Village of St Edward at Green The

Based on record review and interview, the facility failed to ensure notification was made to the appropriate parties, and a change in condition was thoroughly assessed for Resident #78. This affected one resident (#78) of three residents reviewed for change in condition. The facility census was 77.

Findings include:

Review of the medical record for Resident #78 revealed an admission date of 10/25/21 and a discharge date of 11/16/23. Diagnoses Included hyperlipidemia, dementia, and hypertension.

Review of the incident report dated 10/27/23 at 9:05 A.M. revealed an aide found Resident #78 on the floor. The residents' vital signs were taken, and the resident appeared a little more confused and sorer and was given as needed (prn) medications. Resident #78 was sent to the hospital. The residents' vital signs were not noted in the report, and the physician and family were not notified.

Review of the Medication Administration Record (MAR) for October 2023 revealed Resident #78 was given Tylenol 325 milligrams (mg) for a pain level of ten on a scale of zero to ten on 10/27/23 at 9:07 A.M.

Interview on 01/18/24 at 11:08 A.M. with the Director of Nursing (DON) revealed the facility gave a verbal report to the paramedics when they arrived to address a Resident #78's change in condition. They did not keep any formal documentation of the residents' condition, nor did they have evidence that this information was shared with the paramedics. She admitted the nurse taking care of the resident on the night of the incident had issues with documentation and should have documented the incident in the residents' medical record as well as conducted a full assessment of the residents' condition while waiting for emergency services to arrive and contacted the resident's' physician and responsible party.

Review of the undated facility policy titled Notification of Condition Change revealed the resident's physician should be notified immediately upon a change of condition and the responsible party would be notified as soon as possible but within 24 hours of discovery.

This deficiency represents noncompliance investigated under Complaint Number OH00149646.

Based on record review and interview, the facility failed to ensure incidents were documented, assessed, and investigated thoroughly. This affected four residents (#17, #51, #66, and #78) of four reviews for accidents. The facility census was 77. Findings include: 1. Review of the medical record for Resident #17 revealed an admission date of 02/24/23. Diagnoses included bipolar disorder, anxiety, chronic kidney disease, and dementia. Review of the functional assessment dated 4/23/23 revealed Resident #17 had the potential for falls. Review of the physician's orders for December 2023 revealed an order for diabetic inserts and a home healthcare evaluation for physical and occupational therapies. Review of the incident log dated 10/01/23 through 01/17/23 revealed Resident #17 had a fall on 11/07/23, 11/19/23, 11/23/23, 12/07/23, 12/13/23, and 01/15/24. Review of the incident report for the fall dated 11/07/23 at 1:50 A.M. revealed the state tested nurse's aide (STNA) answered the call pendant and called for a nurse because Resident #17 was found on the floor. The nurse entered the apartment and found him lying on his right side in front of the toilet. The resident stated he fell going to the bathroom. The residents' vital signs were taken, and he was assessed for pain. No injuries were noted. The physician and family were notified. The resident was assessed on each shift after the fall until 11/08/23 at 10:05 P.M. The facility did not do the post-fall assessments for 72 hours, each shift after the fall. Review of the incident report for the fall dated 11/23/23 at 1:02 A.M. revealed Resident #17 was found lying on the floor. He stated he got up to go to the bathroom but lost his balance. The incident report revealed vital signs were taken; however, they were not noted in the medical record. The resident was noted to have an abrasion to his left hip. The physician and family were notified. The resident was assessed on each shift after the fall for 72 hours. Review of the incident report for the fall dated 12/07/23 at 11:20 A.M. revealed staff was summoned by activity staff to the Chapel due to Resident #17 being lowered to the ground. He had his walker with him and shoes on. The resident stated he stood up and got dizzy and someone helped him sit on the floor. Vital signs were taken, and no injuries were noted. The physician and family were notified. There was no documented evidence in the residents' electronic medical record (EMR) of the fall. The resident was assessed on each shift after the fall until 12/09/23 at 2:33 P.M. There were progress notes assessing the resident from a fall on the day before (12/07/23) but nothing in the EMR about the actual fall. Review of the incident report for the fall dated 01/15/24 at 3:30 P.M. revealed the nurse was called to Resident #17's room because the resident was on the floor. The resident was sitting on his buttocks, legs extended, and hands in his lap. The resident was directly outside his bathroom in his apartment, his walker was nearby. The resident reported he was going to the bathroom and just fell; he said he did not hit his head. The report revealed vital signs were taken, however, they were not noted in the medical record. No injuries were noted. The physician and family were notified. The resident was assessed on each shift after the fall until 01/17/24 at 6:07 A.M. He was not assessed for 72 hours each shift after the fall. 2. Review of the medical record for Resident #51 revealed an admission date of 09/09/21. Diagnoses included diabetes, chronic obstructive pulmonary disease (COPD), multiple sclerosis, and low back pain. Review of the functional assessment dated 10/24/23 revealed Resident #51 had the potential for falls. Review of the physician's orders for 10/18/23 revealed an order for a physical therapy evaluation and treatment. Review of the incident log dated 10/01/23 through 01/17/23 revealed Resident #51 had a fall on 10/08/23, 12/08/23, and 12/23/23. Review of the incident report dated 10/08/23 at 12:10 P.M. revealed Resident #51 was lying on his left side on the floor with a pillow between his knees and a pillow under his head with his shoes on and fully clothed. The resident had just returned to his room with an attendant via wheelchair and during a transfer the resident collapsed his legs and was lowered to the floor with the attendant. The resident stated his knees buckled. The report revealed vital signs were taken, however, they were not noted in the medical record. The report also revealed there were no witnesses, however, the initial notation indicates the resident was with an attendant. There were no injuries. The physician and family were notified. Review of the nursing note dated 12/08/23 at 5:07 P.M. revealed Resident #51 was found on his back with his hands folded on his stomach and his legs stretched out. He denied hitting his head. The resident could not explain what happened. He was assessed, and no injuries were noted, and his daughter was notified. The resident was assessed on each shift after the fall until 12/11/23 at 2:17 A.M. The facility did not assess the resident for 72 hours each shift. There was also no incident report or investigation. Review of the incident report dated 12/22/23 at 5:11 P.M. revealed Resident #51 was on the floor. He stated he slipped trying to grab his remote and did not hit his head. The report revealed vital signs were taken, however, they were not noted in the medical record. was no injury and no evidence the physician or family had been notified. There was no documented evidence in the residents' EMR of the fall. The resident was assessed on each shift after the fall until 12/24/23 at 6:36 P.M. There were progress notes assessing the resident from a fall on the day before (12/22/23) but nothing in the chart about the actual fall. 3. Review of the medical record for Resident #66 revealed an admission date of 12/08/21. Diagnoses included osteoporosis, depression, vitamin D deficiency, anemia, and dementia. Review of the progress note dated 12/13/23 at 5:29 P.M. revealed Resident #66 had a dime sized bruise on the right side of her forehead, the resident stated she bumped her head. Her daughter and the Director of Nursing (DON) were notified. Review of the incident log dated 10/01/23 through 01/17/23 revealed no evidence of an incident for Resident #66. Review of the investigation dated 12/13/23 at 5:42 P.M. revealed STNA #207 was providing incontinence care when the resident became combative. STNA #207 wedged her against the wall to prevent her from falling, and the resident struck her forehead on the grab bar. A witness statement obtained from Licensed Practical Nurse (LPN) #206 revealed STNA #207 told her the resident tried to hit her and she had to hold her against the wall to finish changing her or she would have fallen to the floor. STNA #207 revealed the resident might have hit her head against the wall, but she wasn't really sure. There was no written witness statement from STNA #207 and no assessment of the resident. Interview on 01/18/24 at 8:11 A.M. with the DON revealed the investigation was complete. She confirmed there was no witness statement from STNA #207 and no assessment of the resident. 4. Review of the medical record for Resident #78 revealed an admission date of 10/25/21 and a discharge date of 11/16/23. Diagnoses Included hyperlipidemia, dementia, and hypertension. Review of the functional assessment dated 05/18/23 revealed Resident #78 had the potential for falls. Review of the incident report dated 10/27/23 at 9:05 A.M. revealed an aide found Resident #78 on the floor. The residents' vital signs were taken, and the resident appeared a little more confused and sorer and was given prn medications. The resident was sent to the hospital. The residents' vital signs were not noted in the report, and the physician and family were not notified. Review of the Medication Administration Record (MAR) for October 2023 revealed Resident #78 was given Tylenol 325 milligrams (mg) for a pain level of ten on a scale of zero to ten on 10/27/23 at 9:07 A.M. Review of the incident log dated 10/01/23 through 01/17/23 revealed no evidence of a fall for Resident #78 on 10/27/23. Interview on 01/18/24 at 8:11 A.M. with the DON revealed the facility did not investigate falls. Interview on 01/18/24 at 11:08 A.M. with the DON revealed the facility did initial neurological checks after a fall, then the nurse determined if they needed to be ongoing. Any neurological checks would be documented in the progress notes. If there was evidence of a head injury they would be done, but they were not done for all unwitnessed falls. She also revealed they did not collect witness statements for falls and confirmed that facility policy states witness statements are to be obtained. She revealed the nurses would implement any new interventions they felt necessary and document them in the progress notes, and reassessments would occur every shift after a fall for 72 hours. Review of the facility policy titled Fall/Observed on Floor ProtocolBased on record review and interview, the facility failed to ensure incidents were documented, assessed, and investigated thoroughly. This affected four residents (#17, #51, #66, and #78) of four reviews for accidents. The facility census was 77.

Findings include:

1. Review of the medical record for Resident #17 revealed an admission date of 02/24/23. Diagnoses included bipolar disorder, anxiety, chronic kidney disease, and dementia.

Review of the functional assessment dated 4/23/23 revealed Resident #17 had the potential for falls.

Review of the physician's orders for December 2023 revealed an order for diabetic inserts and a home healthcare evaluation for physical and occupational therapies.

Review of the incident log dated 10/01/23 through 01/17/23 revealed Resident #17 had a fall on 11/07/23, 11/19/23, 11/23/23, 12/07/23, 12/13/23, and 01/15/24.

Review of the incident report for the fall dated 11/07/23 at 1:50 A.M. revealed the state tested nurse's aide (STNA) answered the call pendant and called for a nurse because Resident #17 was found on the floor. The nurse entered the apartment and found him lying on his right side in front of the toilet. The resident stated he fell going to the bathroom. The residents' vital signs were taken, and he was assessed for pain. No injuries were noted. The physician and family were notified. The resident was assessed on each shift after the fall until 11/08/23 at 10:05 P.M. The facility did not do the post-fall assessments for 72 hours, each shift after the fall.

Review of the incident report for the fall dated 11/23/23 at 1:02 A.M. revealed Resident #17 was found lying on the floor. He stated he got up to go to the bathroom but lost his balance. The incident report revealed vital signs were taken; however, they were not noted in the medical record. The resident was noted to have an abrasion to his left hip. The physician and family were notified. The resident was assessed on each shift after the fall for 72 hours.

Review of the incident report for the fall dated 12/07/23 at 11:20 A.M. revealed staff was summoned by activity staff to the Chapel due to Resident #17 being lowered to the ground. He had his walker with him and shoes on. The resident stated he stood up and got dizzy and someone helped him sit on the floor. Vital signs were taken, and no injuries were noted. The physician and family were notified. There was no documented evidence in the residents' electronic medical record (EMR) of the fall. The resident was assessed on each shift after the fall until 12/09/23 at 2:33 P.M. There were progress notes assessing the resident from a fall on the day before (12/07/23) but nothing in the EMR about the actual fall.

Review of the incident report for the fall dated 01/15/24 at 3:30 P.M. revealed the nurse was called to Resident #17's room because the resident was on the floor. The resident was sitting on his buttocks, legs extended, and hands in his lap. The resident was directly outside his bathroom in his apartment, his walker was nearby. The resident reported he was going to the bathroom and just fell; he said he did not hit his head. The report revealed vital signs were taken, however, they were not noted in the medical record. No injuries were noted. The physician and family were notified. The resident was assessed on each shift after the fall until 01/17/24 at 6:07 A.M. He was not assessed for 72 hours each shift after the fall.

2. Review of the medical record for Resident #51 revealed an admission date of 09/09/21. Diagnoses included diabetes, chronic obstructive pulmonary disease (COPD), multiple sclerosis, and low back pain.

Review of the functional assessment dated 10/24/23 revealed Resident #51 had the potential for falls.

Review of the physician's orders for 10/18/23 revealed an order for a physical therapy evaluation and treatment.

Review of the incident log dated 10/01/23 through 01/17/23 revealed Resident #51 had a fall on 10/08/23, 12/08/23, and 12/23/23.

Review of the incident report dated 10/08/23 at 12:10 P.M. revealed Resident #51 was lying on his left side on the floor with a pillow between his knees and a pillow under his head with his shoes on and fully clothed. The resident had just returned to his room with an attendant via wheelchair and during a transfer the resident collapsed his legs and was lowered to the floor with the attendant. The resident stated his knees buckled. The report revealed vital signs were taken, however, they were not noted in the medical record. The report also revealed there were no witnesses, however, the initial notation indicates the resident was with an attendant. There were no injuries. The physician and family were notified.

Review of the nursing note dated 12/08/23 at 5:07 P.M. revealed Resident #51 was found on his back with his hands folded on his stomach and his legs stretched out. He denied hitting his head. The resident could not explain what happened. He was assessed, and no injuries were noted, and his daughter was notified. The resident was assessed on each shift after the fall until 12/11/23 at 2:17 A.M. The facility did not assess the resident for 72 hours each shift. There was also no incident report or investigation.

Review of the incident report dated 12/22/23 at 5:11 P.M. revealed Resident #51 was on the floor. He stated he slipped trying to grab his remote and did not hit his head. The report revealed vital signs were taken, however, they were not noted in the medical record. was no injury and no evidence the physician or family had been notified. There was no documented evidence in the residents' EMR of the fall. The resident was assessed on each shift after the fall until 12/24/23 at 6:36 P.M. There were progress notes assessing the resident from a fall on the day before (12/22/23) but nothing in the chart about the actual fall.

3. Review of the medical record for Resident #66 revealed an admission date of 12/08/21. Diagnoses included osteoporosis, depression, vitamin D deficiency, anemia, and dementia.

Review of the progress note dated 12/13/23 at 5:29 P.M. revealed Resident #66 had a dime sized bruise on the right side of her forehead, the resident stated she bumped her head. Her daughter and the Director of Nursing (DON) were notified.

Review of the incident log dated 10/01/23 through 01/17/23 revealed no evidence of an incident for Resident #66.

Review of the investigation dated 12/13/23 at 5:42 P.M. revealed STNA #207 was providing incontinence care when the resident became combative. STNA #207 wedged her against the wall to prevent her from falling, and the resident struck her forehead on the grab bar. A witness statement obtained from Licensed Practical Nurse (LPN) #206 revealed STNA #207 told her the resident tried to hit her and she had to hold her against the wall to finish changing her or she would have fallen to the floor. STNA #207 revealed the resident might have hit her head against the wall, but she wasn't really sure. There was no written witness statement from STNA #207 and no assessment of the resident.

Interview on 01/18/24 at 8:11 A.M. with the DON revealed the investigation was complete. She confirmed there was no witness statement from STNA #207 and no assessment of the resident.

4. Review of the medical record for Resident #78 revealed an admission date of 10/25/21 and a discharge date of 11/16/23. Diagnoses Included hyperlipidemia, dementia, and hypertension.

Review of the functional assessment dated 05/18/23 revealed Resident #78 had the potential for falls.

Review of the incident report dated 10/27/23 at 9:05 A.M. revealed an aide found Resident #78 on the floor. The residents' vital signs were taken, and the resident appeared a little more confused and sorer and was given prn medications. The resident was sent to the hospital. The residents' vital signs were not noted in the report, and the physician and family were not notified.

Review of the Medication Administration Record (MAR) for October 2023 revealed Resident #78 was given Tylenol 325 milligrams (mg) for a pain level of ten on a scale of zero to ten on 10/27/23 at 9:07 A.M.

Review of the incident log dated 10/01/23 through 01/17/23 revealed no evidence of a fall for Resident #78 on 10/27/23.

Interview on 01/18/24 at 8:11 A.M. with the DON revealed the facility did not investigate falls.

Interview on 01/18/24 at 11:08 A.M. with the DON revealed the facility did initial neurological checks after a fall, then the nurse determined if they needed to be ongoing. Any neurological checks would be documented in the progress notes. If there was evidence of a head injury they would be done, but they were not done for all unwitnessed falls. She also revealed they did not collect witness statements for falls and confirmed that facility policy states witness statements are to be obtained. She revealed the nurses would implement any new interventions they felt necessary and document them in the progress notes, and reassessments would occur every shift after a fall for 72 hours.

Review of the facility policy titled Fall/Observed on Floor Protocol

Based on review of the medical record, interview with staff, and facility policy review the facility failed to protect Residents #4 and #16 from sexually aggressive behavior from Resident #80. This affected two residents (#4 and #16) of three residents reviewed for abuse.

Findings include:

Review of the medical record revealed Resident #80 was admitted to the facility on 01/21/23 with diagnoses including hypertension, insomnia, inappropriate sexual behaviors, anxiety disorder, and Alzheimer's dementia. He was discharged on 06/21/23.

Review of the admission assessment dated 01/21/23 revealed Resident #80 was alert and oriented to person only.

Review of the nurse's note dated 02/17/23 at 4:34 P.M. revealed the nurse spoke with the Nurse Practitioner (NP) concerning Resident #80 pursuing a female resident on the unit, being found in a female resident's room, and kissing on occasion. The other resident was agreeable to the contact. A new order was received for cimetidine (antihistamine and antiacid also used for sexual aggression) 400 milligrams once daily.

Review of the physician's orders revealed Resident #80 had an order dated 02/17/23 for cimetidine 400 milligrams once daily for Alzheimer's disease.

Review of the nurse's note dated 02/22/23 at 3:14 P.M. revealed the facility spoke to Resident #80's wife concerning him approaching other female residents making sexual remarks and attempting to kiss them. His wife indicated he had always been very sexual. She was informed of a new order for a psychiatric consult and potential medication and treatment to attempt to control the behaviors.

Review of the physician's orders revealed Resident #80 had an order dated 02/24/23 to increase cimetidine 400 milligrams to twice daily for Alzheimer's disease. It was discontinued on 04/17/23.

Review of the Level of Care Assessment dated 02/25/23 revealed Resident #80 demonstrated sexually inappropriate behaviors.

Review of the physician's orders revealed Resident #80 had an order dated 03/20/23 Provera (female hormone) 5 milligrams once daily for inappropriate sexual behaviors.

Review of the physician's orders revealed Resident #80 had an order dated 04/17/23 to increase the Provera to 10 milligrams once time daily for anxiety and to discontinue the cimetidine 400 milligrams twice daily.

Review of the medical record revealed Resident #16 was admitted to the facility on 05/16/23. Diagnoses included chronic kidney disease, senile degeneration of the brain, dementia, and hypothyroidism.

Review of the admission assessment dated 05/16/23 revealed Resident #16 was alert and oriented to person only.

Review of the medical record revealed Resident #4 was admitted to the facility o 05/26/23. Diagnoses included bipolar disorder, hallucinations, malignant neoplasm of the skin and vascular dementia. She resided on the secured memory care unit (SMCU) at the facility.

Review of the admission assessment dated 05/26/23 revealed Resident #4 was alert and oriented to person only.

Review of the nurse's note dated 06/05/23 at 7:30 A.M. revealed Resident #80 was sitting on the couch in the common area next to a female resident holding her hand and attempting to kiss her.

Review of the nurse's note dated 06/05/23 at 8:15 A.M. revealed Resident #80 was found in another female resident's room; both had their shoes off and were attempting to lay down in the bed together. When approached to come down for breakfast, Resident #80 indicated it was not fair they interrupted them. He was redirected to put his shoes back on and come out to the dining area.

Review of the nurse's note dated 06/06/23 at 2:02 P.M. revealed psychiatric services returned the facilities call regarding Resident #80's increased sexual behaviors and an order was received for 400 milligrams of Tagamet (cimetidine) twice daily if okay with his primary care physician.

Review of the physician's orders revealed Resident #80 had an order dated 06/06/23 for cimetidine 400 milligrams twice daily for sexual behaviors.

Review of the behavior note dated 06/11/23 at 10:22 A.M. revealed Resident #80 continued to go after other female residents, insisting they were his wife. He would not listen to staff and was getting angry with attempts to redirect him. He would stomp his feet and curse at the staff.

Review of the pan of care note dated 06/12/23 at 1:13 P.M. revealed it was discussed Resident #80 continued confusion of female resident being his wife or sister, Resident #80 occasionally trying to kiss female residents, going into other resident's rooms, or bringing them to his room. He had limited activity involvement. His wife was aware of his worsening confusion and increased behaviors.

Review of the nurse's note dated 06/13/23 revealed Resident #80 had sexual exploitations with verbal sexual communication to a female resident while on the couch. The residents were redirected to separate parts of the living room furniture.

Review of the Alert Note dated 06/16/23 at 6:30 P.M. revealed the staff entered the room of Resident #4 and found her and a male resident [Resident #80] were standing near the bed, both were naked from the waist down. The male resident was assisted from the room and Resident #4 was assisted to the bathroom. The nurse assessed the resident and found no redness, bruising, swelling, or bleeding to genitalia or other body parts. Resident #4 denied any discomfort or pain. Upon review of camera footage: Resident #4 and the male resident were noted to be sitting in the common area, resident on couch and the male resident sitting in chair next to couch, conversing. Resident #4 rose from the couch at 2:40 P.M. with her walker and began walking towards her apartment, the male resident rose from the couch at 2:41 P.M. and followed Resident #4 to her room and both were observed entering the room together without signs of struggling. After the male resident left the room, Resident #4 was asked about circumstance behind the male resident being in her room and if she was agreeable to him being there and the events that occurred while he was there. She only smiled and did not verbally respond. After multiple questions, the resident began repeating the questions in response. The NP was notified, and no new orders were given. Resident #4's sister was notified of the situation. She stated, I'm not surprised and she pursued a neighbor and caught him too. Resident #4's sister was laughing during the conversation. She declined an offer to move Resident #4 from the unit or a room change. The sister indicated she felt they were both just seeking affection and she was accepting of any further contact between her sister and the male resident. The Administrator was notified. It had been noted by staff that Resident #4 and the male resident have been seeking each other's company and holding hands for days/weeks prior.

Review of the 15-minutes check form revealed 15-minutes checks began on Resident #80 at 3:45 P.M. on 06/16/23.

Review of the Alert Note dated 06/16/23 at 5:45 P.M. revealed the staff discovered Resident #80 in a female resident's [Resident #4] room, naked from waist down. Per staff report, both the residents were standing by bed, naked from the waist down. Resident #80 became verbally aggressive and combative with staff when they attempted to assist him with dressing. Staff alerted this writer and upon entering the female resident's room, Resident #80 was noted to be standing by the bed and the female resident was near the bathroom door. Resident #80 was yelling at the staff stating he did not need help with his pants. He was easily calmed and redirected when instructed to sit in the chair and put his clothes on. Resident #80 was assisted from the room and every 15-minute checks were initiated. Resident #80 was unable to say what happened. Neither resident noted to be traumatized by the encounter. Upon reviewing the camera footage: Resident #80 and a female resident were observed sitting in common area, he was in a chair, and she was on couch next to each other. They were talking to each other. At 2:40 P.M. the female resident got up and walked towards her room. At 2:41 P.M. Resident #80 got up and followed her to her room and they entered her room together without any signs of force. The staff were observed going to the female resident's room approximately 30 minutes later and entering the room. The resident's son, Administrator and NP were notified.

Review of the nurse's note dated 06/19/23 at 5:40 A.M. revealed Resident #80 was found in the common bathroom while a female resident was on the toilet. He refused to leave the bathroom.

Review of the Behavior note dated 06/20/23 at 1:17 P.M. revealed Resident #80 went up to another resident [Resident #16] and grabbed her butt. The female resident turned around and smacked Resident #90 on his chest, no injury was noted, and the Director of Nursing (DON) was notified. Staff also report he grabbed a volunteer's breast on the way back from church this morning.

Review of the nurse's note dated 06/20/23 at 5:24 P.M. revealed Resident #16 refused to go to some activates due to a male resident [Resident #80] was going to be there. She stated she does not want to be near him, and she appears to be afraid of him.

Review of the nurse's note dated 06/20/23 at 6:18 P.M. revealed a male resident [Resident #80] went up behind Resident #16 and grabbed her butt. She turned around and smacked the male resident. No injury was noted. She stated he was a bad man.

Review of the nurse's note dated 06/21/23 at 10:01 A.M. revealed the staff has reported Resident #80 having an increase in inappropriate behaviors, touching other resident and staff on the buttocks and breasts. A call was placed to psychiatric services with no return call. The NP was notified a local psychiatric hospital and provided information on Resident #80's history of sexual behaviors and increased incidents. The screening was competed, and they would be able to admit him. The resident's son was notified.

On 07/07/23 at 9:20 A.M. an interview with Licensed Practical Nurse (LPN) #100 revealed Resident #80 was no longer at the facility. She stated he was sent out and the family placed him in a long-term care facility. She stated Resident #80 had been inappropriate with a few female residents. She stated she was not here when he was found with Resident #4. She stated she was working when he grabbed Resident #16 on the butt.

On 07/07/23 at 11:30 A.M. an interview with the Administrator revealed the facility started 15-minutes checks on Resident #80 after the incident on 06/16/23 with Resident #4. She stated prior to the 15-minute checks, they were not doing any type of interventions for his behaviors. She verified there was documentation prior to the incident with Resident #4 on 06/16/23 of Resident #80's sexual behavior.

On 07/07/23 at 11:50 A.M. an interview with State Tested Nursing Assistant (STNA) #101 revealed she was working the day Resident #80 smacked Resident #16 on the butt. She stated they were in the dining room after lunch and Resident #16 was standing at a table in the dining room when Resident #80 walked past her and reach out and grabbed her butt. She stated Resident #16 turned around and smacked him in the arm. She stated Resident #16 was very upset and did not want him around her after that incident. She stated she was the one who found Resident #80 in Resident #4's room. She stated she could not find Resident #80, so she went looking for him and she found him in the room of Resident #4 and they both had their pants down. She stated he did not have his hands on her, but you could tell he had done something to her. She stated another staff member went and got the DON; they got his pants up and got him out of the room. She stated Resident #4 did not really know what was going on. She stated Resident #4 and #80 have had incidents prior to this but were always redirected before anything happened.

On 07/07/23 at 11:55 A.M. an interview with LPN #100 revealed on 06/20 23 she had been in the dining with her back turned away from Resident #16 and #80. She stated she heard Resident #16 smack Resident #80, but she had not witnessed the incident. She stated after that incident Resident #16 stayed away from Resident #80. She stated she did not want anything to do with him.

On 07/07/23 at 11:58 A.M. an interview with Personal Care Assistant #102 revealed she was working on 06/20/23 when Resident #80 grabbed Resident #16's butt. She stated she was in the dining room after lunch, Resident #80 was sitting in a chair along the wall and Resident #16 was standing in the dining room. She stated she was talking to the nurse, and Resident #80 quickly got up out of his chair, walked over to Resident #16 and grabbed her butt, and she turned around and slapped him. She stated Resident #16 was very upset. She stated she was not sure what had happened but Resident #16 was scared of him after that incident and would not go anywhere near him.

On 07/07/23 at 1:00 P.M. an interview with LPN #103 revealed she was off the unit when the incident occurred and by the time she had heard about it he was dressed and already escorted out of her room. She stated Resident #80 was always seeking Resident #4 out. He tried to hold her hand, kiss her and he made jesters with his mouth and tongue towards her. She stated Resident #4 would turn her heads away from him and become bashful towards him, like she did not know what to do. She stated she attempted to redirected him and get them engaged in other activities, separate them. She stated he has had these types of behaviors with other female residents also.

On 07/07/23 at 1:19 P.M. an interview with the DON revealed the activity assistant came to her office and stated Resident #80 was in room of Resident #4 and he was naked. She stated she was surprised they had their clothes off. She stated Resident #80 was upset, she asked him why, and he stated he did not need anyone to help him get his pants on. She told him to go sit down and put them on and he did. She stated she had everyone but STNA #101 leave the room, and she had STNA #101 take Resident #4 into the bathroom and get her dressed. She stated LPN #103 completed an assessment of Resident #4 and reported to her there was no trauma noted.

On 07/07/23 at 1:25 P.M. an interview with Activity Assistant #105 revealed she was going to get Resident #4 for an activity and that was when she and STNA #101 realized neither Resident #4 nor #80 were in the sitting area. She stated she and STNA #101 went to Resident #4's room and another staff member went to Resident #80's room. She stated they found both residents in Resident #4's room with their pants down. She stated she went to find the nurse but was unable to locate her, so she went and told the DON. She stated she had seen Resident #80 do inappropriate thing with the residents many times. She stated she had gone to the DON and told her it was very hard to conduct an activity when she had to keep stopping to tell Resident #80 to keep his hands to himself and stop touching the ladies. She stated she was never directed by the DON on what to do in those situations.

Review of the abuse policy titled, Resident Freedom from Abuse, Neglect, Restraint, Coercion, and Misappropriation of Property

Based on observation and interview, the facility failed to ensure proper sanitization of the bins of cornstarch, sugar, and flour and left scoops in all three bins. This had the potential to affect all 74 residents residing in the facility.

Findings include:

A tour of the kitchen on 06/08/23 at 10:00 A.M. revealed scoops were observed in the cornstarch bin, the flour bin, and the sugar bin.

An interview with Director of Dietary #881 on 06/08/23 at 10:10 A.M. verified the scoops in the cornstarch bin, the flour bin, and the sugar bin.

Based on record review and interview, the facility failed to evacuate residents capable of self-evacuation during at least two fire drills on each shift and failed to transmit a fire alarm signal with verification of the signal within 12 hours of activation of a silent alarm. This had the potential to affect all 74 residents residing in the facility.

Findings include:

Review of records for facility fire drills conducted between 06/30/22 to 05/20/23 had no documented evidence residents capable of self-evacuation were evacuated on the fire drills dated 06/30/22, 07/11/22, 08/12/22, 09/19/22, 10/12/22, 10/14/22, 12/12/22, 12/16/22, 01/26/23, 02/15/23, 02/28/23, 03/31/23, 04/28/23, and 05/20/23.

Further review of records for facility fire drills conducted between 06/30/22 to 05/20/23 revealed there was no documented evidence of confirmation that the facility transmitted a fire alarm signal and verified receipt of the signal within 12 hours of activation of the silent alarm documented on 02/28/23. Review of facility fire drill records revealed the documentation was unclear as to the method of fire alarm activation. There was no indication whether alarms were physically activated, coded, or silent, except for the fire drill record dated 02/28/23 in which silent was hand-written in the fire drill scenario section.

Interview on 06/08/23 at 11:10 A.M. with Director of Facility Services #882 revealed the sign-in sheet contained signatures of employees who participated in the fire drills and no residents living in the facility were evacuated during any of the 14 fire drills conducted in the last 12 months, including 06/30/22, 07/11/22, 08/12/22, 09/19/22, 10/12/22, 10/14/22, 12/12/22, 12/16/22, 01/26/23, 02/15/23, 02/28/23, 03/31/23, 04/28/23 and 05/20/23.

Further interview on 06/08/23 at 11:12 A.M. with Director of Facility Services #882 confirmed fire drills conducted on the third shift were silent alarms and he had not verified successful alarm transmission after fire drills conducted on the third shift on 08/12/22, 10/14/22, 02/28/23 and 05/20/23 including a follow-up to verify transmission and receipt of the fire alarm signal.

Based on observation, review of Material Safety Data Sheet (MSDS), and interview the facility failed to ensure chemical cleaners were stored in a safe manner on the secured memory care unit (SMCU). This had the potential to affect all 26 residents (Resident #49,#50, #51, #52, #53, #54, #55, #56,#57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, AND #74) residing in the SMCU. The facility census was 74.

Findings include:

Observation during the lunch meal on the SMCU on 06/08/23 at 12:00 P.M. revealed a bottle of Virex Plus (all-purpose disinfectant cleanser) sitting on the counter. Also noted in an unlocked cabinet under the servery counter were chemical cleaners including a bottle of Pledge (multi-surface cleanser spray), a bottle of stainless-steel cleaner, and a can of Claire Disinfectant (hospital grade multipurpose disinfectant for hard, non-porous surfaces). The label on the Pledge bottle read keep out of reach of children. The label on the stainless-steel cleaner read keep out of reach of children. The label on the can of Claire Disinfectant read keep out of reach of children. The label on the Virex Plus read hazardous to humans.

Interview on 06/08/23 at 12:05 P.M. with State Tested Nursing Assistant (STNA) #840 verified the cleaners were present and in an unlocked space. She then went on to state the half door between the kitchen area and the dining area was usually locked but it was broken at the time.

Review of the MSDS for Pledge reads causes skin irritation, serious eye damage, and toxic if inhaled.

Review of the MSDS for Claire Disinfectant reads may cause irritation on skin, eye irritation, and may cause nose, throat and respiratory irritation with inhalation.

Review of the MSDS for the stainless-steel cleaner reads may be fatal if swallowed or enters airways.

Review of the MSDS for Virex Plus reads causes severe burns, serious eye damage, and causes serious burns to mouth throat, throat, and stomach if ingested.

Based on interview and record review the facility failed to ensure the grievance committee members consisted of one staff member to two residents and/or family members. This had the potential to affect all 74 residents residing in the facility.

Findings include:

Review of facility Grievance Committee information reveled two staff members including the Administrator and Director of Resident Life (DRL) #871, two residents (Resident #15 and Resident # 3) and one family member (Family Member #832).

Review of the resident handbook page 13 reveled the makeup of the Grievance Committee should be a ratio of not more than one staff member to every two residents, sponsors, or outside representatives.

An interview with the Administrator on 06/08/23 at 1:10 P.M. verified the Grievance Committee consisted of two staff members, (Administrator and DRL #871) and two residents, (Resident #15 and Resident #35), and one family member (Family Member #832).