Wrightsville Manor Health And Rehab

F-F600.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 13 115406 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115406 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wrightsville Manor Health and Rehab 337 West Court Street Wrightsville, GA 31096

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Resident R2 was observed by staff on 11/29/2024 going in and out of the room of Resident R1. On 11/29/2024, sexual abuse was identified between Resident R1 and Resident R2. Resident R2 was observed in Resident R1's room, standing over her bed while she was in Level of Harm - Immediate bed asleep. Resident R2 was seen leaving Resident R1's room, adjusting his belt in the lobby with a small amount of blood on jeopardy to resident health or his pants observed. safety

Review of progress notes dated 11/29/2024 at 00:30 am revealed Registered Nurse (RN) BB was called to Residents Affected - Few Resident R1 room by Licensed Practical Nurse (LPN) AA. RN BB noted a large amount of bright red blood on the right side of Resident R1 brief. It appeared to be coming from the vaginal area.

Hospital records on 11/29/2024 at 6:10 am revealed an evaluation for a sexual assault exam. Abrasions were noted at 1:00 -3:00 o'clock as well as at 9:00 o'clock. Small vaginal tear at 5:00 o'clock. Patient was given Sexually Transmitted Infection (STI) prophylaxis.

A review of the local police report dated 11/29/2024 at 6:41 am revealed that the officer was advised that one of the on-duty nurses at the facility entered the room of Resident R1 and witnessed Resident R2 over the top of Resident R1. Resident R2 fled from the room. The nurse then noticed blood around the private area of Resident R1, at which time she went to locate Resident R2. When Resident R2 was located, he had his hands in front of his pants in his private area. Blood was noticed on his pants by the zipper. The facility collected Resident R1 and Resident R2 clothing. The officer was notified of four facility staff members that had witnessed Resident R2 on numerous occasions going in and out of the room belonging to Resident R1 on

the night in question. The officer stated that after talking with the physician and collecting the sexual assault kit, it was determined that Resident R1 had been a victim of rape. The officer notified and advised the Administrator at

the facility that Resident R2 was going to be arrested for the rape of Resident R1, then turned back over to the facility because of his mental capacity.

Interview with the DON on 1/29/2025 at 10:00 am revealed that she does not know if Resident R1 was raped, but it depends on what you define as rape. She stated that if Resident R2 did something to Resident R1, it would be with his hands because he was not capable of sexually assaulting Resident R1. She stated that Resident R2 would not have known how to fasten his brief back and fasten Resident R1's brief. The DON further revealed that Resident R2 was starting back on medroxyprogesterone, and the medication was sent with him to the other facility after the incident. The DON revealed that they moved Resident R2 down to the locked unit until they could get him to a behavioral facility. The DON stated that he was arrested and returned to the facility several hours later.

Interview with the Administrator on 1/29/2025 at 3:01 pm revealed she is the abuse coordinator. The administrator stated that the DON had informed her of the incident between Resident R1 and Resident R2. She stated that she came right over to the facility. She stated that Resident R1 was sent to the ER for evaluation, and they placed Resident R2 on

the locked unit to monitor him closely. The Administrator stated that they started 15-minute checks on Resident R2 until they could get him sent out to the behavior unit, but he was not placed on one-on one.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 13 115406 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115406 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wrightsville Manor Health and Rehab 337 West Court Street Wrightsville, GA 31096

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Interview with RN BB on 1/29/2025 at 8:50 pm revealed that an LPN AA saw the male resident fiddling with his pants. She stated that she assessed him and saw some bright red blood on his pants. She stated that the Level of Harm - Immediate blood looked fresh. RN BB stated that a CNA was going into the Resident R1's room to check on her, and she noticed jeopardy to resident health or the blood was on her. She stated this was right after the male resident (Resident R2) left her (Resident R1) room. RN BB safety revealed that the resident did not have any blood on her previously in her brief. RN BB stated that she checked the female resident, and she had a small BM. She stated that she saw some blood and checked to Residents Affected - Few ensure the blood was not coming from the stool. RN BB stated that there was some blood in the female's vaginal area. She stated that she tried to make sure the blood wasn't coming from the urinary area. LPN AA stated that the blood was definitely coming from the vagina. She stated that the Resident R1 flinched when she wiped

the area, and Resident R1 had not done that before.

Interview with the Administrator on 2/4/2025 at 3:20 pm revealed that the Administrator stated that she did not do follow-up interviews with staff because she had three staff written statements.

The facility implemented the following actions to remove the IJ:

1. Director of operation reviewed Abuse Neglect and Exploitation misappropriation program in-serviced Administrator and DON on 2/5/2025.

2. Administrator and DON signed job descriptions on hire date. Director of operations reviewed job descriptions on 2/5/2025.

3. The facility held Ad Hoc QAPI meeting 2/5/2025, to review the Immediate Jeopardy findings Medical Director was over the phone. Administrator, DON, Adon, Treatment nurse, MDS, Social Service, Activity, Maintenance, Housekeeping, HR, Admissions, Dietary, IFP, CNA, Unit Manager.

4. The allegations of sexual abuse of Resident R1 have been reported and investigated by administrator and DON and

the necessary corrective actions were taken to assure they do not happen again, Resident R2 was removed from facility and is discharged . Resident R1 has a room monitor with camera and it stays on at the nurse's station to allow staff to see Resident R1, 12/9/24.

5. Abuse prevention is given by HR on hire 2/5/2025. No new employee will be able to work without receiving education.

6. Social Service director has called and emergency Abuse and prevention and resident rights meeting to be held 2:30pm 2/7/2025. The meeting was held with resident counsel.

7. Social Service director completed interview with all residents 2/5/2025, asking them has a person been in their room touching or hurting them, all that could answer stated no. Residents that could not answer were reviewed on skin assessments for injury, tears, bruises.

8. 12-2-2024 skin assessments were started on all residents weekly by treatment nurse. Each hall is on a different day, treatment nurse observes for any skin tears, bruises, sores, etc.

Skin assessments were completed 12/6/2024.

The facilities corrective actions for

F-F835 were completed by 2/6/2025, and the facility alleges the immediacy of IJ to be removed by 02/08/2025. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 13 115406