Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to protect three of 31 residents in the survey sample from abuse (Residents #60, #50 and #35), which resulted in harm cited at past non-compliance. The findings include: 1. The facility failed to protect Resident #60 from sexual abuse from CNA (certified nursing assistant) #5. A review of the facility synopsis of event dated 4/10/23 revealed Incident Type: allegation of abuse/mistreatment. Resident #60 reported an incident to the nursing supervisor. He stated that while getting his brief changed two days ago, his CNA (certified nursing assistant) mouth touched his penis for two seconds. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 7/6/23, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring total dependence for transfer and bathing; extensive assistance for bed mobility, dressing, hygiene and independent for eating / locomotion. A review of the comprehensive care plan dated 4/12/23 revealed, PROBLEMS: Resident has a history of trauma. He reports he was sexually abused. APPROACHES/TASKS: Nursing will continue to offer counseling and will coordinate counseling services, if accepted by resident. Resident-specific ways to comfort resident if a trigger occurs: Allow resident to express feelings and validate them. Refer to SW (social worker) or chaplain for support. Resident-specific ways to decrease triggers: Resident requests to have female CNA's (certified nursing assistants). Staff to speak calmly and tell him what they want to do beforehand (changing clothes, all activities of daily living). Staff will ensure safety of resident by ensuring physical setting is safe and interpersonal interactions promote a sense of safety. Staff will promote collaboration and mutuality with resident by partnering with him and sharing power and decision-making. Staff will promote trustworthiness and transparency by maintaining transparency and building and maintaining trust with resident. Staff will uphold resident's empowerment and choice by supporting shared decision-making, choice, and goal setting. Staff will honor resident's self-advocacy skills. A review of the physician's progress note dated 4/10/23 at 3:33 PM, revealed, Seen for recent incident regarding abuse. Resident mentioned the same story about the aide having an inappropriate contact with him; he refused to allow me to examine him as he said there were no injuries and he was in no pain. I asked again and he was very clear that he did not wish to be examined. He was upset at the incident and was agreeable to follow-up and get some therapy/counseling on the next behavioral health visit. A review of Resident #60's Trauma Assessment dated 4/11/23, revealed, Is there a history of trauma, briefly describe the event: Resident reported on April 7th the 3-11 shift that his assigned CNA was changing him on the bed. CNA was reported to put his mouth briefly on resident's penis. Resident asked him to stop and he did. Self-Reporting Scale 0-10 (0= does not impact me at all 10= this impacts me a great deal). Using a Self-Reporting Scale, how much does this trauma impact your daily life: Resident said 10. What coping skills do you use to deal with thoughts of the traumatic event? Resident is unable to articulate an answer to this. Would you like the opportunity to meet with a counselor/therapist to discuss traumatic events that may continue to impact your life? Resident told me no - that he would talk with staff as needed. He told physician that he would. Is there anything you would like your social worker to know? Want to be able to talk with someone. Wants to sit outside. Wants to talk with his father and stepmother. Work with a female CNA only. A review of the director of nursing (DON) note dated 4/10/23 at 9:29 AM, revealed, Meeting with resident, social worker and myself. Resident is reporting an incident that happened on Friday night with his assigned CNA. Resident stated that when the aid was providing peri care his aide momentarily put his mouth on his penis. Resident stated he told him to stop and he did, closed his brief and left the room. Resident said that it was the first time having the CNA and he has not had him since. A review of the 4/11/23 3:22 PM care coordination note, revealed, Resident came to see me today. He talked a little about the incident that occurred on 4/7. Resident asked to call his parents - we called his stepmother and they talked for about 10 minutes. Resident's mood was calm, he said it was his 1st time coming to the first floor today. He went to recreational therapy and pt (physical therapy). He did not appear upset or frightened. A review of the 4/17/23 11:00 AM care coordination note, revealed, Checked on resident this morning. He said he enjoyed participating in the Walk-in-Roll event on Saturday the 15th. He declined to come to the 1st floor to socialize. He said he didn't feel like it. He had his tv on and was playing a computer game. A review of the 4/17/23 psychological services progress note, revealed, Patient readily discussed the recent incident of sexual abuse by a staff person, relating preoccupation about the incident and anxiety about his future safety and worry about interpersonal relationships. He related about how he had been a resident for a long time and previously felt safe there. Help patient to develop plan for coping with anxiety and build ways to improve self-esteem. A review of the hepatitis and STI (sexually transmitted infections) lab profile obtained 4/19/23, revealed Hepatitis B, HCV (hepatitis C virus), RPR (rapid plasma regain) and HIV (human immunodeficiency virus) all non-reactive. A review of the social services note dated 4/20/23 at 3:56 PM, revealed, Resident came to writer's office, requested to speak with writer in his room. Writer provided active listening and therapeutic support. Helped resident to recall several strategies he uses to self-soothe, validated feelings. Resident expressed gratitude for counseling support, staff support. A review of the 4/24/23 psychological services progress note, revealed, Patient has had individual therapy to improve anxiety and depression. The incident of sexual abuse is now also a focus of treatment due to increased symptoms. A review of the social services note dated 4/26/23 at 10:49 AM, revealed, Resident came to see SW (social worker) today for supportive listening. He said he was feeling fine. A review of the social services note dated 5/3/23 at 2:44 PM, revealed, SW spoke with resident. He was smiling and reported he was in a good mood. A review of the social services note dated 5/4/23 at 3:29 PM, revealed, Today, resident came to SW and asked to call his stepmother. We called her and resident said he was feeling sad from thinking about the traumatic event that occurred. Resident said he wanted to talk with the chaplain. SW took resident to see the chaplain and they have talked. Resident has come to see SW several times and said he was doing okay. His father/stepmother will come to visit this week (May 6 or 7). A review of the social services note dated 5/16/23 at 10:51 AM, revealed, Resident came to see SW yesterday the 15th and today the 16th. He is in a calm mood and said he feels better. Resident saw his father the previous weekend and said they had a nice visit. A review of the social services note dated 6/5/23 at 2:21 PM, revealed, Resident came to see me. He wanted to call his brother and they had a nice talk. Resident said he had some problems sleeping over the weekend. He said he didn't know what was wrong. He said he slept well last night. A review of the social services note dated 6/12/23 at 5:04 PM, revealed, Writer checked in with resident in his room, he asked when the court case would occur. Informed resident that I did not have concrete information but that it would take some time. Resident expressed satisfaction with that answer, then began discussing his latest music project and his visit with his dad. A review of the social services note dated 6/23/23 at 3:56 PM, revealed, Writer checked in with resident in his room, he states he is feeling good. Talked about his haunted house ideas, making new friends, and the TV show he was watching. A review of the social services note dated 7/10/23 at 1:30 PM, revealed, Quarterly assessment note for 7/6/23. Resident scored 14 on the BIMS - unable to tell me the current day of week. He scored 00 on the resident Mood Interview - no mood concerns noted. Resident likes to come to the first floor for certain programs. He likes to watch tv and play video games. His mood has been good. His father comes to visit 1 -2 times a month and he enjoys these visits very much. He has no discharge plans. He has a legal guardian. Quarter goal to assist as requested. A review of CNA (certified nursing assistant) #5's employee record, revealed the following. CNA #5 was hired on 1/9/23. Reference checks were obtained and were positive in describing CNA #5. The Virginia State Police Criminal background check was obtained on 12/20/22 and found 'no identifiable records. His nurse aid certification was obtained on 12/19/22 from the Virginia Department of Health Professions (DHP) License Lookup site. Certification was current and additional public information was listed as 'no'. According to the facility's timeline of this incident, On 3/23/23, a senior investigator from the Virginia DHP requested information on CNA #5. After this request ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing reviewed CNA #5's performance record. There were no other resident complaints, and the charge nurses and other staff did not observe any problems with CNA #5. Based on all available information, ASM #1 and ASM #2 determined that CNA #5 was doing his job well and giving good care to residents. A review of the Virginia DHP license lookup site on 7/18/23 revealed, CNA #5's nurse aide certification was suspended 6/27/23 due to The Board of Nursing (BON) concluding that CNA #5 is a substantial danger to public health and safety. In review of the BON actions, it references, he sexually assaulted four residents in his care. One resident was located in another facility in another location and the three residents located at this facility. An interview was conducted on 7/18/23 at 2:00 PM with Resident #60. When asked if he could describe the events related to the sexual abuse, Resident #60 stated, From what I can remember, he was changing me and he bent down and he touched his mouth to my penis. Police talked to me and filed a report. It was a Friday (4/7/23), Good Friday and I had just come back from services and it happened. Resident #60 stated, Ever since then, I am not the same, I have been talking with the staff working here. He (CNA #5) is not here. I have talked with the police and detective a couple of times. It was a bad situation. I felt bad. I told him to stop. It was not good for me. When asked how he felt now, Resident #60 stated, Better now. I feel safe here and felt safe before. An interview was conducted on 7/18/23 at 3:00 PM with ASM #2, the director of nursing. When asked to describe the events regarding 4/10/23 sexual abuse allegation for Resident #60, ASM #2 stated, As soon as we knew about it, we started the investigation. We suspended the CNA while we investigated. We assessed and interviewed all male residents beginning on 4/10/23. We called the police, informed VDH-OLC (Virginia Department of Health-Office Licensure Certification). On 4/11/23 during the investigation we discovered (Resident #35) had also been sexually abused. Virginia DHP (Department of Health Professions) was informed of the two residents alleging sexual abuse and our investigation. On 4/13/23 DHP investigators arrived at facility. (Resident #50) also stated that CNA #5 had sexually abused him multiple times. An interview was conducted on 7/18/23 at 3:15 PM with RN (registered nurse) #1. When asked to describe the events regarding 4/10/23 sexual abuse allegation for Resident #60, RN #1 stated, It was reported to me by a CNA on Monday morning. (Resident #60) said something to the CNA and she got me to hear the issue. He told me the CNA (#5) was taking care of him and mouth touched his penis and CNA #5 lifted his head up. RN #1 stated that (Resident #60) did not want him to take care of him anymore. I reported it to the DON and I met with the COO/CEO (chief operating officer/chief executive officer). I called the residents family. The physician was notified and saw the resident. An interview was conducted on 7/18/23 at 3:20 PM with LPN (licensed practical nurse) #9. When asked to describe the events regarding 4/10/23 sexual abuse allegation for Resident #60, LPN #9 stated, This was not known to me till later. I did not know that it happened. When asked if he had observed CNA #5 during the shift, LPN #9 stated, Yes, I never had any complaints till this situation happened. He was eager to be here and eager to help. Offered aid to other CNA's. None of the residents reported to us real time. An interview was conducted on 7/19/23 at 10:30 AM with CNA #4. When asked to describe the events regarding 4/10/23 sexual abuse allegation for Resident #60, CNA #4 stated, The resident told me that a male CNA had sexually assaulted him a couple of days earlier, that he touched the resident's penis with his mouth. I informed the nursing supervisor immediately. ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the interim administrator was made aware of the above concern on 7/19/23 at 9:05 AM. According to the facility's policy Abuse Prohibition which reveals in part, All residents at the facility will be treated with dignity and respect for their individuality. Abusive or neglectful acts towards residents by employees, visitors, relatives or others, in any form, will not be tolerated. Abuse can consist of any sexual contact. Administrator will direct investigation which shall include at a minimum: interviews with abused resident, the alleged abuser, staff person discovering incident, witnesses and others who may have necessary information. Investigation may also require physical/medical exam of the allegedly abused resident by nursing and/or medical staff. The facility developed and implemented a plan of correction, which contained the following 5 points: 1. The employee involved in the incident is no longer employed by the facility. Resident 1 (Resident #60) and Resident 2 (Resident #35) were assessed by the physician. Resident 3 (Resident #50) refused the assessment. Residents 1, 2 and 3 were assessed for psychosocial distress and care plans were revised as necessary. Residents have been referred to a psychologist for evaluation and treatment. 2. All current residents were interviewed by Social Services as they may have been affected. Interviews completed of all residents on 4/13/23. Any new allegations of abuse verbalized will be reported according to the facility abuse policy and the potential threat removed immediately while an investigation is in process. 3. Social Services/designee will be responsible for monitoring residents for abuse/psychological distress and ensuring any allegations verbalized will be reported according to the facility abuse policy. The Director of Social Services/designee has inserviced staff regarding abuse and the facility abuse policy including requirements/removing a potential threat immediately while an investigation is in process. Staff inservicing was completed on 4/21/23. 4. Social Services will meet weekly with residents affected and provide assistance as needed for a period of two months. 5. The Director of Social Services/designee will meet with the residents on the second Tuesday of each month to review resident rights and abuse. Any allegations of abuse will be investigated immediately as per the facility abuse policy. Education and training will be provided to staff on an ongoing basis. The Director of Social Services/designee will identify and report any trends and/or patterns to the quality assurance committee on at least a quarterly basis. 6. Completion date 5/9/23. The credible evidence including the Plan of Correction, education, in-service sign in sheets, audits and Quality Council minutes were reviewed and found to be in order. Random interviews were conducted with staff on varying shifts regarding abuse education and training and failed to reveal any concerns. Review of current residents failed to identify any concerns. Past non-compliance. 2. The facility failed to protect Resident #50 from sexual abuse from CNA (certified nursing assistant) #5. A review of the facility synopsis of event dated 4/14/23 revealed Incident Type: allegation of abuse/mistreatment. Resident #50 reported an incident to the social worker, that while being cared for his CNA (certified nursing assistant) mouth touched him inappropriately. The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 5/18/23, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bed mobility: total dependence for transfer, dressing, eating, hygiene, bathing and locomotion. A review of the comprehensive care plan dated 4/14/23 revealed, PROBLEMS: Resident has a history of trauma. He reports a former caregiver was sexually inappropriate with him. APPROACHES/TASKS: Nursing will continue to offer counseling and will coordinate counseling services, if accepted by resident. Resident-specific ways to comfort resident if a trigger occurs: He reports he enjoys going to a local park/garden. Encourage him to speak with a trusted staff member. Resident-specific ways to decrease triggers: Resident stated none. Staff will ensure safety of resident by ensuring physical setting is safe and interpersonal interactions promote a sense of safety. Staff will promote collaboration and mutuality with resident by partnering with him and sharing power and decision-making. Staff will promote trustworthiness and transparency by maintaining transparency and building and maintaining trust with resident. Staff will uphold resident's empowerment and choice by supporting shared decision making, choice, and goal setting. Staff will honor resident's self-advocacy skills. A review of the social services note dated 4/13/23 at 12:58 PM, revealed, Today, resident came to my office and asked to call his mother. He had reported that while being taken care of by a staff person, he was touched inappropriately. His mother, DON (director of nursing), Medical director and CEO (chief executive officer) were notified. The police and health department were also notified. A review of the physician progress note dated 4/13/23 at 1:55 PM, revealed, Seen primarily for recert (recertification) but also to discuss the recent assault allegations. Resident was going out and mentioned that he would discuss it tomorrow. He appeared well. I mentioned possibly doing some testing as well. Will follow up in am. Orders renewed. A review of Resident #50's Trauma Assessment dated 4/14/23, revealed, Is there a history of trauma, briefly describe the event: Resident expressed an allegation of sexual misconduct against a staff person on 3-11 shift. Self-Reporting Scale 0-10 (0= does not impact me at all 10= this impacts me a great deal). Using a Self-Reporting Scale, how much does this trauma impact your daily life: Resident said 0. What coping skills do you use to deal with thoughts of the traumatic event? He said, I go to (Name of Park) to get my mind off of it. Would you like the opportunity to meet with a counselor/therapist to discuss traumatic events that may continue to impact your life? He declined counseling services. Is there anything you would like your social worker to know? Want to be able to talk with someone. Wants to sit outside. Wants to talk with his father and stepmother. Work with a female CNA only. A review of the hepatitis and STI (sexually transmitted infections) lab profile obtained 4/14/23, revealed Hepatitis B, HCV (hepatitis C virus), RPR (rapid plasma regain) and HIV (human immunodeficiency virus), chlamydia and gonococcus all non-reactive. A review of the social services note dated 4/17/23 at 11:07 AM, revealed, Resident came to see me this morning .His family came to visit over the weekend, and he enjoyed their support. A review of the social services note dated 4/24/23 at 11:01 AM, 5/2/23 at 11:20 AM, and 5/16/23 at 10:54 AM revealed no voiced concerns. A review of the social services note dated 5/24/23 at 2:14 PM, revealed, Annual assessment note for 5/18/23. Resident scored 12 on the BIMS - unable to tell me the current year. Resident scored 00 on the resident Mood Interview - no mood concerns voiced. Resident experienced a traumatic event that included a staff person. Resident has not expressed any negative consequences from the event. He gets up daily in his w/c (wheelchair) and likes to ride to the park or to sit outside. Resident has a circle of peers he likes to talk with. Resident has a cell phone to call his family. His parents are supportive and visit often. We reviewed his advanced directives and he said he is satisfied with his current plans. He said he understands that he can make changes when he wants. We reviewed his discharge plans. He said he understands that he has the right to request to move at any time. Quarter goal to assist as requested. A review of the social services note dated 6/14/23 at 4:33 PM, revealed, SW met with resident in his room for weekly check-in. He states he feels fine and safe knowing alleged assailant is not allowed in the building . A review of the social services note dated 6/22/23 at 2:22 PM, revealed, SW met with resident in his room. SW asked how he's been feeling and he stated, great! He states he would like to speak with the detective in his case but doesn't have his name or number. He states the detective texted his number to the resident. Resident gave permission for SW to look through his recent texts, but SW did not find a text from detective. SW left message for administrator requesting information. A review of the social services note dated 7/10/23 at 11:46 AM, revealed, Resident asked to talk with me about a personal matter. We discussed his concern and he was satisfied with our talk. He said he is doing well and sleeping fine. An interview was conducted on 7/18/23 at 3:00 PM with ASM #2, the director of nursing. When asked to describe the events regarding the sexual abuse allegation for Resident #50, ASM #2 stated, On 4/13/23 DHP (department of health professions) investigators arrived at facility. (Resident #50) stated that (CNA #5) had sexually abused him multiple times on that day. He had not previously disclosed to us that he had been assaulted. An interview was conducted on 7/18/23 at 3:15 PM with RN (registered nurse) #1. When asked to describe the events regarding 4/13/23 sexual abuse allegation for Resident #50, RN #1 stated, this resident stated that CNA #5 had performed oral sex on him multiple times and had ejaculated in his room. He stated that CNA #5 had also watched pornographic content with him in his room. An interview was conducted on 7/18/23 at 3:20 PM with LPN (licensed practical nurse) #9. When asked to describe the events regarding the sexual abuse allegation for Resident #50, LPN #9 stated, This was not known to me till later. I did not know that it happened. When asked if he had observed (CNA #5) during the shift, LPN #9 stated, Yes, I never had any complaints till this situation happened. He was eager to be here and eager to help. Offered aid to other CNA's. None of the residents reported to us real time. An interview was conducted on 7/19/23 at 7:40 AM with Resident #50. When asked if he could describe the events related to the sexual abuse, Resident #50 stated, he (CNA #5) was changing me and he bent down and he touched his mouth to my penis. I told him to stop that I did not like it. He wanted to know if I was sure he did not want any of this and showed me his penis. There was another time when the CNA ejaculated in my room. I did not report this when they first asked. There were several of us he did this to. Police talked to me and filed a report. He (CNA) is not here. I have talked with the detective. It did not make me feel good or safe. I did not feel good. I told him to stop. When asked how he was feeling now, Resident #50 stated, it is all good now, there are no issues. He is not working here anymore. When asked if this had occurred more than once, Resident #50 stated, no. ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the interim administrator was made aware of the above concern on 7/19/23 at 9:05 AM. According to the facility's policy Resident Rights and Abuse Prohibition which reveals, The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The facility developed and implemented a plan of correction, which contained the following 5 points: 1. The employee involved in the incident is no longer employed by the facility. Resident 1 (Resident #60) and Resident 2 (Resident #35) were assessed by the physician. Resident 3 (Resident #50) refused the assessment. Residents 1, 2 and 3 were assessed for psychosocial distress and care plans were revised as necessary. Residents have been referred to a psychologist for evaluation and treatment. 2. All current residents were interviewed by Social Services as they may have been affected. Interviews completed of all residents on 4/13/23. Any new allegations of abuse verbalized will be reported according to the facility abuse policy and the potential threat removed immediately while an investigation is in process. 3. Social Services/designee will be responsible for monitoring residents for abuse/psychological distress and ensuring any allegations verbalized will be reported according to the facility abuse policy. The Director of Social Services/designee has inserviced staff regarding abuse and the facility abuse policy including requirements/removing a potential threat immediately while an investigation is in process. Staff inservicing was completed on 4/21/23. 4. Social Services will meet weekly with residents affected and provide assistance as needed for a period of two months. 5. The Director of Social Services/designee will meet with the residents on the second Tuesday of each month to review resident rights and abuse. Any allegations of abuse will be investigated immediately as per the facility abuse policy. Education and training will be provided to staff on an ongoing basis. The Director of Social Services/designee will identify and report any trends and/or patterns to the quality assurance committee on at least a quarterly basis. 6. Completion date 5/9/23. The credible evidence including the Plan of Correction, education, in-service sign in sheets, audits and Quality Council minutes were reviewed and found to be in order. Random interviews were conducted with staff on varying shifts regarding abuse education and training and failed to reveal any concerns. Review of current residents failed to identify any concerns. Past non-compliance. No further information was provided prior to exit. 3. For Resident #35 (R35), the facility staff failed to protect the resident from sexual abuse from a staff member CNA (certified nursing assistant) #5. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/25/2023, the resident scored a 12 out of 15 on the BIMS (brief interview for mental status) score indicating the resident moderately impaired for making daily decisions. In Section G - Functional Status, R35 was coded as requiring extensive assistance of one or more staff members for all of his activities of daily living except locomotion as the resident was independent after set up assistance was provided. The facility synopsis of event dated, 4/14/2023, documented in part, Additional/Update Information Related to the Reported Incident: In the discovery process for the allegation made by (R60), 2 additional residents, (R50) and (R35) made complaints against (CNA - certified nursing assistant #5). Staffing assignments confirmed that he was caring for the resident who made the allegations .Outcome of Investigation: Allegations were verified by evidence collected including victim interviews and assignment of staffing schedules with the incident timeline .Steps taken to investigate the allegation: Alleged victim's account were consistent in interview with facility staff, Department of Health Professions investigator and law enforcement. No evidence of psychosocial distress or harm as expressed by the resident or noticed by care team or direct care staff Conclusion: Allegations were verified by evidence collected which included interviews with all three victims by facility staff, Department of Health Professionals investigators and law enforcement in which their accounts remained consistent and the alignment of staff schedules with the time in which the incidents occurred .As a result of a verified finding of abuse, such as physical, sexual, or mental abuse, identify counseling or other interventions planned and implemented to assist the resident. (R60), (R35). and (R50) will receive continued monitoring to determine if there are any physical or mental changes or negative outcomes of the abuse. They will all receive trauma informed care assessments to determine if further counseling is needed. If counseling is needed, it will be arranged by the resident's care team. Each resident's care plan will be modified to include the incident . (Name of a physician) examined (R35) and (R50). (R60) refused a physical exam. (Name of physician) ordered STD (sexually transmitted disease) testing. (R60) refused the blood draw required for the test. Results for (R35) and (R50) are pending. The progress note dated, 4/11/2023 at 1:39 p.m. documented, Resident came to SW (social worker) office. SW invited DON (director of nursing) to meet with resident and she joined meeting. The progress note dated, 4/11/2023 at 1:40 p.m., documented, Meeting with social worker, (R35) and myself. Resident stated that last Tuesday a staff member was playing with his (expletive - penis) He also stated that the staff member unzipped his pants and asked him if he would like some of it. (R35) said he told him no. Investigation will be done. (Name of doctor) notified. The physician note dated, 4/11/2023 at 2:11 p.m. documented in p[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to prevent accidents that resulted in fractured bones for two of 31 residents in the survey sample, Residents #43 and #71. This was cited at harm past non-compliance. The findings include: 1. For Resident #43 (R43), the facility staff failed to transfer the resident with a Hoyer mechanical lift, per the resident's plan of care. This resulted in a fall and R43 sustained a fractured clavicle. R43's comprehensive care plan dated 7/31/17 documented, (R43) requires assistance with ADL (activities of daily living) tasks r/t (related to) Dx (diagnoses): Cerebral Palsy, Spasticity and Mood Disorder. Approaches/Tasks: FULL MECHANICAL LIFT-Hoyer Lift for all transfers. R43's [NAME] dated 1/28/23 documented, Transferred using full mechanical lift (Hoyer). A review of R43's clinical record revealed a nurse's note dated 1/28/23 that documented, CNA (Certified Nursing Assistant) reported res (resident) fell to to [sic] floor during transfer. res was yelling before bed, CNA says she didn't [sic] feel comfortable with hoyer transfer so she did stand and pivot transfer from w/c (wheelchair) to bed. her shoe on right foot not on all the way, res slipped and fell ontop [sic] of CNA on the floor. CNA rolled her to her back to get help. assessed and transferred by hoyer to the bed x3 [times three staff]. c/o (complained of) pain to left shoulder, no signs of injury. ice applied and tylenol given. res said she did not hit her head. mother notified. vitals normal. X-ray results dated 1/30/23 documented an acute distal clavicle fracture. A facility synopsis of events dated 2/3/23 documented, On Saturday January 28, 2023, (R43) sustained a clavicle fracture after being transferred from her wheelchair to the bed . (CNA #1) C.N.A. was interviewed on 2/3/23 by (ASM [administrative staff member] #2), DON (Director of Nursing) in regard to fall related transfer on 1/28/23 with (R43). She asked (CNA #1) if she knew what the documented transfer method was for (R43). (CNA #1) stated that it was a Hoyer transfer with two staff members. (ASM #2) asked her why she tried to execute a stand pivot transfer instead of following the care plan. (CNA #1) said she felt more comfortable doing it that way because of her behaviors. The resident was noted to have been yelling during this shift 3PM to 11PM. (CNA #1) explained the fall incident by saying she [sic] that she stood the resident up from her power wheelchair and her right shoe came off. The change in balance then precipitated the fall .Unfortunately, humans [sic] error caused this incident by diverting from the care plan for transferring the resident. CNA #1 was not available for interview during the survey. On 7/18/23 at 3:53 p.m., an interview was conducted with CNA #2. CNA #2 stated the CNAs are made aware of how a resident should be transferred via a sign on the back of the resident's room door, the resident's care plan, and in the computer system when documenting transfers. CNA #2 stated it is important to follow a resident's care plan for transfers for safety reasons. On 7/18/23 at 4:33 p.m., ASM (administrative staff member) #1 (the executive vice president) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Mechanical Lifts and Transfers documented, Residents who need assistance to transfer to bed or chair will have their Care Plan reflect the proper method .Full body mechanical lifts are to be used with a two person transfer only . A facility plan of correction dated 2/1/23 documented, Staff member transferred the resident using stand pivot instead of 2 person Hoyer lift. Resident slipped and fell on top of C.N.A. Resident was transferred to bed via Hoyer lift and 3 staff assist. 1. Resident complained of left shoulder pain after fall, assessment was completed by Charge nurse with no signs of injury noted. (R43) received Tylenol and ice was applied for complaint of pain. 1/29 resident again complained of pain. MD (Medical Doctor) notified, and X-Ray was ordered. 1/30 X-Ray showed left distal clavicle fracture. MD and mother were notified. Referral to (name of orthopedic company). 1/31 resident was seen by MD at (name of orthopedic company), ice and rest ordered. 2. All residents that are transferred incorrectly are at risk of injury. 3. Staff member that did the incorrect transfer was interviewed and stated that she knew the resident was a 2 person Hoyer transfer and she did a stand pivot instead. Staff member was terminated for not following correct procedure. Staff Development Coordinator to educate all nursing staff on the Mechanical lift Policy. 4. The Nursing Supervisor/Manager on each shift will monitor weekly for 4 weeks staff compliance. 5. Dates of Completion: 4/4/23. Credible evidence for this plan of correction was verified during the survey. Past non-compliance. 2. For Resident #71 (R71), the facility staff failed to properly transfer the resident with a sit to stand lift by utilizing the leg strap. This resulted in a fall and R71 sustained a fractured right ankle. R71's comprehensive care plan dated 7/26/17 documented, (R71) is at risk for falls r/t (related to) altered mobility, disease process and use of psychotropics. Approaches/Tasks: Transfers-Use sit to stand lift for all transfers . R71's [NAME] report dated 2/20/23 documented, Transfer using the sit to stand lift only. The care plan and [NAME] failed to document specific instructions for using a sit to stand lift. A nurse's note dated 2/20/23 documented, Assigned cna (certified nursing assistant) was transferring resident from shower chair using a seat [sic] to stand lift, Res. (Resident) fell on her knees landing on right leg. c/o (Complained of) pain to right leg, upper and lower leg X-ray ordered. A note signed by the orthopedist on 2/21/23 documented a non-displaced right ankle fracture. A facility synopsis of events dated 3/1/23 documented, On Monday February 20, 2023, (R71) sustained a ground level fall while being transferred in her room from shower chair to her wheelchair. Initial reports of right leg pain and x-ray were negative. The following day, however, the resident complained of right ankle pain and exhibited swelling in the right ankle. Additional x-rays revealed a fracture in the right ankle .At the time of the fall, (R71) separated her feet of [sic] the foot plates of the sit-to-stand lift and from there tilted forward and slid to the ground from her position in the shower chair. (CNA #2) confirmed there was no lower leg strap used during the transfer which was her omission. Logically, the use of the strap may have prevented this fall .Unfortunately, as the C.N.A. mentioned in our discussion, she lost her focus and did not use the lower leg strap to help stabilize the resident during the transfer. This incident was caused by human error and by diverting from the care plan for transferring the resident . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/27/23, R71 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 7/18/23 at 8:33 a.m., an interview was conducted with R71. The resident stated she has not refused leg straps while being transferred with the sit to stand lift. On 7/18/23 at 3:53 p.m., an interview was conducted with CNA #2. CNA #2 stated she did not use the leg strap while transferring R71 on 2/20/23 and the resident slid and fell. CNA #2 stated not using the leg strap was her mistake and the CNAs are supposed to make sure they use leg straps with sit to stand lift transfers. On 7/18/23 at 4:33 p.m., ASM (administrative staff member) #1 (the executive vice president) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Sit to Stand Mechanical Lift documented, Residents who need assistance to transfer to bed or chair will have their Care Plan reflect the proper method .Raise the resident's leg and feed the strap under and up between the legs. Ensure the sling is not twisted or creased under the thigh. Repeat this procedure with the other leg . A facility plan of correction dated 2/23/23 documented, Staff member transferred the resident using sit to stand lift. Resident moved her feet off platform and fell to her knees. C.N.A. did not attach straps to her legs before being transferred. Resident was transferred to bed via Hoyer lift and 3 staff assist. 1. Resident complained of right knee pain. Knee was noted to be swollen with bruising. MD (Medical Doctor) was notified and Xray's were ordered. Results showed no fracture of knee or tibia/fibula. Resident then complained of right ankle pain. Sent to (name of orthopedic company) 2/21/23 and was diagnosed with fracture of the right BiMalleolar, and was placed in a walking boot. 2. All residents that are transferred incorrectly using a sit to stand lift are at risk of injury. 3. Staff member that did the incorrect transfer was interviewed and stated that the resident will not let her put leg straps on when using the sit to stand lift. Staff member was put on a 3 day suspension and will have training when she returns. The staff development coordinator will in-service the nursing staff on the proper transfer using the sit to stand lift. Residents that use the sit to stand for transfer will also be instructed on the proper technique for using the sit to stand lift and there will be no deviations. 4. The Nursing Supervisor/Manager will monitor for 4 weeks staff compliance. 5. Dates of Completion: 4/7/23. Credible evidence for this plan of correction was verified during the survey and no further deficiencies regarding safety and accidents were cited. Past non-compliance.