying to get into her room. Resident 3 stated that staff took him to another area of the facility. Resident 3 stated she did not have hearing in one ear and had a hearing aide for the other ear but it was broken. Resident 3 stated she was so scared because of the assault, staff at her assisted living installed a loud doorbell. Resident 3 stated that the Social Worker and DON came to her assisted living to get a statement about what happened. Resident 3 stated her and resident 2 were back away from the main hall and we were more accessible for this guy to enter their rooms. Resident 3 stated resident 1 had not entered her room previously. Resident 3 stated that detectives from the local police department came to talk to her and informed her that resident 1 had died. The facility's Abuse, Neglect and Exploitation Policy with a reviewed/revised date of 9/30/22 and implemented on 10/24/22 revealed the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: .'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also including the deprivation by an individual, including a care taker, of foods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. .'Sexual Abuse' is non-consensual sexual contact of any type with resident. V. Investigation on Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, the facility did not ensure each resident received adequate supervision and services to prevent accidents. Specifically, for 1 out of 34 sampled residents, one resident sustained a skin tear to his face after falling off the bed during wound care. Resident identifier: 75. Findings include: Resident 75 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, osteomyelitis of vertebra, sacral and sacrococcygeal region, stage 4 pressure ulcer, acute respiratory failure, contracture of muscle (multiple sites), dependence on respiratory (ventilatory) status, tracheostomy status, severe protein-calorie malnutrition, need for assistance with personal care, bed confinement status, and cognitive communication deficit. Resident 75's medical records were reviewed on 5/18/22. A quarterly Minimum Data Set assessment dated [DATE], revealed that resident 75 required total dependence with two plus persons physical assistance for bed mobility. A review of resident 75's physician's orders revealed the following wound care orders: a. L (Left) hip wound tx (treatment): Cleanse with NS (normal saline) or wound spray. Apply collagen to wound bed, cover with regular alginate . Cover with bordered foam dressing. Daily and PRN (as needed). Order initiated on 5/12/22. b. R (Right) hip wound tx: Cleanse with NS or wound spray. Apply medical grade honey to wound bed. cover with foam dressing. Daily and PRN. Order initiated on 5/5/22. c. R upper back inferior wound tx: cleanse with NS or wound spray. Apply medical grade honey. Cover with foam dressing. Daily and PRN. Order initiated on 5/17/22. d. R upper back superior wound tx: Cleanse with NS or wound spray. Apply medical grade honey. Cover with foam dressing. Daily and PRN. Order initiated on 5/17/22. e. Sacrum wound vac (vacuum): Clean with NS or wound spray. Oil emulsion to exposed bone. Pack undermining with collagen powder, and apply collagen powder to wound bed . Change vac 3 times week, Tu (Tuesday), Th (Thursday), Sat (Saturday) and PRN. Order initiated on 5/17/22. A progress note dated 4/21/22, written by Nurse Practitioner (NP) 1 and signed by the Wound Care Nurse (WCN) revealed that resident 75, has severe contractures and remains in the fetal position and is very stiff. An Event report created on 5/17/22, revealed that resident 75 had a witnessed fall during wound care treatment. The following was located within the Event Details. a. A progress note dated 5/17/22 at 2:21 PM, revealed that resident 75 had sustained a fall during wound care. The progress note read, During wound care, resident [75] was on his side, as wound nurse turned ¾ turn to reach for a sponge, resident [75] slipped off the bed, and onto the floor, bed in low position. He [resident 75] received a skin tear to his R lateral face, near his eye. Steri strips put in place. Resident [75] examined from head to toe with no other issues noted .MD (Medical Director), DON (Director of Nursing), floor nurse, and family notified . b. A progress note dated 5/17/22 at 11:41 PM, revealed, patient assessed often. Patient has no decline from fall . right eye has steri strips intact. c. A progress note dated 5/18/22 at 4:10 PM, revealed, continue to monitor [resident 75] after recent witnessed fall no changes from baseline or change in LOC (level of consciousness). [Resident 75] is contracted and very frail. On 5/19/22 at 9:05 AM, an interview was conducted with the WCN. The WCN stated that resident 75 was unable to move by himself, and he always required at least two people during his cares. The WCN stated that resident 75 was severely contracted in a fetal position. The WCN stated that she and NP 1 were conducting a dressing change for resident 75's wounds, located on his backside. The WCN stated that she and NP 1 were holding resident 75 on his side, and as the WCN took a hand off resident 75 to reach for gauze, resident 75 slid off the bed and onto the floor. On 5/19/22 at 9:30 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1 and CNA 2. CNA 1 stated that resident 75 required at least two people for all of resident 75's care. CNA 2 stated that resident 75 could not move at all by himself and required two or more people to keep him safe during cares. On 5/23/22 at 1:00 PM, an interview was conducted with NP 1. NP 1 stated she was conducting wound care with the WCN on the day resident 75 fell on 5/17/22. NP 1 stated that she and the WCN were on opposite sides of resident 75's bed, with resident 75's backside facing NP 1. Resident 75's front side was facing the WCN. NP 1 stated that resident 75 was positioned on his side, and resident 75 was, closer to the left side of the bed, with the bed being in the lowest position. NP 1 stated that resident 75 was being held up by herself and the WCN. NP 1 stated that she was attempting to write the date on the new bandages for resident 75's backside wounds, and at the same time the WCN took a hand off resident 75 to reach for gauze. NP 1 stated that once the WCN took her hand off resident 75, he slid off the bed and onto the floor. NP 1 stated that once resident 75 slid off the bed, the WCN and NP 1 got resident 75 back into the bed, conducted neurological checks, assessed resident 75's head, and started vital signs. NP 1 stated that usually there were three people in the room during wound care, however NP 1 stated they did not think it was unreasonable to have two people in the room for resident 75's wound care. NP 1 stated wound care for resident 75 had been done with two people in the past.