Based on family interviews, staff interviews and a clinical record review, the facility staff failed to provide the required supervision for 1 resident (Resident #1) which resulted in an unwitnessed fall that caused facial contusion and a closed displaced phalanx (fracture) of the left ring finger, which constituted harm at past non-compliance. The findings included: Resident #1 was originally admitted to the facility 5/22/2015 and was current resident in the facility. Resident #1's diagnoses included a stroke with left hemiparesis and dementia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/24/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 2 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing and locomotion, extensive assistance of one person with bed mobility, transfers, walking, personal hygiene, dressing, and toileting and supervision after set-up with eating. A nurse's note date 4/27/23 read, the resident fell out of her wheel chair while outside and hit the right side of her face. The resident was transported to the hospital and diagnosed with a contusion to her face and a closed displaced phalanx (fracture) of the left ring finger. A splint was applied and an order to follow up with an orthopedist or hand surgery specialist. The resident's care plan with a revision date of 5/5/23 had a problem which read, (name of resident) is at risk for falls. A fall mat is in place for safety. The resident had falls 6/18/21 and 4/27/23. The goal read, minimize risks for falls/minimize injuries related to falls through 6/22/23. The interventions included, Ensure resident not outside unsupervised. Implement preventative fall interventions/devices. Fall mat at bedside for safety. Maintain needed items within reach. Offer assistance with toileting during care opportunities. An interview was conducted with Resident #1's daughter by telephone on 6/7/23 at approximately 9:14 a.m. The daughter elaborated on her mother being left in a wheel chair outside unsupervised, and falling from the wheel chair onto the driveway. An interview was also conducted with daughter #2 on 6/7/23 at 9:40 a.m., she talked about the fall outside while the resident was unsupervised as well of the injuries sustained. On 6/7/23 at approximately 2:20 p.m., an interview was conducted with certified nursing assistant (CNA) #1. CNA #1 stated Resident #1 attends the PACE program one day each week, she feeds herself well, is totally incontinent of her bladder and bowels, can self propel her wheel chair some days short distances and when she is in bed her bed is kept in the lowest position. An interview was conducted with CNA #2 on 6/7/23 at approximately 2:55 p.m. CNA #2 stated she had been employed with the facility for about three months. She also stated Resident #1 asked her to take her outside and she took her outside and left her for she had to return to her unit to care for other residents. CNA #2 stated since the fall of Resident #2 she has been educated to notify the nurse prior to allowing a resident to go outside and she has been re-inserviced on the facility's fall prevention program. An interview was conducted with the Front Desk Receptionist (FDR) on 6/8/23 at 2:45 p.m. The FDR stated on 4/27/23 at approximately 2:00 p.m., she observed a resident was on the ground near the bench in the parking lot with the wheel chair she was sitting in nearby. The FDR also stated another resident was observed nearby but there was not any staff present. She stated she immediately came into the facility and called for help and nursing staff responded to her call. The FDR stated the PACE transporter did not leave her outside for they always bring the resident inside the building. An interview was conducted with CNA #3 on 6/8/23 at 10:55 a.m. CNA #2 stated if a resident desires to go out to smoke, it is required that they sign out in the book at the nurse's station and notify the nurse on duty. If the resident is independent, they may go out unassisted but if they are not independent a staff member must stay outside with the resident. CNA #3 stated also all staff are to monitor residents for fall potentials. An interview was conducted with Licensed Practical Nurse (LPN) #1 on 6/8/23 at 11:25 a.m. LPN #1 stated all staff are to identify fall risk and hazards, spills, positioning/sloughing, in the chair keeping personal possession nearby, toileting, and rounding frequently to know where abouts of the resident. All residents who had experienced falls since 4/27/23 were reviewed during the survey. There was one resident who should utilize a wheel chair for locomotion who fell walking without a wheel chair. A lack of supervision wasn't identified as the root cause. Eighteen additional falls were also reviewed, but lack of supervision was not identified as a root cause Date of Corrective action plan, 4/28/23. The facility developed a five-point plan secondary to Resident #1's fall with facial bruising a left ring finger fracture. 1. The facility determined based on Resident #1's cognition she should have been supervised while outside. 2. The facility completed a 100 percent review of all falls in the facility for the previous 30 days to determine like-residents (residents with a BIMS score below 12), had prior unwitnessed falls outside and a 100 percent of environmental conditions was completed there were no environmental hazards outside. 3. One hundred (100) percent education for all nurses by the Director of Nursing and Staff Development Coordinator to educate on resident supervision while outside and Resident with BIMS under 12 to require visual observation while outside of the community front doors. 4. The Administrator, Director of Nursing and Staff Development Coordinator to complete weekly audits 5 times per week for 5 weeks that include environmental observations, staff interviews regarding the education above and resident interviews. All Quality Assurance and Performance Improvement (QAPI) finding will be forwarded to the QAPI committee. 5. Corrective action was completed on 5/4/23. On 6/8/23 at approximately 1:40 p.m., the above allegations were shared with the Administrator, Director of Nursing and two corporate consultants. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided, and no concerns were voiced. It was determined that the facility implemented its Corrective Action Plan, and there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance at the time of the current survey for the regulatory requirement, F-689.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, complaint investigation, and family and staff interviews, the facility staff failed to ensure one resident (Resident #297), in the survey sample of 46 residents, was free from sexual assault which resulted in harm. The findings included: Resident #297 was admitted to the facility on [DATE] with a diagnosis of dementia, anemia, diabetes, cardiovascular disease, aphasia, and cerebrovascular disease. In the most recent Minimum Data Set (MDS) dated [DATE], it was coded that this resident had a BIMS score of 3 out of a possible score of 15 which indicated severe impairment in the cognitive skills necessary for daily decision-making. Resident #297 required extensive assistance for bed mobility and was dependent on staff for transfers, dressing, grooming, eating, toileting and bathing. A Care Plan dated 06/07/21 indicated: Focus- Altered or at risk for altered behaviors and/or mood due to acute confusion. Goal- resident will display a positive affect. Interventions- Ensure the resident feels safe in her environment. Resident History: The perpetrator, Resident #145 was admitted on [DATE] with diagnoses that included PVD, AFib, anxiety, a history of gangrene above the knee (AKA) with orthopedic aftercare, neuropathy, malnutrition, HTN, and weakness. On the resident's most recent MDS with ARD of 6/11/21, the resident's BIMS was a 13 in a possible score of 15 which indicated intact cognition with the necessary skills needed for daily decision-making. The resident did not trigger for wandering or other behaviors. The resident required extensive assistance for bed mobility, transfers, dressing, toileting, and hygiene. He was independent in eating. The resident used a wheelchair for mobility. Resident #145 was on the following medications: Voltaren gel, Ultram, cholecalciferol, omeprazole, gabapentin, Lexapro, metoprolol, and apixaban. The Sex offender's database did not have him listed as an offender. A nursing note dated 8/24/21 at 05:10 a.m. indicated, While CNA was (sic) doing there 2 hour rounding the CNA a (sic) patient in Resident #297 room with her gown up and brief slid to the side. Immediately removed the other party involved to his room and did a thorough head to toe assessment on patient. Resident #297 had scant light pink blood on chuck that was under her but no physical trauma to the vagina that (writer) was able to see externally. Authorities were made aware and all responsible parties were notified. A Facility Incident/Accident Report (FRI) dated 08/24/21 at (14:02) indicated, Incident Description: On August 24, 2021, at 5:10 a.m., Resident #145 was spotted in Resident #297 room. CNA #4 cracked door and saw Resident #145 with his hands down Resident #297 brief. Resident #145 was immediately separated and put in his room. A staff member was put outside his room to watch him. Former LPN #9 agency nurse immediately called the police. The police showed up around 8:00 a.m. Police officers questioned both residents. Resident #297 was sent to the hospital. At 9:00 am. Police Officer detective showed up and interviewed Resident #145. She left after interviewing Resident #145 at facility to speak with Resident #297 family at the hospital. Immediate Action Taken-Description: Resident separated, Police called. Resident sent to hospital. Resident #145 arrested from facility. Interviews started and skin assessments started. Immediate discharge given to resident. Injuries Observed at Time of Incident: No injuries observed at time of incident. A Local Police Incident Report dated 08/24/21 at 09:22 AM indicated: Last Known Secure: 08/24/21 at 05:00 AM At Found: 08/24/21 at 7:06 AM Crime: 1: Sexual Battery Weapons/Tools - 1. (Hands, ETC.) The FRI indicated: Two Police Officers arrived at approximately 0800. They interviewed both residents. Resident #297's family member had already arrived at the Center. The FRI indicated: A Detective interviewed Resident #145 and also went to local hospital to meet with Resident #297's and her family. During this initial police investigation, Resident #145 remained on 1:1 observation with staff. The FRI indicated: Nursing Supervisor reports going to Resident #145 after providing care for Resident #297. Nursing Supervisor reports asking Resident #145 what did you do. Nursing Supervisor reports he answered I am sorry and I touched her. The FRI indicated : At approximately 0930 Officer called center and said to continue to secure Resident #145, and that they would be out to arrest him. Local Police arrived at 1330 and removed him from center. During a phone interview on 9/20/22 at 6:11 a.m. with CNA #4, she stated during her shift rounds on 8/24/21, she noticed Resident #297 door was open which she usually keeps closed at night. CNA #4 stated she went into the room and observed Resident #145 with his hand in Resident #297's brief. CNA #4 stated she asked Resident #145 to leave the room. CNA #4 stated she called for the (former ADON Staff #7) who was working during the shift. CNA #4 was asked if Resident #145 was a wanderer. CNA #4 stated, No. CNA #4 was asked if Resident #4 had been caught in Resident #297 room before and she stated, No. CNA #4 was asked if Resident #145 had been seen in other female resident rooms and she stated, No. A Review of a written statement given by the former Assistant Director of Nursing (ADON) #7 dated 8/24/21 indicated: At 5:10 called to room [ROOM NUMBER] by CNA #4. On arrival to Resident #247 room where Resident #145 (Perpetrator) was in his wheelchair facing the door saying 'I'm sorry.' Observed Resident #247 laying on her back with her gown up around her neck exposing her breast, abdomen, and legs. Her diaper was opened on the right side. Her eyes were open and she was following our movements around the bed. We [name of former agency LPN #9 and former ADON#7] examined Resident #247 for any injuries. None were noted. There was a smear of blood on the disposable pad beneath her. Our exam did not reveal any bleeding. [Name of CNA #4] bathed and dressed Resident #247. [Name of former ADON #7] checked her 15 minutes later and she was resting comfortably with eyes closed. Excerpts from the above-written statement of former ADON Staff #7 included .Went into Resident #145's room and asked him what he was doing and he stated, 'I was in someone's room but I don't know why.' Asked what he was doing in the room with Resident #297 and he stated, 'I don't know.' You do know what you were doing in there; he shook his head yes. Tell me what you did, and he said 'I touched her.' I asked him where he touched her and he said 'down there' pointing to his groin. He again stated he was sorry. The statement indicated that on 8/24/21 at 5:40 a.m., the former ADON staff #7 called Resident #297's daughter and explained the incident to her. She said she would be at the facility in a little while. After the incident, Resident #145 (perpetrator) remained in his room in the bed for the remainder of the shift. During a phone interview on 9/21/22 at 3:59 p.m., former ADON Staff #7 stated CNA #4 called her to Resident #297's room and reported that Resident #145 was observed with his hands inside Resident 297's brief. After removing Resident #145 from the room, the Former ADON Staff #7 stated she asked CNA #4 to clean Resident #297 up. She stated she called the Administrator, DON, Family, and physician. An aide was assigned to watch Resident #145 and sit outside of his room. Former ADON Staff #7 was asked to describe Resident #145. She stated he was usually up near the nursing station during the day. He was not a wanderer nor had he had behaviors of seeking out female residents. During a phone interview on 9/22/22 at 10:13 a.m., the former DON Staff #8 stated she received a call from the Former ADON Staff #7 regarding CNA #4 observing Resident #145 in Resident #297 room with his hands in the brief of Resident #297. The Former DON Staff #8 stated she arrived around 5:30 a.m. the family arrived around 6:30 am. She stated Agency staff LPN #9 called the police, but she was not sure what time the police were called. She said the police arrived around 8:00 a.m. Former DON Staff #8 was asked to describe Resident #145. She stated she did not know much about the resident. She said she had only been working at the facility for about two weeks and was not aware of him going into other resident rooms. A written statement given by agency staff LPN #7 indicated: To Whom It May Concern (writer Agency Staff LPN #7 name) worked on 8/24/21 when it was reported to her that one of the patients had been sexually assaulted by another resident. A thorough head-to-toe exam was performed and noticed scant light pink blood on chux under Resident #297. The male who was involved was immediately removed and asked what happened and he admitted to putting his hands up Resident #297's vagina. All parties were notified. During an interview on 9/22/22 at 4:59 p.m. with agency Staff LPN #7, she stated Resident #297 was assessed after the sexual assault was reported by CNA #4. She said a scant amount of blood was on her brief. The family was notified, the Administrator was notified, and the physician was notified. She said the family came and the rest of the resident's daughters arrived and asked that 911 be called. The Agency Staff LPN Other #7 was asked to describe Resident #145. She stated she did not know the resident, it was her first time at the facility. During a phone interview on 9/22/22 at 4:35 p.m., former Administrator #10 was asked to describe Resident #145. He stated, as far as he knew, the resident was not a wanderer. He would come to the nursing station and talk with the staff. A sex registry background check did not indicate he had committed any previous acts of sexual assault. The former Administrator #10 stated, all parties were notified and a follow-up FRI report was submitted to the State survey and certification agency. During a phone interview on 9/20/22 at 11:39 a.m., Resident #297's daughter stated she received a call from the facility after 5:00 am on 8/24/21 and when she arrived at the facility, her mother had been cleaned up and given a bath. She asked the former ADON #7 to call 911 and send her mother to the hospital. The resident's daughter stated, after her sisters arrived they went to the hospital and were met there later on by the police. She stated her mother was not able to talk or call out for help nor was she able to defend herself against any type of assault. A facility policy for Abuse, Neglect, and Exploitation dated 5/6/21 indicated: Sexual abuse -includes, but is not limited to, non-consensual sexual contact of any type, sexual harassment, sexual coercion, or sexual assault. Complaint Deficiency

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a closed record review, complaint investigation, family and staff interviews, the facility staff failed to preserve evidence following an incident of sexual abuse for one resident (Resident #297) in the survey sample of 46 residents. The findings included: Resident #297 was admitted to the facility on [DATE] with a diagnosis of dementia, anemia, diabetes, cardiovascular disease, aphasia, and cerebrovascular disease. In the most recent Minimum Data Set (MDS) dated [DATE], it was noted this resident had a BIMS score of 3 which indicated the resident was severely impaired in the skills needed for daily decision-making. Resident #297 required extensive assistance for bed mobility and was dependent on staff for transfers, dressing, grooming, eating, toileting and bathing. A Care Plan dated 06/07/21 indicated: Focus- Altered or at risk for altered behaviors and/or mood due to acute confusion. Goal- resident will display a positive affect. Interventions- Ensure the resident feels safe in her environment. The perpetrator, Resident #145 was admitted on [DATE]. He had a diagnosis of PVD, AFib, anxiety, a history of gangrene with AKA with orthopedic aftercare, neuropathy, malnutrition, HTN, and weakness. On the resident's most recent MDS with ARD of 6/11/21, the resident's BIMS was a 13 which indicated he was cognitively intact with the skills for daily decision-making. He did not trigger for wandering or other behaviors. The resident required extensive assistance for bed mobility, transfers, dressing, toileting, and hygiene. He was independent in eating. The resident was coded to use a wheelchair for mobility. Resident #145 was on the following medications: Voltaren gel, Ultram, cholecalciferol, omeprazole, gabapentin, Lexapro, metoprolol, and apixaban. The Sex offender's database does not have him listed as an offender. A nursing note dated 8/26/21 -Late Entry - Indicated: Late Entry for the incident on 8/24/21 at 5:10 am: Male resident was immediately removed from residents room when he was found in her room, by a CNA (certified nursing assistant), with his hands between her legs. He was escorted to his room where he went to bed and remained on 1:1 surveillance. Patient did not appear to be upset. She was lying in bed with her eyes open and following (sic) writers (movements). Physical exam was completed, No bruising noted and no scratches or other signs of injury noted to back, buttocks or vaginal area. There was no discharge or drainage noted from vaginal area. Breast appeared to be untouched and had no s/s of any bruising, scratches etc. There was a smear of blood located on her diaper however the exam did not reveal any signs of trauma or blood visible at time of exam. Patient did not voice any discomfort nor pain with words or facial expressions. She was given a bed bath, gown changed and bedding changed. She was resting comfortably in bed with eyes closed when her family arrived. A Review of a written statement given by the former Assistant Director of Nursing (ADON) #7 dated 8/24/21 indicated: At 5:10 called to room [ROOM NUMBER] by CNA #4. On arrival to Resident #247 room where Resident #145 (Perpetrator) was in his wheelchair facing the door saying 'I'm sorry.' Observed Resident #247 laying on her back with her gown up around her neck exposing her breast, abdomen, and legs. Her diaper was opened on the right side. Her eyes were open and she was following our movements around the bed. We [former agency LPN #9 and former ADON#7] examined Resident #247 for any injuries. None were noted. There was a smear of blood on the disposable pad beneath her. Our exam did not reveal any bleeding. [Name of CNA #4] bathed and dressed Resident #247. [Name of former ADON #7] checked her 15 minutes later and she was resting comfortably with eyes closed. During a phone interview on 9/21/22 at 3:59 p.m., former ADON#7 stated that CNA #4 cleaned up Resident #247 up at her request. She said the bed was messy and her diaper was changed. The former ADON #7 stated, she had the assigned CNA #4 to wash Resident #247's peri area, put on a new diaper and a clean gown, change the linen, and change her blanket. She stated during the interview that she instructed staff to make sure to clean Resident #247 up before law enforcement was contacted and before Resident #247 was transferred to the emergency room for examination. She was asked if this incident was investigated as a sexual assault and she stated, Yes. She was also asked if she had sexual abuse training and responded that she had, but her personal training folder did not have evidence of abuse training or what to do in cases of suspected sexual assault. During the above interview, former ADON #7 was asked if Resident #145 (Perpetrator) was examined for potential evidence to which she said she did not know. She was asked bathing or clean the resident, and washing linens and or clothing before the resident had been examined would impede the investigation, and responded that she messed up. The former ADON #7 was also asked if the bed linens, diapers, are gowns were preserved for evidence and responded, No, the disposable items were discarded and the linens were sent to laundry to be washed. During a phone interview on 9/20/22 at 6:11 a.m., the assigned CNA #4 stated she was instructed by former ADON#7 to clean up Resident #247, give her a bed bath to include the peri-area, change her brief and place the resident in a clean gown. CNA#4 also said she was also instructed to change the resident's bed linens. During a phone interview on 9/20/22 at 11:39 a.m., Resident #247's daughter stated she received a call from the facility after 5:00 a.m. on 8/24/21. When she arrived at the facility, her mother had been cleaned up and given a bath. She asked the former ADON #7 to call 911 and send her mother to the hospital. A facility Abuse policy dated 5/26/21 indicated: Sexual abuse- Includes, but is not limited to, non-consensual sexual contact of any type, sexual harassment, sexual coercion, or sexual assault. Protection of Resident: In Allegations of Sexual Abuse every effort will be made to preserve evidence on both the resident and the perpetrator. Resident and perpetrator: a. Will not be bathed or cleaned b. Will not receive incontinence care c. The Incontinence brief will not be changed e. No oral care will be provided f. Both resident and perpetrator will be evaluated in the ER. g. Linens will be bagged and provided as evidence if applicable h. Police to be notified. Complaint Deficiency