**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, resident record reviews, review of a facility policy titled Abuse, Neglect and Exploitation, review of Facility Reported Incidents (FRIs) received by the State Agency, and review of the facility's investigative files, the facility failed to protect the residents' rights to be free from sexual and physical abuse perpetrated by residents. Specifically: 1.) The facility failed to ensure Resident Identifier (RI) #49 was free from sexual abuse perpetrated by RI #1, a resident with a history of sexually inappropriate behavior to include vulgar comments and obscene language. On 09/12/2024 RI #1was found unsupervised in the Activity Room with his/her hand on RI #49's breast. The facility had not developed and implemented interventions to ensure RI #1 was supervised in a manner to protect other residents and monitored appropriately for behaviors that could affect residents' safety. On 08/28/2024 RI #1's dosage of Seroquel (an antipsychotic medication ordered to treat RI #1's Schizophrenia) was decreased. The facility did not ensure the staff were providing enhanced supervision or monitoring and documenting RI #1's behaviors to ensure residents' safety following the Gradual Dose Reduction (GDR) of Seroquel. It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect and Exploitation. On 05/06/2025 at 6:45 PM, the Administrator, Director of Nursing (DON), [NAME] President of Clinical Reimbursement, [NAME] President of Clinical Operations, Regional Director of Clinical Operations, and Senior Regional Director of Clinical Operations were provided a copy of the IJ template and notified of the findings of immediate jeopardy and substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation at F600- Free from Abuse and Neglect. The IJ began on 09/12/2024 and continued until 05/09/2025 when the survey team verified onsite that corrective actions had been implemented. On 05/09/2025 the immediate jeopardy was removed, F600 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as the result of the investigation of complaint /report number AL00048797. The facility further failed to ensure RI #11 and RI #1 were protected from physical abuse that did not rise to the jeopardy level. 2.) On 10/04/2023, the facility failed to protect RI #1 from physical abuse when RI #262 hit RI #1 in the face. 3.) On 10/15/2024 the facility failed to protect RI #11 from physical abuse when RI #2, a resident with a history of behaviors, hit RI #11 on the arm. These deficient practices affected three of eight residents sampled for abuse. These deficient practices were cited as a result of the investigations of facility reported incident/complaint/report numbers AL00048797, AL00049328, and AL00045759. Findings include: Cross-Reference F605 and F740. Review of the facility's policy titled, Abuse, Neglect and Exploitation, with an implemented date of 05/20/2022, and a revised date of 09/12/2024, revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations . It includes verbal abuse, sexual abuse, physical abuse, . Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment . Sexual Abuse is non-consensual sexual contact of any type with a resident . Verbal Abuse means the use of oral, written or gestured communication sounds that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability . Policy Explanation and Compliance Guidelines: . 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. The components of the facility abuse prohibition plan are discussed herein: . III. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect . that achieves: . B. Identifying, correcting and intervening in situations in which abuse . is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents and assure staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; . D. The identification, ongoing assessment, and care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict . 1) On 09/12/2024 at 5:35 PM the State Agency received a FRI alleging that RI #1 was observed touching RI #49's breast in the activity room. RI #49 was admitted to the facility on [DATE]. RI #49's quarterly MDS assessment with an ARD of 07/07/2024 documented a BIMS score of 10 of 15 which indicated moderate cognitive impairment. RI #1 was admitted to the facility on [DATE] and had diagnoses to include: Paranoid Schizophrenia, Vascular Dementia, Bipolar II Disorder, and Borderline Personality Disorder. A review of RI #1's PASRR Level I Screening & Results dated 10/04/2019 documented . 5. Does the individual's current behavior or recent history within 1 year indicate that they are a danger to self or other . Yes history of sexual inappropriate behaviors . A review of RI #1's comprehensive care plan titled Care Plan Report revealed: Focus Behaviors . AEB [as evidenced by] . cursing, threatening and criticizing others, taunting and provoking others, name calling and demeaning names . sexual remarks and slurs and inappropriate behaviors such as sexually inappropriate and social behaviors of sexual and vulgar remarks, impulsive episodes and cursing out others. Date initiated: 06/02/2022 Revision on 09/06/2022 . Interventions . Counsel concerning invading others personal space and sexual boundaries as needed . Observe for effectiveness of current medication regimen . Observe for episodes of behaviors and response to interventions . The care plan did not provide direction to staff regarding how or when RI #1 needed to be supervised. A review of RI #1's Progress Notes revealed a Nursing Progress Note dated 03/15/2023 that documented: . Resident verbally aggressive and offering sex to staff . RI #1's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 08/03/2024 documented a Brief Interview for Mental Status (BIMS) score of 7 of 15, which indicated the RI #1 had severe cognitive impairment. A review of Certified Nursing Assistant (CNA) mood and behavior documentation for RI #1 from August 2024 to October 2024 was conducted. The review of the documents revealed the monitoring was not completed each shift per the instructions. No behaviors were documented on 09/12/2024. A review of RI #1's Electronic Medication Record (EMAR) for August and September 2024 revealed a task to monitor for behaviors each shift with start date of 08/18/2022. The review of the documents revealed the monitoring was not completed each shift per the instructions. No behaviors were documented on 09/12/2024. A review of RI #1's Behavior Monitoring notes in 2024 revealed no behaviors were documented except a note on 07/04/2024 which documented refusal of a vaccination and that the resident was combative with the writer of the note. Surveyors attempted and were unable to view video footage during the survey. An interview was conducted with RI #49 on 04/30/2025 at 10:07 AM. RI #49 was asked about the incident involving RI #1 on 09/12/2024. RI #49 indicated he/she knew RI #1 due to their shared residence at the facility, but he/she did not recall the incident. On 05/01/2025 at 10:25 AM, an interview was held with Certified Nursing Assistant (CNA) #15 regarding the incident that occurred on 09/12/2024, involving RI #1 and RI #49. CNA #15 reported that while passing by the Activity Room around 4:00 PM, she observed RI #1 touching RI #49's breast. She said that both residents were seated at a table in the Activity Room and that RI #1's hand was on the RI #49's breast and not under the shirt. CNA #15 said she intervened by separating the residents, remaining in the room, and calling for the nurse who was outside the door. She said no staff members were present in the room during the incident. CNA #15 said the Activity Director finished her shift at 4:00 PM. CNA #15 said the presence of staff in the Activity Room might have prevented the incident. CNA #15 said she this incident was sexual abuse and that RI #49 likely felt violated. On 05/01/2025 at 4:17 PM, an interview was held with LPN #13 regarding the incident involving RI #1 and RI #49 that occurred on 09/12/2024. LPN #13 reported that while she was outside the Activity Room, she heard CNA #15 calling for assistance. Upon entering the room, LPN #13 observed RI #1 with his/her hand on RI #49's breast. LPN #13 stated that she helped to separate the residents and took RI #1 to his/her room. LPN #13 said that the incident was sexual abuse and that RI #49 did not want for RI #1 to touch him/her. An interview was held with CNA #22 on 05/04/2025 at 11:50 AM. CNA #22 said that residents were prohibited from being in the Activity Room without supervision and that a staff member should have been present during the incident. She said unsupervised residents in the Activity Room could engage in arguments or altercations. An interview was conducted with the Activity Director (AD) on 05/03/2025 at 12:17 PM. The AD was questioned regarding the incident that took place on 09/12/2024 involving RI #1 and RI #49. The AD acknowledged that she was aware of the incident but did not witness it firsthand. When asked whether residents were permitted to be in the Activity Room unsupervised, she did not know. The AD said not providing supervision in the Activity Room could lead to resident altercations. She said that the incident involving RI #1 and RI #49 might have been prevented had staff been present, as RI #1 would not have touched RI #49 in front of staff. An interview was conducted with Former Administrator (FA) #10 on 05/05/2025 at 3:55 PM. During the interview, the FA was questioned regarding the incident involving RI #1 and RI #49 that occurred on 09/12/2024. According to the FA, LPN #13 informed her that RI #1 had touched RI #49's breast. The FA said she did not know how long the residents were in the Activity Room unsupervised. She said residents were typically not permitted to be in the Activity Room without supervision, which was usually provided by the AD. The FA said the incident involving RI #1 and RI #49 was sexual abuse and that RI #49 would have likely felt violated. On 05/06/2025 at 2:03 PM, an interview was held with the Director of Nursing (DON) regarding the level of supervision for RI #1. The DON indicated that she was not aware of any specific supervision requirements for RI #1. The DON stated that the RI #1 needed standard supervision, which included monitoring every two hours, as well as during activities, dining, and smoking. When asked about the interventions in RI #1's care plan at the time of the incident could have safeguarded RI #49 and other residents from potential abuse by RI #1. The DON said that the interventions explaining to RI #1 the reasons for not engaging in sexually inappropriate behavior, interacting with RI #1, and redirecting or removing the resident from situations when they became disruptive or agitated. ************************************************ On 05/09/2025, the facility submitted an acceptable removal plan, which documented: F600 Removal Plan 05/09/2025 1. Immediate action(s) taken for the resident(s) found to have been potentially affected include: a. The facility failed to ensure RI #49 was free from sexual abuse perpetrated by RI #1, when RI #1, a resident with a history of sexually inappropriate behavior to include vulgar comments and obscene language, was found alone in the activity room at the facility, with his/her hand on RI #49's breast. b. CNA #15 witnessed RI #1 touch RI #49 on the right breast upon entering the activities room. CNA #15 instructed RI #1 to stop touching RI #49 as she entered the room and approached the residents to separate them. CNA #15 called out for assistance and LPN #13 was present in the hallway outside of the activities room door passing medications and entered the activities room and witnessed RI #1 touch RI #49 on the right breast. Residents were immediately separated. RI #1 was immediately taken to his room and placed on 1:1 observation. c. Resident #49 was assessed by RN #16 on 9/12/24 at approximately 1700. d. 1:1 observation was initiated on 9/12/24 immediately following the occurrence of the incident. Provider was contacted, and resident was assessed on 9/13/24 - Recommendation was to discontinue 1:1 sitter and to provide close monitoring while resident out of bed in common areas. 1:1 observation was maintained for five days as a follow-up provider visit was scheduled for Monday 9/16/2024. NP assessed RI #1 on 9/16/2024 and resident continued to have no further behaviors so 1:1 monitoring was stopped the following day on day 5, 9/17/24. The assigned staff were to complete the documentation flow sheet. Charge nurses verified staff were 1:1 with RI #1 during the above noted dates, and staff submitted the flow sheet to the DON for review when completed. No behaviors were observed during that time. 1:1 observation was in place from 9/12/24 to 9/17/24. RI #1 was unable to transfer out of bed without the assistance of the staff. CNAs assigned to RI #1 were verbally instructed by charge nurses at the start of each shift to notify nurse once resident is assisted out of bed so he can be monitored. This directive was also noted on the CNA's care Kardex. This directive was put into effect following the completion of the 1:1 observation. e. On 05/07/2025, the Regional Director of Clinical Operations conducted an in-service for the Administrator and Director of Nursing covering all types of abuse and the facility's responsibility to ensure resident safety. 2. Identification of Other Residents Having the Potential to Be Affected a. This incident had the potential to affect vulnerable residents, that are unable to consent, residing in the facility. 29 residents with BIMS of 10 or greater were interviewed by Care Manager/designee on 5/07/25 using the Abuse screening interview form, if BIMS less than 10 form allows for staff observation with no abuse findings. b. On 5/07/2025, DON/Designees conducted a comprehensive audit of all PASRR forms of all residents in facility to identify all residents with a history of potentially inappropriate sexual behaviors. 0 additional residents were identified upon completion of the audit. RI #1 is the only resident will this history noted on his PASARR. c. On 5/07/2025, The Clinical Reimbursement Specialist reviewed all residents' care plans for any residents identified with known history of sexually inappropriate behaviors. Two additional residents were identified to have a history of sexually inappropriate behaviors. The 2 additional residents were identified by reviewing all residents' care plans to determine if any other resident was care planned for a history of inappropriate sexual behavior or comments. 3. Actions Taken / Systems to Be Put into Place to Reduce the Risk of Future Occurrences a. On 05/7/2025, the Regional Nurse Consultant/Designees provided one-on-one in-service training to the Administrator and Director of Nursing on the facility's Abuse Policy. b. Three residents are identified with a known history of sexually inappropriate behaviors and have interventions identified in their comprehensive person-centered care plan with individualized interventions in place to prevent the occurrence of abuse. These interventions include that each resident will not be in common areas with other residents unsupervised at any time as none of the three residents identified are physically able to transfer out of bed without the assistance of the staff. Interventions were added by the DON and Clinical support specialist on 05-07-2025. The two common areas located within the center are the dining room and the activities room. No residents are unsupervised in the dining room as the dining room is locked when meal service is complete. Meal services are supervised by the charge nurse and CNA assigned to the dining room that shift. The activities room is always supervised by a staff member. The identified Residents will be kept in highly visible areas when not in a common area. Nurse, CNAs, housekeepers, dietary staff, administrative staff and therapy staff have been in-serviced and will assist in monitoring these individuals. All staff have been in-serviced that the individuals identified in the communications book cannot be left alone in common areas with other people. The CNA assigned to the identified individuals will notify their charge nurse as directed by their care Kardex when these residents are out of bed as none of these residents are physically capable of transferring out of bed unassisted. If any of the identified residents are in the activities room, the activity director or designee hosting the activity will monitor them. If any of the identified residents are in the dining room the CNAs and nurses assigned to assist in the dining room that shift would be responsible for monitoring these residents in the dining room. All staff have been in-serviced to monitor these residents while in any common areas including the hallways of the facility to maintain every 15-minute observations. All three residents have been placed on every 15-minute observations while out of bed, to be signed off by the observing staff member every 15 minutes. If in activities, the Activities Director will visually observe the resident and sign the observation. If in the dining room, the CNA and/or charge nurse assigned to the dining room will visually observe the resident and sign the observation. If near or at nurses' station, the nurse will visually observe the resident and sign the observations. The charge nurse is responsible for ensuring the observations are made and that the observation monitoring sheet is signed off at the end of the shift. The DON is responsible for collecting the observation sheets and the Administrator is responsible for maintaining these records. Care Plans will be monitored and revised with comprehensive assessments and for any changes by the MDS Coordinator/IDT team during their care plan meetings. c. On 5/9/25, the Dietary Dept. has been in-serviced by the Regional Director of Clinical Operations on the process for ensuring the dining room remains locked between meal services to ensure no resident is unsupervised in the dining room. d. On 5/07/2025 All staff were provided training on the process to ensure that any residents identified with a known history of sexually inappropriate behaviors will not be alone/unsupervised in common areas with other residents. No residents are unsupervised in the dining room as the dining room is locked by the dietary aid when meal service is complete. Meal services are supervised by the charge nurse and CNA assigned to the dining room that shift. The activities room is always supervised by a staff member. If the activities director is not present, the activities room will be locked. The identified Residents will be kept in highly visible areas when not in a common area. Nurse, CNAs, housekeepers, dietary staff, administrative staff and therapy staff have been in-serviced and will assist in monitoring these individuals. All staff have been in-serviced that the individuals identified in the communications book cannot be left alone in common areas with other people. The CNA assigned to the identified individuals will notify their charge nurse as directed by their care Kardex when these residents are out of bed. If any of the three residents identified as having history of sexually inappropriate behaviors is in the activities room, the activity director or designee hosting the activity would be monitoring him/her; if in the dining room the CNAs and nurses assigned to assist in the dining room that shift would be responsible for monitoring these residents in the dining room. All staff have been in-serviced to monitor these residents while in any common areas including the hallways of the facility. Training included that these residents will be listed in the nursing communication binders located at each nurse's station and interventions were added to the Kardex of each identified individual instructing that these identified individuals must be supervised in common areas and in highly visible areas when out of room. DON/designee will monitor the schedule for staff who have not completed the training. DON/designee will provide training prior to the start of the shift. Staff not physically present were in-serviced via phone. No staff are permitted to work until this training is completed. Facility-wide staff training completed. 63 of 65 staff trained (two staff members on FMLA). e. On 5/9/2025, an additional in-service began, by the Regional Director of Clinical Operations, to train all staff (CNAs, Nurses, Nurse Managers, Administrator, activity staff) that the three residents identified will remain on every 15-minute observations while out of bed. Staff has been educated to continue the process noted on their Kardex that as soon as any of these residents are out of bed, the charge nurse is notified who will then initiate the observation sheet for that day and ensure the observations are continued and signed for the entirety that these residents are out of bed to prevent the risk of occurrence of abuse. f. The Resident Care Manager is responsible for monitoring the list of residents located within the Nursing Communications binders located at each nurse's station and updating the list for any changes due to admissions, discharges, and changes noted on comprehensive assessments. On 5/08/2024, Resident Care Manager, RN #16 was in-serviced by Clinical Operations Support Nurse on her specific responsibilities in updating and maintaining the list of residents located in the Nursing Communications binders. 1 of 1 staff member in-serviced. g. Facility-wide staff training began on 05/07/2025, by the Director of Nursing/ designee covering abuse policy. This policy emphasizes that all residents have the right to be free from sexual abuse, outlines how to identify abuse, and mandates immediate protection when abuse is suspected or observed. h. The in-service provided also included the process for when any staff observe behaviors. Staff should report behaviors to their charge nurse immediately for documentation in the medical record in the nursing progress notes and document the behavior in the PRN option of the CNAs POC charting. Behaviors are reported during shift-to-shift reports by charge nurses. IDT team reviews documentation in daily (Monday-Friday) clinical meetings, including review of behavior monitoring alerts, all nurses progress notes and nursing summaries for interventions/follow up. All of this information is read aloud by the DON to the IDT team members present during each meeting and assigns follow-up to the designated team member responsible for the item needing follow-up. Staff were educated during this in-service as well as during the Abuse Policy in-service on the process for behaviors that require immediate intervention. ii. DON/designee will provide training prior to the start of the shift. Staff not physically present were in-serviced via phone. No staff are permitted to work until this training is completed. 63 of 65 staff trained (two staff members on FMLA). iii. DON/designee will monitor each department's schedule for staff who have not completed the training. DON/designee will provide training prior to the start of the shift. Staff not physically present were in-serviced via phone. No staff are permitted to work until this training is completed. 63 of 65 staff trained (two staff members on FMLA). i. On 5/9/25, all Nurses, CNAs and housekeepers scheduled to work 5/10/25, 5/11/25 and 5/12/25 have been in-serviced on the process for every 15 minute observations for the identified residents or will be contacted via telephone prior to be able to clock in for their scheduled shift. j. The observations will be discussed daily, Monday thru Friday in the morning clinical meeting. The IDT team will discuss these observations during the weekly clinical risk meeting. k. Ad hoc QAPI meetings were held on 05/07/2025 and 05/08/2025 with key facility personnel, including the Administrator, Director of Nursing, maintenance director, Human resources, Dietary manager, activities director, Clinical Operations Support and the Regional Nurse Consultant. The meetings focused on ensuring all residents are protected from all forms of abuse, the importance of close supervision for residents identified to have a history of inappropriate sexual behaviors. Removal plans were reviewed by all team members present and approved at that time. 9 department head members attended QAPI meeting on 5/7/25. 10 department head members attended QAPI meeting on 5/8/25. QAPI Committee meeting was held 05/07/2025 to review allegations involving sexually inappropriate behaviors, including nonconsensual touching of sexual organs of other residents, to include incidents originating 12/2/24 - current Investigations. The Interdisciplinary Team (IDT) identified 3 residents requiring care plan reviews that were completed related to sexually inappropriate behaviors. The Quality Assurance and Performance Improvement (QAPI) team initiated a review to identify trends in sexual behaviors and behaviors associated with GDRs, assess potential behavioral triggers, and ensure that appropriate, individualized interventions were implemented and documented in the care plans. One of the two newly identified residents are currently on hospice services and no longer gets up out of bed to common areas. He/She has a history of making verbal sexual remarks with no recent documentation noted. 9 department head members attended QAPI meeting on 5/7/25. Facility requests for IJ removal plan to be effective on 5-09-25. ********************************************************* After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 05/09/2025. ******************************************************** 2.) The facility reported a FRI that alleged that on 10/04/2023 at 10:45 PM RI #262 struck RI #1 in the face. The residents were separated, and Emergency Medical Services (EMS) were requested for transport to the emergency room for psych services, and local law enforcement were notified. RI #262 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease, Anxiety Disorder, Adjustment Disorder with Depressed Mood and Vascular Dementia, unspecified severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. RI #262's quarterly MDS assessment with an ARD of 09/24/2023 documented a BIMS score of 0 of 15 which indicated that RI #262 had severe cognitive impairment. RI #262'S comprehensive care plan titled Care Plan Report revealed: . FOCUS . The resident is resident to care . exhibits aggressive behavior with [his/her] care refusals . Date initiated: 09/26/2023 . Cancelled Date: 03/04/2024 . The care plan did not include what level of supervision RI #262 required to keep residents safe. On 05/05/2025 at 2:50 PM an interview was conducted with Speech Pathologist (SP) said, on 10/04/2023 RI #262 was holding RI #1 from behind and had his/he arms wrapped around the waist of RI #1. The SP further said she yelled for help and did not leave RI #1. On 05/05/2025 at 3:10 PM an interview was conducted with LPN #19, the nurse on duty when the incident occurred. LPN #19 said on 10/04/2023 she heard the SP yelling for help and responded. LPN #19 said upon entering their room she saw RI #1's upper chest on the bed and legs hanging off the bed with the SP supporting RI #1's upper body. LPN #19 said, RI #262 was immediately removed from the room and was placed 1 on 1 observation. LPN #19 said she assessed RI #1 and he/she had a scratch to the forehead and some pain to the lip of RI #1. LPN #19 said, RI #1's forehead was cleansed with wound wash and triple antibiotic appointment applied. On 05/05/2025 at 4:12 PM an interview was conducted with Registered Nurse (RN) #9, the Unit Manager Nurse on duty when the incident occurred. RN #9 said, on 10/04/2023 when she entered the resident room, she did not see the altercation but heard RI #1 and RI #262 fussing over a bedside table. She further said, she saw a small scratch on RI #1's forehead. RN #9 said the incident was physical abuse. When asked how a reasonable person would feel in this situation, she said, it would make them feel bad and scared if they just got jumped. A telephone interview was conducted with the FA #20 on 05/06/2025 at 10:56 AM. During the interview, the FA #20 said, he became aware of the incident involving RI #1 and RI #262 on 10/04/2023. FA #20 said, RI #262 had taken RI #1's over the bed table and words were exchanged, and RI #262 hit RI #1 in the face. FA #20 said it was substantiated due to the injury to the forehead. FA #20 said, RI #262 was sent to the emergency room at local hospital for psychiatric evaluation. The FA #20 said there was sufficient evidence to substantiate physical abuse. The facility investigative file contained a form titled, Follow-up Incident Investigation to Alabama Department of Public Health (ADPH) / Administrative Summary Final Report for RI #1 dated 10/11/2023 which documented that RI #262 struck RI #1 in the face on 10/04/2023. A conclusion to the report was documented as follows: In conclusion, the facility completed an investigation and there is sufficient evidence to substantiate an allegation of physical abuse (Resident to Resident). (RI #262) transferred to the hospital on [DATE] for psych evaluation . (RI #1) is monitored for any psychosocial changes. (RI #262) transferred to two different hospitals on 10/04/2023. After the incident, the residents were separated as roommates. A review of RI #262's hospital medical record indicated he/she was admitted on [DATE] and discharged on 10/12/2023. The hospital medical record document titled Discharge Summary documented: REASON FOR admission (Quoted from H&P): . admitted to geriatric unit for dementia with behavioral disturbances. Per report pt was brought to emergency department for aggressive and combative behavior . 3) On 10/16/2024 at 10:39 AM the State

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of a facility policy titled Unnecessary Drugs the facility failed to ensure adequate monitoring for behaviors was completed accurately, properly, and consistently while a Gradual Dose Reduction (GDR) for a psychotropic medication was being attempted. Specifically, RI #1 had a dose reduction of Seroquel on 08/28/2024 and the facility did not have a documented system to include timeframe and instructions to staff on monitoring for behaviors while a GDR attempt was in progress. The Certified Nursing Assistant (CNA) and the nurses' behavior monitoring documentation on the Electronic Medication Record (EMAR) was not completed accurately and in a manner to validate whether RI #1 had behaviors or escalation of behaviors. RI #1 had a history of sexually inappropriate behaviors and on 09/12/2024 RI #1 sexually abused RI #49, 15 days after the dose reduction. It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from abuse, neglect and exploitation. On 05/06/2025 at 6:45 PM, the Administrator, Director of Nursing (DON), [NAME] President of Clinical Reimbursement, [NAME] President of Clinical Operations, Regional Director of Clinical Operations, and Senior Regional Director of Clinical Operations were provided a copy of the IJ template and notified of the findings of immediate jeopardy and substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation at F605-Free from Chemical Restraints . The IJ began on 09/12/2024 and continued until 05/09/2025 when the survey team verified onsite that corrective actions had been implemented. On 05/09/2025 the immediate jeopardy was removed, F605 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as the result of the investigation of complaint /report number AL00048797. Findings Include: Cross-Reference F600 and F740. Review of the facility's undated policy titled, Unnecessary Drugs, revealed: Policy: It is the facility's policy that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical and psychosocial well-being free from unnecessary drugs. Policy Explanation and Compliance Guidelines: . 3. The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents and/or representatives, other professionals and the interdisciplinary team . d. Adequate monitoring for efficacy and adverse consequences; . 8. Information gathered during the initial and ongoing evaluations will be incorporated into the resident's comprehensive care plan that reflects the person-centered medication related goals and parameters for monitoring the resident's condition . RI #1 was admitted to the facility on [DATE] and had diagnoses to include: Paranoid schizophrenia, Vascular Dementia, Bipolar II Disorder, and Borderline Personality Disorder. RI #1's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 08/03/2024 documented a Brief Interview for Mental Status (BIMS) score of 7 of 15, which indicated RI #1 had severe cognitive impairment. A review of RI #1's comprehensive care plan titled Care Plan Report revealed: Focus The resident uses antipsychotic and antidepressant medications daily r/t [related to] [his/her] dx [diagnosis] of intermittent explosive disorder, dementia with behavioral disturbances, major depressive disorder and bipolar 2 Date initiated: 05/02/2022 Revision on 05/23/2024 . Interventions . Monitor for change in mood and behaviors . The care plan did not include parameters for monitoring the resident's condition. Continued review of RI #1's Care Plan Report revealed: Focus The resident is resistive to care and has hallucinations r/t schizophrenia, Dementia and history of non-compliance with medication regimen. Date initiated: 01/04/2023 Revision on: 01/03/2023 Interventions . Observe for effectiveness of current medication regimen . A review of RI #1's Physician's Orders revealed RI #1 had an order for: . QUEtiapine Fumarate [Seroquel] oral tablet 150 MG . Give 150 mg [milligram] by mouth at bedtime . Start Date . 10/19/2023 . End Date . 08/28/2024 . A review of Consultant Pharmacist Medication Regimen Review dated 08/19/2024 documented: . Quetiapine 150 mg HS started 10/2023. If no present behaviors noted from 150 mg, please consider another dose reduction to find lowest effective dose . AGREE: Please write order . A review of RI #1's Progress Notes reveal an onsite note documented by Certified Registered Nurse Practioner (CRNP) #24 dated 08/28/2024 documented: . Spoke with resident regarding reduction of quetiapine and patient states it was fine . GDR [gradual dose reduction] made and quetiapine reduced to 100 mg . Further review of RI #1's Physician's Orders documented the following: . QUEtiapine Fumarate Oral Tablet 100 MG . Give 1 tablet by mouth at bedtime . Start Date . 08/28/2024 . End Date . 10/23/2024 . A review of Certified Nursing Assistant (CNA) mood documentation for RI #1 from August 2024 to October 2024 was conducted. The document directed staff to document the resident's mood each shift with a corresponding code related to the resident's mood. A review of the documents revealed this was not completed each shift. Seven of 12 shifts from August 28th to August 31 were blank and not completed. 32 of 60 shifts in September 2024 were blank and not completed including 13 of 24 shifts from September 1st to September 12th. A review of CNA behavior documentation revealed an X was documented 19 of 30 shifts in September 2024. The document instructed staff to document numbers 0-12 to correspond to different behaviors including . 10- Sexually Inappropriate . 12- None of the above observed. The instruction's key did not include an X or provide the meaning of an X. A review of nurses' behavior monitoring task on RI #1's EMAR revealed check marks were documented each shift in August 2024 and each shift in September 2024 except one shift on 09/27/2024 which was blank. The instructions for the behavior monitoring documentation on the EMAR was: Anti-Psychotic Monitor for any behaviors (Harassing disruptive loud behaviors, cursing, sexual slurs and remarks) Document: 'Y' if behavior IS noted during the shift 'N' if NO behavior noted during the shift Use chart code 9 and 'Other/See Nurses Notes' putting in specific progress note findings Document TOTAL # [number] of episodes per shift, Non-Pharmacological Interventions Attempted and Outcomes every shift related to PARANOID SCHIZOPHRENIA . Start Date 09/18/2022 . D/C [discontinued] Date 02/04/2025 1407. There was no instruction to document a check mark. The behavior monitoring task had a start date of 08/18/2022. A review of RI #1's Progress Notes and Nursing Notes revealed no Behavior Monitoring notes were documented from 08/28/2024 through 09/11/2024. An interview was completed with the Director of Nursing (DON) on 05/06/2025 at 5:28 PM. During this interview, the DON was asked to examine the Medication Administration Record (MAR) for RI #1 from September 2024 and the CNA documentation for September to October 2024. The DON stated that she could not provide an opinion whether the forms were completed accurately because she was not employed at the facility at the time the forms were filled out. An interview was held with the Social Services Designee (SSD) on 05/06/2025 at 2:57 PM. During the interview, the SSD was asked about the procedure for communicating GDRs to direct care personnel, including nurses, CNAs, and activities staff. The SSD explained that when a GDR was attempted nursing staff or she would verbally alert all staff members to be alert for any increased resident behaviors and were instructed to report back to either the SSD or the nursing staff. The SSD said the importance of monitoring residents following a GDR was to ensure they received the appropriate dosage for effectiveness and to prevent any escalation in behaviors. The SSD said that enhanced monitoring of residents exhibiting behaviors after a GDR could safeguard other residents from potential abuse by enabling staff to recognize problematic behaviors before they escalated into conflicts. An interview was conducted with the Medical Director (MD) on 05/06/2025 at 3:36 PM. During the interview, the MD was questioned regarding the GDR for RI #1 that took place on 08/28/2024. The MD indicated that residents with a history of behavioral issues should be closely monitored following a GDR to prevent the emergence of new behaviors. He noted that while there was no established standard for the duration of monitoring. The MD emphasized that the purpose of monitoring was to ensure that any changes in a resident's condition were not attributable to the medication adjustment. He also mentioned that heightened observation of residents with behavioral issues after a GDR could safeguard other residents by identifying subtle behavioral changes at an early stage. ************************************************ On 05/09/2025, the facility submitted an acceptable removal plan, which documented: F 605 Removal Plan 05/09/2025 1. Immediate action(s) taken for the resident(s) found to have been potentially affected include: a. The facility failed to ensure monitoring for behaviors after a psychotropic/antipsychotic GDR, was completed accurately, properly, and consistently for RI #1 who had a dose reduction of Seroquel on 8/28/2024. b. On 05/07/2025, the Regional Nurse Consultant conducted an in-service with the Director of Nursing addressing the proper procedure for monitoring behaviors after a psychotropic/antipsychotic dose reduction is initiated and the proper procedure for order entry for all monitoring orders. 2. Identification of other residents having the potential to be affected: a. This had the potential to affect all residents prescribed a recommended GDR during the last 30 days. On 5/7/25, A comprehensive audit was completed on all residents with a GDR during that period to ensure proper monitoring order procedure followed. Two residents were identified on this audit as having a GDR in the last 30 days. All current behavior monitoring orders for the two residents identified and for RI #1 were audited for accurate order entry. This was completed on 5/07/25 by DON/Designee. 3. Actions taken/systems to be put into place to reduce the risk of future occurrences include: a. On 5/7/25, The Regional Nurse Consultant in-serviced the DON regarding the process to follow with monitoring specific target behaviors with an increase in monitoring during the 30-day period following a GDR. The process included: i. Upon receiving the recommendation of GDR, the DON/designee reviews the recommendations, contacts the physician prior to implementation. If the physician does not approve, they will provide rational and document it in the progress notes or the DON/designee will document it in the progress notes. If the resident has a prior history of a failed GDR, this should be documented in the residents' CP by the MDS Coordinator/Designee and nurse's notes. If approved the charge nurse will initiate the order in the resident's record. ii. The monitoring order will be entered into EMR by the charge nurse entering the prescribed psychotropic/antipsychotic order or GDR. All components including special documentation parameters for accurate and complete documentation/assessment to be recorded as written in the order. iii. All physicians' orders are reviewed each morning in the morning clinical meeting for accuracy of order entry as well as during the weekly clinical risk meetings. iv. The 30 days following the start date of the GDR, the monitoring frequency will be increased to twice per shift. iv. If during that period any increase in targeted behaviors or any new behaviors are observed, the provider will be notified by the charge nurse immediately and address accordingly. v. The GDRs will be reviewed weekly during clinical risk meetings during the first 30 days of initiation of GDR. vi. A GDR audit tool was implemented 5/7/25 by the Regional Nurse Consultant/Designee. B. The DON was in-serviced on process for utilizing GDR Monitoring Tool and proper monitoring order entry on 5/7/25 by the Regional Nurse Consultant. C. On 5/7/25, the DON and Regional Nurse Consultant conducted in-services with all staff on the above process for monitoring residents when GDR attempted. Staff identify these target behaviors through a structured, person-centered approach that emphasizes observation, communication, and individualized care planning. The residents' target behaviors are identified in their care plans and in their behavior monitoring order. 63 of 65 staff trained (two staff members on FMLA). D. On 5/7/25, DON/Designee conducted an in-service with all staff that included the process for monitoring target behaviors. The in-service included how these behaviors are identified and the process for reporting behaviors. The in-service included; New GDRs will be monitored twice per shift by documentation within Behavior Monitoring Orders in the MAR for the first 30 days that a GDR is attempted. GDR attempts will be tracked via GDR Monitoring Tool and reviewed weekly during clinical risk meetings during those first 30 days to monitor for changes in behaviors associated with the attempted GDR. Medication Monitoring Orders Batch Order Set will be utilized for all behavior and medication monitoring orders. The Behavior Monitoring Order will be edited/updated to note the specific targeted behaviors for that resident as listed in their CP. The Monitoring Order will have all components including special requirement documentation parameters attached within the order in the MAR. Orders will be documented accurately according to the directions noted within the order text. (IE: Chart Y/N for yes or no if noted behavior or side effect occurred. Order document number associated with list of targeted behaviors within the order text.) The nurse assigned documents the behavior on the eMAR and then as directed in the monitoring order, the nurse will then make a progress note detailing the behavior. The in-service on targeted behaviors included identifying, reporting and documentation. All LPNs/RNs have been educated and the education is located in the Nursing Communications Binder for nurses to reference. 63 of 65 staff trained (two staff members on FMLA). E. The DON included this process in the in-service provided to all staff on 5/7/2025. The monitoring order will be entered into EMR by the charge nurse entering the prescribed psychotropic/antipsychotic order or GDR. All components including special documentation parameters for accurate and complete documentation/assessment to be recorded as written in the order. All physicians' orders are reviewed each morning in the morning clinical meeting for accuracy of order entry as well as during the weekly clinical risk meetings. The 30 days following the start date of the GDR, the monitoring frequency will be increased to twice per shift. If during that period any increase in targeted behaviors or any new behaviors are observed, the provider will be notified by the charge nurse immediately. This process is also noted in the Nursing Communications binders. 63 of 65 staff trained (two staff members on FMLA). Facility requests for IJ removal plan to be effective on 05/09/25 **************************************************************** After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 05/09/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, resident record review, and review of a facility policy titled Behavioral Health Care Services, the facility failed to ensure residents with behaviors were managed and addressed to protect other residents from abuse, and to ensure other residents' safety and privacy was protected from residents with combative, aggressive, and sexual behaviors. Specifically, 1.) The facility failed to ensure staff documented the presence of or absence of target behaviors that were identified in Resident Identifier (RI) #1's Care Plan to ensure RI #1's behaviors were managed. RI #1 had diagnoses of Schizophrenia and Bipolar Disorder and a history of sexually inappropriate behavior. On 09/12/2024 RI #1 was found by staff in the Activity Room unsupervised with RI #49 and RI #1 had his/her hand on RI #49's breast. The facility failed to accurately document changes in occurrences of behaviors including the frequency. The facility failed to establish and communicate the level of supervision and monitoring required when a Gradual Dose Reduction (GDR) attempt was made on 08/28/2024. It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.40 Behavioral Health Services. On 05/06/2025 at 6:45 PM, the Administrator, Director of Nursing (DON), [NAME] President of Clinical Reimbursement, [NAME] President of Clinical Operations, Regional Director of Clinical Operations, and Senior Regional Director of Clinical Operations were provided a copy of the IJ template and notified of the findings of immediate jeopardy in the area of Behavioral Health at 740-Behavioral Health Services. The IJ began on 09/12/2024 and continued until 05/09/2025 when the survey team verified onsite that corrective actions had been implemented. On 05/09/2025 the immediate jeopardy was removed, F740 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as the result of the investigation of Facility Reported Incident (FRI)/complaint /report number AL00048797. The following deficiency did not rise to the level of IJ. 2) The facility failed to manage RI #2's behavior on 10/15/2024 when RI #2 hit RI #11 in the arm. These deficiencies were cited as a result of the investigation of complaint/report number AL00049328. These failures affected RI #1, RI #49, RI #2, and RI #11 four of 27 sampled residents. Findings include: A facility policy titled Behavioral Health Care and Services with an implemented date of 05/20/2022 and a revised date of 05/04/2025 documented: Policy: It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning and well-being . Policy Explanation and Compliance Guideline: 1. Behavioral health encompasses a resident's whole emotional and mental well-being, . 3. The facility will ensure the necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice and safety . 7. The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. The assessment and care plan will include goals that are person-centered and individualized to reflect and maximize the resident's dignity, autonomy, socialization, independence, choice, and safety. Staff will: . b. Obtain history from medical records, the resident, and as appropriate the resident's family and friends regarding mental, psychosocial, and emotional health. f. Assess and develop a person-centered care plan for concerns identified in the resident's assessment. g. Share concerns with the interdisciplinary team (IDT) to determine underlying causes of mood and behavior changes . h. Accurately document the changes, including frequency of occurrence and potential triggers in the resident's record. i. Ensure appropriate follow-up as needed. j. Discuss potential modifications to the care plan. k. Evaluate resident and care plan routinely to ensure the approaches are meeting the needs of the resident. 10. All facility staff, including contracted staff and volunteers, shall receive education to ensure appropriate competencies and skill sets for meeting the behavioral health needs of residents. Behavioral health training as determined by the facility assessment will include, but is not limited to, the competencies and skills necessary to provide the following: a. Person-centered care and services that reflect the resident's goals for care. 11. Facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each resident . 1) RI #1 was admitted to the facility on [DATE] and had diagnoses to include: Paranoid Schizophrenia, Vascular Dementia, Bipolar II Disorder, and Borderline Personality Disorder. A review of PASARR Level I Screening & Results dated 10/04/2019 documented . 5. Does the individual's current behavior or recent history within 1 year indicate that they are a danger to self or other . Yes history of sexual inappropriate behaviors . A review of RI #1's comprehensive care plan titled Care Plan Report revealed: Focus Behaviors r/t [related to] bipolar do [disorder], personality do, paranoid do and dementia with behaviors of hallucinations and inappropriate social behaviors AEB [as evidenced by] . cursing, threatening and criticizing others, taunting and provoking others, name calling and demeaning names . sexual remarks and slurs and inappropriate behaviors such as sexually inappropriate and social behaviors of sexual and vulgar remarks, impulsive episodes and cursing out others. Date initiated: 06/02/2022 Revision on 09/06/2022 . Interventions . Counsel concerning invading others personal space and sexual boundaries as needed . Observe for effectiveness of current medication regimen . Observe for episodes of behaviors and response to interventions . RI #1's Care Plan Report further revealed: Focus The resident uses antipsychotic and antidepressant medications daily r/t [related to] [his/her] dx [diagnosis] of intermittent explosive disorder, dementia with behavioral disturbances, major depressive disorder and bipolar 2 Date initiated: 05/02/2022 Revision on 05/23/2024 . Interventions . Monitor for change in mood and behaviors . A review of RI #1's Progress Notes revealed a Nursing Progress Note dated 03/15/2023 that documented: . Resident verbally aggressive and offering sex to staff . A review of Certified Nursing Assistant (CNA) mood documentation for RI #1 from August 2024 to October 2024 was conducted. The document directed staff to document specific behaviors each day as either cooperative, passive, agitated, or depressed/withdrawn. A review of the documents revealed this was not completed each shift. A review of Certified Nursing Assistant (CNA) behavior documentation revealed an X was documented 19 of 30 shifts in September 2024. The document instructed staff to document numbers 0-12 to correspond to different behaviors including . 10-Sexually Inappropriate . 12- None of the above observed. The instructions key did not include an X or provide the meaning of an X. A review of RI #1's Electronic Medication Record (EMAR) behavior documentation from August 2024 to October 2024 revealed the monitoring was not completed per instructions. A review of RI #1's Behavior Monitoring notes in 2024 revealed no Behaviors Monitoring notes were documented except on 07/04/2024 which documented refusal of a vaccination and that the resident was combative with the writer of the note. An interview was held with the Social Service Designee (SSD) on 05/03/2025 at 11:40 AM. During the interview, the SSD was questioned regarding the behaviors of RI #1. The SSD reported that RI #1 exhibited verbally aggressive behavior, including cursing at staff and residents, refusing care and treatment, and engaging in arguments. She noted that RI #1's care plan addressed that RI #1 had behaviors that include sexually inappropriate behaviors. The SSD said that she had overheard RI #1 complimenting staff by stating they are attractive or nice looking. Furthermore, the SSD indicated that these behaviors are recorded in the nurses' notes and on the EMAR. An interview was conducted with CNA #14 on 05/03/2025 at 12:04 PM. During the interview, CNA #14 was questioned regarding the behaviors of RI #1. CNA #14 reported that she had observed RI #1 become loud and refusing care. She indicated that she had not observed any instances of sexual inappropriate behavior from RI #1 towards either staff or residents. An interview was conducted with CNA #22 on 05/04/2025 at 11:50 AM. During the interview, CNA #22 was questioned regarding the incident involving RI #1 and RI #49 that took place on 09/12/2024. CNA #22 stated that she was on duty that day but did not observe the incident. She said unsupervised residents in the Activity Room could potentially engage in arguments or altercations. When asked about RI #1's behaviors, CNA #22 reported that he/she would use profanity toward staff regarding cigarettes and would make comments about staff members appearances and expressed a desire to marry them. CNA #22 said that those behaviors were reported to the nurse. A follow-up interview took place with CNA #22 on 05/05/2025 at 11:51 AM. During this interview, CNA #22 was questioned regarding RI #1's comments, including phrases like hey honey and will you marry me, and whether these comments had been reported. CNA #22 indicated that she would at times report those behaviors or comments to the nurse or she would redirect RI #1. She noted that these behaviors began approximately two years prior, and she had not witnessed any such behaviors from RI #1 in the last three to six months. An interview was conducted with Former Administrator (FA) #10 on 05/05/2025 at 3:55 PM. During the interview, the FA described RI #1 as someone who would flirt with staff by attempting to make them laugh and singing to them. The FA said that RI #1 had a care plan addressing a history of inappropriate sexual behavior, which should have been monitored by the nursing staff and documented in the MAR. An interview was held with the Administrator on 05/06/2025 at 12:15 PM. During the interview, the Administrator was questioned regarding the procedures for documenting and reporting behaviors. The Administrator said that any resident behavior directed towards staff must be documented and included in the care plan. When asked about strategies to prevent behaviors directed at staff from escalating to residents, the Administrator suggested that proper care planning and a referral to psychiatric services could help mitigate such escalations. ************************************************ On 05/09/2025, the facility submitted an acceptable removal plan, which documented: F 740 Removal Plan 05/09/2025 1.Immediate action(s) taken for the resident(s) found to have been potentially affected include: a. The facility failed to ensure target behaviors were identified, managed, and addressed for RI #1, a resident with Schizophrenia and Bipolar Disorder, to prevent and protect other residents from being abused by RI #1, a resident with a history of sexually inappropriate behavior, when on 09/12/2024 RI #1 was found by staff in the activity room at the facility alone and unsupervised with RI #49 and RI #1 had his/her hand on RI #49's breast. b. CNA #15 witnessed RI #1 touch RI #49 on the right breast upon entering the activities room. CNA #15 instructed RI #1 to stop touching RI #49 as she entered the room and approached the residents to separate them. CNA #15 called out for assistance and LPN #13 was present in the hallway outside of the activities room door passing medications and entered the activities room and witnessed RI #1 touch RI #49 on the right breast. Residents were immediately separated. RI #1 on was immediately taken to his room and placed on 1:1 observation. c. Resident #49 was assessed by RN #16 on 9/12/24 at approximately 1700. d. Provider was contacted and resident was assessed on 9/13/24 - Recommendation was to discontinue 1:1 sitter and to provide close monitoring while resident out of bed in common areas. 1:1 observations were maintained for five days as a follow-up provider visit was scheduled for Monday 9/16/2024. NP assessed RI #1 on 9/16/2024 and resident continued to have no further behaviors so 1:1 monitoring was stopped the following day on day 5, 9/17/24. The assigned staff were to complete the documentation flow sheet. Charge nurses verified staff were 1:1 with RI #1 during the above noted dates, and staff submitted the flow sheet to the DON for review when completed. No behaviors were observed during that time. 1:1 observation were in place from 9/12/24 to 9/17/24. RI #1 is unable to transfer out of bed without the assistance of the staff. CNAs assigned to RI #1 were verbally instructed by charge nurses at the start of each shift to notify nurse once resident is assisted out of bed so he/she can be monitored. This directive was also noted on the CNA's care Kardex. This directive was put into effect following the completion of the 1:1 observation. e. RI #1 is now included in our list of residents located within the Nursing Communications binders at each desk. Residents on this list are not to be in common areas with other residents unsupervised. All staff have been in-serviced on this directive. This intervention has also been added to the residents' care plan, behavior monitoring order, and Kardex. f. On 05/07/2025, the Regional Director of Clinical Operations conducted an in-service for the Administrator and Director of Nursing covering all types of abuse and the facility's responsibility to ensure resident safety. 2. Identification of other residents having the potential to be affected: a. Any other residents with inappropriate sexual behaviors in the center have the potential to be affected. b. All residents' PASRRs in the center were audited by the DON/designee on 05/07/2025 for history of sexually inappropriate behaviors. On 5/07/2025, The Clinical Reimbursement Specialist reviewed all residents' care plans for any residents identified with known history of sexually inappropriate behaviors. Two additional residents were identified to have a history of sexually inappropriate behaviors. Each of these 3 residents have individualized interventions in their care plans, with specific targeted behaviors to prevent the occurrence of abuse. All three residents noted with history of sexually inappropriate behaviors have intervention to prevent abuse. None of these residents are physically capable of transferring out of bed unassisted. They are to be always monitored while in common areas with other residents. They will not be in common areas unsupervised. All three residents have been placed on every 15-minute observations while out of bed, to be signed off by the observing staff member every 15 minutes. If in activities, the Activities Director will sign the observation. If in the dining room, the CNA and/or charge nurse assigned to the dining room with sign the observation. If near or at nurses' station, the nurse will sign the observations. The charge nurse is responsible for ensuring the observation monitoring sheet is signed off at the end of the shift. The DON is responsible for collecting the observation sheets and the Administrator is responsible for maintaining the records. 63 of 65 staff trained (two staff members on FMLA). c. The Regional Nurse consultant/Designee reviewed resident progress notes from 4/01/2025-current reviewing for sexually inappropriate behaviors none noted. 3. Actions taken/systems to be put into place to reduce the risk of future occurrences include: a. On 5/07/25 the Regional Nurse Consultant provided in-service for the Administrator and Director of Nursing training on the facility's Behavioral Health Services Policy and facility's Abuse Policy to include management of sexually inappropriate behaviors and behaviors that that increase residents risk of abuse such as masturbation, unwanted touching of sexual organs by another resident, cursing, shadowing, calling out, and disrobing. b. Facility-wide staff training was initiated on 05/07/2025, by the Director of Nursing/ designee. No staff are permitted to work until this training is completed. The training covered: i. The abuse policy. This policy emphasizes that all residents have the right to be free from sexual abuse, outlines how to identify abuse, and mandates immediate residents when abuse is suspected or observed, by physically moving the resident and the aggressor away from each other. When abuse is suspected or observed report to abuse coordinator once residents have been provided safety. An incident report is completed, and reports are reviewed by the DON and Administrator. ii. Prevention of Abuse, Neglect and Exploitation. a. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship; B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; C. Assuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment; D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect; E. Ensuring the health and safety of each resident with regard to visitors such as family members or resident representatives, friends, or other individuals subject to the resident's right to deny or withdraw consent at any time and to reasonable clinical and safety restrictions. (See Resident Right to Access and Visitation Policy); F. Providing residents, representatives, and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution; and providing feedback regarding the concerns that have been expressed; G. Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur; and iii. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. iv. When any staff observe behaviors, staff should report behaviors to charge nurse for documentation in the medical record. Behaviors are reported during shift-to-shift reports by charge nurses. IDT team reviews documentation in clinical meetings weekly during clinical risk meeting and daily during morning clinical meeting for interventions/follow up. During morning clinical meeting, all of this information is read aloud by the DON to the IDT team members present during each meeting and assigns follow-up to the designated team member responsible for the item needing follow-up. As part of the weekly risk meeting, behaviors, psychotropic medications, and monitoring orders are reviewed and documented by the IDT team members during the meeting as needed. Staff identify these target behaviors through a structured, person-centered approach that emphasizes observation, communication, and individualized care planning. The residents' target behaviors are identified in their care plans and in their behavior monitoring order. v. On 5/7/25, DON/Designee conducted an in-service with all staff that included the process for monitoring target behaviors. The in-service included how these behaviors are identified and the process for reporting behaviors. a. Residents identified with a potential for exhibiting inappropriate sexual behaviors reviewed during weekly risk meetings, by the interdisciplinary team. Residents identified with a potential for/history of exhibiting inappropriate sexual behaviors, individualized, person-centered care plans will be developed by the MDS coordinator/Designee, implemented by all staff providing care to the residents. Each nurse assigned to the identified residents each day will observe to ensure care planned interventions that are listed on the care Kardex for the CNA are in place and effective. The charge nurses will communicate with the IDT team as needed if care planned interventions are ineffective, and the MDS Coordinator/Designee will revise CP as necessary. All three residents have been placed on every 15-minute observations while out of bed, to be signed off by the observing staff member every 15 minutes. If in activities, the Activities Director will visually observe the resident and sign the observation. If in the dining room, the CNA and/or charge nurse assigned to the dining room will visually observe the resident and sign the observation. If near or at nurses' station, the nurse will visually observe the resident and sign the observations. The charge nurse is responsible for ensuring the observations are made and that the observation monitoring sheet is signed off at the end of the shift. The DON is responsible for collecting the observation sheets and the Administrator is responsible for maintaining the records. b. 63 of 65 staff trained (two staff members on FMLA). c. DON/designee will monitor the schedule for staff who have not completed the training. DON/designee will provide training prior to the start of the shift. Staff not physically present were in-serviced via phone. No staff are permitted to work until this training is completed. 63 of 65 staff trained (two staff members on FMLA). vi. An audit was completed on 5/7/25 by the Clinical Reimbursement Specialist. Care plans of the three residents identified to have a history of sexually inappropriate behaviors including RI #1 were reviewed to ensure they were appropriate, person centered and that they considered pertinent history of the residents. All three residents had revisions made to their care plans to include the added directive that those residents will not be in common areas unsupervised with other residents. The revisions were made by the Director of Nursing and by the Clinical Operations Support nurse on 5/7/25 and 5/8/25. vii. On 5/7/2025 by DON/Designee, all residents identified with a history of sexually inappropriate behaviors had an audit completed to ensure behavior monitoring orders are appropriately entered to include specific target behaviors and appropriate supporting documentation attached to the order. Staff identify these target behaviors through a structured, person-centered approach that emphasizes observation, communication, and individualized care planning. The residents' target behaviors are identified in their care plans and in their behavior monitoring order. f. On 5/7/25, An in-service with all staff included the process for monitoring target behaviors. The in-service included how these behaviors are identified and the process for reporting behaviors. CNAs document these behaviors on an as needed basis in their POC. Nurses document the behaviors in the eMAR and then if occurred, charted in the nurses' notes as directed by the monitoring order. The nursing progress notes and POC alerts are read aloud in morning clinical meetings Monday thru Friday. The in-services on monitoring target behaviors, monitoring residents on psychotropic medications/GDR Monitoring process and the in-service on monitoring target behaviors are all also located in the nursing communications binder for nurses and CNAs to reference as needed. 63 of 65 staff trained (two staff members on FMLA). g. QAPI Committee meeting was held 05/07/2025 to review allegations involving sexually inappropriate behaviors, including nonconsensual touching of sexual organs of other residents, to include incidents originating 12/2/24 - current Investigations. The Interdisciplinary Team (IDT) identified 3 residents requiring care plan reviews that were completed related to sexually inappropriate behaviors. The Quality Assurance and Performance Improvement (QAPI) team initiated a review to identify trends in sexual behaviors and behaviors associated with GDRs, assess potential behavioral triggers, and ensure that appropriate, individualized interventions were implemented and documented in the care plans. Any trends will be communicated to the Medical Director. 9 department head members attended QAPI meeting. h. On 5/9/2025, an additional in-service began, by the Regional Director of Clinical Operations to train all staff (CNAs, Nurses, Nurse Managers, Administrator, Dietary staff, Housekeeping Staff, administrative staff) that the three residents identified will remain on every 15-minute observations while out of bed. Staff has been educated to continue the process noted on their Kardex that as soon as any of these residents are out of bed, the charge nurse is notified who will then initiate the observation sheet for that day and ensure the observations are continued and signed for the entirety that these residents are out of bed to prevent the risk of occurrence of abuse. On 5/9/25, all Nurses, CNAs and housekeepers scheduled to work 5/10/25, 5/11/25 and 5/12/25 have been in-serviced on the process for the every 15 minute observations for the identified residents. DON/designee will monitor the schedule for staff who have not completed the training. DON/designee will provide training prior to the start of the shift. Staff not physically present were in-serviced via phone. No staff are permitted to work until this training is completed. i. This directive of maintaining these observations will continue for each of the identified residents on an individual basis based upon their behaviors observed. The observations will be discussed daily, Monday thru Friday in the morning clinical meeting. The IDT team will discuss these observations during the weekly clinical risk meeting. It will be a collaborative effort and decision of the interdisciplinary team when these observations can be reduced or discontinued based on those findings. j. The regional nurse consultant in-serviced the DON 5/7/25 regarding the process to follow with monitoring specific target behaviors with an increase in monitoring during the 30-day period following a GDR. Monitoring orders will list target behaviors specific to each resident identified with sexually inappropriate behaviors. Monitoring orders with be reviewed for accuracy on initiation of order and daily in morning clinical meeting weekly in clinical risk meeting. Facility requests IJ removal plan to be effective on 05-09-2025. **************************************************************** After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 05/09/2025. ************************************************************** 2) RI #2 was admitted to the facility on [DATE] and had diagnoses to include: Psychotic Disturbance, Mood Disturbance, Anxiety Disorder, and Major Depressive Disorder. RI #2's quarterly MDS assessment with an ARD of 09/13/2024 documented a BIMS score of 8 of 15, which indicated that RI #2 had moderate cognitive impairment. A review of RI #2's comprehensive care plan revealed RI #2 may exhibit outbursts toward staff and may become combative, striking out by hitting and/or kicking. This care plan was initiated on 06/28/2022 and revised on 07/29/2024. The care plan did not provide direction to staff regarding the level of supervision required to protect residents and ensure safety. A review of a Progress Note for RI #2, dated 07/19/2024, indicated the following behaviors: During an onsite psychological visit, RI #2 was observed to ball up his/her fist and attempted to strike another resident while passing through the door. A verbal intervention was conducted, during which RI #2 was informed that such actions would not be allowed, and the potential consequences of retaliation and injury were explained. RI #2 reacted with anger and directed profanity towards the writer. The inappropriate nature of his/her behavior and language was addressed, along with the associated risk of injury stemming from such conduct. A review of the Progress Note for RI #2, dated 07/24/2024, indicated that the appointment was a follow-up to the visit to the 07/19/2024 visit. During this session, RI #2 denied feelings of anger and was advised against hitting others and using derogatory language towards others. RI #2 did not want to talk with the provider, leading to the termination of the interview. Staff were directed to observe and intervene in any behavioral disturbances as necessary. An interview with Social Services Designee (SSD) was conducted on 05/03/2025, at 4:17 PM. The SSD was questioned regarding the behaviors of RI #2. She indicated that RI #2 had exhibited verbal aggression towards both staff and other residents and had made attempts to physically strike staff. When asked about strategies for managing RI #2's behaviors, the SSD said that if the aggression was directed at a staff member, they should leave when safe and return later. If the aggression was directed at other residents, staff should intervene and remove RI #2 from the situation. A telephone interview with FA #10 took place on 05/05/2025 at 4:20 PM. The FA reported that RI #2 had instances of verbal outbursts, including the use of racial slurs, and a refusal to accept care. She said that staff should not compel a resident to receive care but should pause and attempt again later. In cases of verbal altercations between residents, staff should intervene, remove the resident, and de-escalate the situation. When asked about the management of RI #2's behavior on 10/15/2024, she confirmed that staff was present in the room and did intervene. When questioned about the possibility of preventing the incident, she suggested that if the situation had been identified earlier, RI #2 could have been removed and the incident could have been prevented. On 10/16/2024 at 10:39 AM the State Agency received a FRI alleging that RI #2 struck RI #11 on the arm.