**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' right to be free from sexual, physical, and verbal abuse perpetrated by staff and residents. 1.) On 01/13/2025 at approximately 2:00 AM, Licensed Practical Nurse (LPN) #13 observed Resident Identifier (RI) #44's call light was on. The Certified Nursing Assistant (CNA) assigned to care for RI #44, CNA #23, was on her lunch break at that time and the CNA assigned to care for RI #20, CNA #12, was not permitted to enter RI #44's room. LPN #13 administered medications to another resident and then responded to the call light. Upon entering the room, LPN #13 witnessed RI #20 sitting on RI #44's bed next to RI #44 who had severely impaired cognition and did not have the capacity to consent to the situation. RI #20 was nude from the waist down and was looking at RI #44 and caressing RI #44's hip and thigh. RI #44's Responsible Party (RP) reported RI #20 had previously entered RI #44's room and was looking at RI #44's roommate who had disrobed. The RP also reported that more recently, they had observed RI #20 masturbating in his/her room with the door open and looking into RI #44's room. The Medical Director (MD) also reported that RI #20 would look in at a resident (identified as RI #33) while the resident was undressing. The MD said, because RI #20 would watch the other resident undress, the other resident had been moved to another room. The medical record indicated that the resident, identified as RI #33, was moved to the [NAME] Wing on 10/10/2024. Following the incident on 01/13/2025, RI #20 was also moved to the [NAME] Wing. The facility failed to communicate RI #20's behaviors to staff and ensure interventions were developed and implemented to ensure RI #20 was supervised in a manner to protect other residents. Specifically, the CNAs who were assigned to RI #20's and RI #44's care at the time of the incident occurred reported they were unaware of that RI #20 had previous sexual behaviors. Further, the facility failed to report the incident to the State Agency until 01/16/2025 when LPN #13 resigned via email and cited one of her reasons for resignation was that the incident of sexual assault had not been reported. 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 04/11/2025 at 5:26 PM, the Administrator (ADM), the Director of Nursing (DON), the [NAME] President of Risk Management, the [NAME] President of Clinical Operations, and the 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 01/13/2025 and continued until 04/14/2025 when the survey team verified onsite that corrective actions had been implemented. On 04/15/2025 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 AL00049904. The facility further failed to ensure RI #20 and RI #219 were protected from physical and verbal abuse that did not rise to the jeopardy level. 2.) On 06/13/2024 the facility failed to protect RI #20 from physical abuse when RI #31, a resident who exhibited unmanaged aggressive verbal and physical behaviors, hit RI #20 in the back of the head three or four times. Staff who witnessed the abuse said anyone would be upset after being hit in the head. 3.) On 05/20/2024, the facility failed to protect RI #219 from physical abuse when RI #42, a resident with a history of behaviors, hit RI #219 and pushed RI #219's head into the pillow while RI #219 was in bed. A witness to the incident said, RI #219 was scared by the abuse. Three of 27 residents sampled for abuse were found to have been abused as determined by the investigations of complaint/report numbers AL00049904, AL00048142, and AL00047903. Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, with an implemented date of 11/16/2024, and a revised date of 11/18/2024, 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, and mental abuse including abuse facilitated or enabled through the use of technology . 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.) Cross-Reference F609, F610, F740, F835, and F867. RI #44 was admitted to the facility on [DATE] and had diagnoses that included Intellectual Disabilities, Microdeletions, and Lack of Expected Normal Physiological Development in Childhood. RI #44's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/24/2024 documented the resident had long-term and short-term memory loss with no memory or recall ability. RI #44's Brief Interview for Mental Status (BIMS) was not assessed because the resident rarely/never understood. RI #20 was admitted to the facility on [DATE] and had a diagnosis of Intercranial Injury with Loss of Consciousness. RI #20's quarterly MDS with an ARD of 12/06/2024 documented a BIMS score of four out of 15, which indicted severe cognitive impairment. A review of RI #20's Care Plan Report revealed: . RI #20 has behavior indicators. (He/She) is sometimes aggressive toward peers and requires redirection. At risk for altercation, complications associated with behavior issues . start date 3/1/2024 . Status Active . When acute behaviors are noted, intervene promptly to manage/redirect . A review of RI #20's Comprehensive Care Plan submitted by the facility immediately following the survey revealed: . Behaviors will be identified and minimized or eliminated without causing harm to resident or staff during acute episode . with appropriate intervention . meds, redirection, diversional activities etc . The Care Plan included the other interventions and start dates including . (RI #20) has had episodes of being sexually inappropriate in the common areas of the facility. Staff is to redirect resident. Start Date 06/05/2024 . Further review of the Comprehensive Care Plan revealed that RI #20 had an intervention related to him/her wandering to roommates side of room. The Care Plan did not include interventions to address RI #20 wandering into other residents' rooms. The facility submitted a Facility Reported Incident (FRI) via the State Agency on 01/16/2025 at 1:30 PM. The FRI was the initial report and indicated LPN #13 submitted a resignation with accusations of sexual assault from a prior incident between RI #44 and RI #20. The report indicated the alleged incident occurred on 01/13/2025 at 2:00 AM. The facility investigative file contained a handwritten Nurse's Note dated 01/13/2025 and signed by LPN #13. The Nurse's Note documented . (CNA #42) came to nurses station to report resident . needed pain medicine. (RI #44's room number) call light came on. As nurse was getting up to pull pain medication no CNA had gotten up to answer the call light. Nurse passed the medication and then went to answer the call light. As nurse was approaching the room she was startled to see (RI #20) without a brief sitting in the bed with (RI #44) looking at (RI #44) and caressing (RI #44's) hip and thigh. As (RI #20) and the nurse made eye contact (RI #20) was startled and immediately stopped touching (RI #44). Nurse ran to the day room looking for (RI #20's) CNA and some assistance. (RI #20) was immediately removed from (RI #44)'s room and returned to (his/her) room. (RI #20) who's room is across the hall from (RI #44) was placed in room (different room number) . (ADM) was immediately called. CNA's were interviewed nurse determined no CNAs assigned were at fault but all were asked to provide statements. Per orders of Administration (RI #20) has been removed from East Wing . to [NAME] Wing . The investigative file also contained a printed email dated 01/16/2025 at 11:14 AM from LPN #13 to the ADM. The email included: . Due to the events that transpired between (RI #44 and RI #20) on 01/13/2025 . I can not and will not associate myself with abuse and this is SEXUAL ASSAULT . In this particular matter my patient has no voice, due to (his/her) limitations of (him/her) being non-verbal . I have provided a detailed account of the events . that can be verified by video footage. Surveyors attempted and were unable to reach LPN #13 for interview during the survey. Surveyors attempted and were unable to view video footage during the survey. On 04/08/2025 at 2:17 PM an interview was conducted with CNA #25 who reported she was working on the [NAME] Wing on 01/13/2025 when the incident occurred. CNA #25 said LPN #13 went to the [NAME] Wing and asked about moving RI #20 to the [NAME] Wing. CNA #25 said LPN #13 told her that RI #20 was found in RI #44's room sitting on RI #44's bed on top of the covers with his/her hand on RI #44's hip and a massaging motion was observed. An interview with CNA #23 was conducted on 04/23/2025 at 2:57 PM. CNA #23 recalled her shift on 01/13/2024, when she was assigned to care for RI #44. She remembered upon her return from her lunch break, LPN #13 informed her that RI #20 had been discovered in RI #44's room. CNA #23 recalled observing RI #20 sitting on the side of the bed earlier while she was assisting RI #44 to the shower, and she stated that this was unusual because RI #20 was typically sleeping at that hour. An interview with CNA #12 was conducted on 04/09/2025 at 6:10 PM. CNA #12 reported that she was assigned to care for RI #20 on 01/13/2025. CNA #12 said LPN #13 informed her of the after the incident had taken place that RI #20 was discovered in RI #44's room, seated on RI #44's bed, and had been relocated to another room. CNA #12 stated, she did not see RI #20 after receiving this information from LPN #13. The facility's investigative file contained a Nurse's Note dated 01/13/2025 that documented I (CNA #12) can not go into (RI #44's roommates) room . So I did not answer (his/her) light! . I did not know where (RI #20) was at or that (he/she) had entered (RI #20)'s room. An interview was conducted with LPN #22 on 04/03/2025 at 2:52 PM. LPN #22 was asked to recall the incident involving RI #20 and RI #44. LPN #22 stated, she was working with LPN #13 on 01/13/2025 and assisted LPN #13 with performing a body audit of RI #44. The facility investigative file contained a document titled Investigation Conclusion dated 01/24/2025 signed by the administrator which documented: . The incident/allegation of sexual abuse is unsubstantiated. The report was generated after the nurse resigned based on the verbiage of her resignation letter. RI #20 was found sitting on the edge of RI #44's bed naked from waist down. When the nurse entered the room, she witnessed RI #20 touching RI #44 on the thigh and hip. RI #20 has wandering tendencies but has never had any issues nor sexual tendencies with any other male or female residents. RI #44's brief was secure and intact and no sign of displacement. RI #44 is non-verbal and RI #20 has severe short term memory. RI #20 was questioned and denied the allegations . An interview was conducted with the Administrator/Abuse Coordinator (ADM) on 04/03/2025 at 3:30 PM. The ADM said RI #20 had wandering behaviors and had entered into other residents' rooms and staff redirected RI #20. The ADM reported that at approximately 2:00 AM on 01/13/2025, he received a phone call from LPN #13, who informed him that she had seen RI #20 sitting beside RI #44's bed, unclothed from the waist down, and that RI #20 was touching RI #44's waist and thigh. The ADM said he inquired whether the two residents had been separated and if there was any indication of sexual contact. According to the ADM, LPN #13 indicated that there did not appear to be any sexual contact between the two residents. Based on the information provided by LPN #13 at the time, the ADM concluded he did not believe sexual abuse had occurred. The ADM said the incident was not reported within two hours to the State Agency because, he did not feel like it was abuse initially. The ADM said if LPN #13 said RI #20 was masturbating or he/she had an erection he would have reported the incident immediately. The ADM said he did not know how RI #20 was able to enter RI #44's room without staff knowing. The ADM said there were three CNAs and two nurses working at the time of the incident. The ADM stated LPN #13 gave two accounts regarding what she did when she found RI #20 in RI #44's room, in one note she said she immediately separated the residents and in another she said she went and got help. The ADM stated the facility tried to clarify LPN #13's statements, but she refused. A review of the facility's investigative file revealed there was no documented interviews or statements that indicated RI #20 was or was not masturbating or whether or not RI #20 had an erection. A follow-up interview was conducted with the Administrator on 04/09/2025 at 12:21 PM. The ADM was asked if he was able to determine how long RI #20 was in RI #44's room he said he did not know. He said the investigation found that a staff member witnessed RI #20 in RI #44's room with no clothes on from the waist down and touching RI #44's leg. An interview with the DON was conducted on 04/03/2024 at 4:45 PM. During the interview, she was questioned about the incident that occurred on 01/13/2025 involving RI #20 and RI #44. The DON stated, she was informed of the situation by the ADM while enroute to work on the same day. She was briefed on the events, during which RI #20 was discovered in RI #44's room, unclothed from the waist down, and making contact with RI #44's leg. When asked whether this constituted sexual abuse, the DON indicated there was no evidence to suggest RI #44 had been sexually abused by RI #20, because RI #44's brief was intact. When questioned about her reasoning for not classifying the incident of a resident sitting on another resident's bed, unclothed from the waist down and touching their leg, as sexual abuse, she explained, RI #20 did not have an erection and was not engaging in masturbation at the time. When asked how a reasonable person might react if someone entered their room, sat on the edge of their bed, was unclothed from the waist down, and touched their leg, she acknowledged that they would likely feel upset. On 04/10/2025 at 6:13 PM a follow-up interview was conducted with the DON, who was asked what level of supervision RI #20 required. The DON said RI #20 required limited assistant with activities of daily living and staff spot checked him/her. The DON said after the one-on-one observations were discontinued on 01/14/2025 the facility staff monitored RI #20 every 15 minutes. The DON said RI #20 was seen by the facility's psychiatric services and they said RI #20 did not need to be on one-on-one observation so they initiated Q15 (every 15) minute checks from 01/15/2025 through 01/30/2025 for elopement and to know where RI #20 was in the building. The DON said staff were still doing close monitoring but it was not being documented. The DON was asked, how did staff know to perform close monitoring. The DON said she did not know but guessed by word of mouth. On 04/13/2025 at 3:52 PM the facility provided forms titled Resident Observation/Monitor Tool that documented ongoing monitoring every 15 minutes was being documented beginning on 01/15/2025. ************************************************ On 04/15/2025, the facility submitted an acceptable removal plan, which documented: F 600 Removal Plan 04/15/2025 1. Immediate action(s) taken for the resident(s) found to have been potentially affected include: a. The facility failed to protect Resident #44's right to be free from sexual abuse. On 01/13/2025 at approximately 2:00 AM, LPN #13 observed Resident #20 seated on Resident #44's bed. Resident #20 was nude from the waist down and was caressing Resident #44's hip and thigh. Resident #44 has severely impaired cognition and lacked the capacity to consent to the situation. b. LPN #13 removed Resident #20 from Resident #44's room on 1/13/25 at approximately 2 am and initiated 1:1 supervision for Resident #20 to ensure safety and prevent further incidents. c. Resident #44 was assessed by LPN #13 and another LPN on 1/13/25 at approximately 2:30 am. d. Behavioral Health was contacted and assessed resident on 1/14/25 - Recommendation was to discontinue 1:1 sitter and initiate Q 15-minute checks while medications have time to become efficacious. Q 15 min checks were initiated by the DON in alignment with nationally recognized nursing practice standards, close monitoring is defined as visual checks every 15 minutes. This frequency is commonly accepted in clinical practice for residents identified as high-risk, including during behavioral concerns, elopement risk, or post-incident observation. The assigned staff were to complete the documentation flow sheet. Charge nurses verified staff were monitoring and observing resident every 15 minutes, and staff submitted the flow sheet to the DON for review when completed. Recommendations from Behavioral Health (BH) were reviewed by the Director of Nursing (DON) or designee. The DON/designee followed the recommendations of the psych provider. The resident continues on Q 15-minute checks and has had no behaviors since 1/13/2025. e. On 04/11/2024, the [NAME] President of Risk Management 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. f. On 4/12/25 [NAME] President of Risk Management provided in-service for the Administrator and Director of Nursing training on the facility's Elopement and Wandering Resident Policy, emphasizing strategies to prevent residents from entering others' rooms and reduce the risk of unsafe wandering and potential for abuse. 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. RI # 20 continues on Q 15 min checks and has had no behaviors since 1/13/2025. All residents with BIMS of 10 or greater were interviewed by Care Manager/designee on 4/13/25 using the Abuse screening interview form, if BIMS less than 10 form allows for staff observation. With no abuse findings. b. On 04/12/2025, the Director of Nursing and the Regional Nurse Consultant conducted comprehensive wandering risk assessments on all residents to identify individuals who may be at risk of entering other residents' rooms and potentially posing a threat of abuse. c. All resident were assessed using Wandering behavior clinical form by the Care Manager/designee on 4/12/25 for wandering and going into other rooms. 8 residents had wandering tendencies and 6 had known history to go into others' rooms. Of the 6 residents who enters others' rooms their BIMS scores are low indicating at least intermittent confusion and they are redirectable. The 8 residents with wandering tendencies' care plans were reviewed by Regional Director of Clinical Reimbursement on 4/14/25 to ensure they were appropriate, and person centered and that they considered safety of all residents. No additional residents were identified as posing a threat of abuse. This was determined using the Staff Abuse awareness and Reporting Questionnaire completed by the Administrator/designee on 4/13/25. 3. Actions Taken / Systems to Be Put into Place to Reduce the Risk of Future Occurrences a. On 04/12/2025, the [NAME] President of Risk Management and the Regional Nurse Consultant provided one-on-one in-service training to the Administrator and Director of Nursing on the facility's 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 of residents when abuse is suspected or observed including to immediately remove the perpetrator from any potential victim by separation of the resident from the aggressor. b. On 4/12/25, the [NAME] President of Risk Management and Regional Nurse Consultant provided one-on-one in-service training on the Elopement and Wandering Residents Policy with the DON and the Administrator. Residents identified at risk for unsafe wandering will be assessed quarterly, on admission and with significant changes. Individualized, person-centered care plans will be developed, implemented, monitored, and revised as necessary. c. On 4/11/2025 All CNAs were trained on the process to ensure that CNAs are stationed in the corridor of the patient care areas for visualization of their assigned rooms throughout the day and night shifts. Training included that break times will be assigned prior to the beginning of both shifts prior to beginning of both shifts by charge nurse to ensure supervision. 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 began. 35 of 38 CNAs trained. d. The charge nurse on the hall is responsible for monitoring the CNAs to ensure they are following the process and to ensure break times are scheduled prior to beginning of both shifts. The charge nurses were trained on this process on 4/11/2025. 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 began. 23 out of 25 Nurse trained. This process began on 1/14/25 to monitor resident movement during the shift, and reduce the risk of residents entering others' rooms, and reduce the risk of abuse. e. Break times will be assigned by the charge nurse prior to the beginning of both shifts to ensure supervision, beginning 4/12/25. f. Facility-wide staff training was began on 04/11/2025, 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 from non-consensual contact/touching, masturbation, indecent exposure toward residents when abuse is suspected or observed, by physically moving the resident and the aggressor away from each other and not leaving the perpetrator without 1:1 supervision until seen by medical provider. When abuse is suspected or observed report to Facility requests IJ removal plan to be effective on 04/15/2025. **************************************************************** 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 04/14/2025. 2.) Cross reference F740. On 06/13/2024 at 1:50 PM the State Agency (SA) received a Facility Report Incident (FRI) alleging RI #20 was physically abused by RI #31 who approached RI #20 from behind, swatted RI #20 several times, hitting RI #20 in the upper back and back of the head, without visual injury, and RI #20 told staff he/she did not feel threatened and was not scared. The FRI continued, RI #31 had demonstrated worsening agitation during the week and was being monitored, the facility assigned a CNA to be with RI #31 at all times until they received a physician order to indicate what to do, and RI #31 would be sent out to the hospital for evaluation. RI #20 was admitted to the facility on [DATE] and had diagnoses to include Epilepsy. RI #20's quarterly MDS assessment with an ARD of 06/07/2024 documented a BIMS score of three of 15 indicating severe cognitive impairment. RI #31 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses to include Alzheimer's Disease. RI #31's quarterly MDS assessment with an ARD of 05/28/2024 documented a BIMS score of three of 15 which indicated severe cognitive impairment. RI #31's care plan for a history of behaviors with a start date of 01/30/2024 described behaviors of being combative with caregivers and at risk for altercations. The facility investigative file contained a handwritten statement, signed by CNA #16 who witnessed the abuse, which documented: June 13, 2024 It was 11:50am, (RI #20) was sitting in (his/her) wheelchair . (RI #31) walked up behind (RI #20) unprovoked and hit (him/her) 4 (four) times open palm in the back. I (CNA #16) blocked (RI #31) from hitting (him/her) again, and separated them. On 04/08/2025 at 9:19 AM an interview was conducted with CNA #16 who witnessed the incident on 06/13/2024 between RI #20 and RI #31. She said, RI #20 was in the hallway and RI #31 thought RI #20 was his/her child who had stolen RI #31's money. RI #31 hit RI #20 in the back of the head three or four times with an open palm. CNA #16 said, she intervened to separate the residents. CNA #16 said, what she witnessed was physical abuse. CNA #16 was asked how would a reasonable person feel about being hit in the back of the head. She said, anyone would be upset about being hit in the back of the head. On 04/08/2025 at 10:26 AM an interview was conducted with LPN #17 who was the nurse at the time of the incident on 06/13/2024. LPN #17 said, they were in the television room and RI #31 was agitated and thought RI #20 was his/her child, whom RI #31 thought (He/she) stole everything we had. LPN #17 said, she instructed RI #20 to go to his/her room and as RI #20 began to go down the hall, RI #31 got up and power walked quickly up behind RI #20 and hit RI #20 in the back of the head three times. LPN #17 said, the residents were separated, body audits revealed no injury, and she thought the physical abuse of being hit in the head surprised RI #20. LPN #17 said, a reasonable person would be upset about being hit in the back of the head. LPN #17 said, RI #31's behaviors and agitation could have increased that week due to Dementia, and some days RI #31's agitation was worse. The facility investigative file contained a typed statement signed by the ADM, dated 06/13/2024, which documented: (11:50 AM), (RI #31) approached (RI #20) and swatted at (him/her) 3-4 times in the back of the upper back and head. (CNA #16) observed (RI #31) approaching (RI #20) and stopped (him/her) as (he/she) began swinging at (RI #20). The two were separated and checked for injuries. (RI #31) had a person assigned to (him/her) for the rest of the evening to monitor . (RI #31) was sent out to the hospital for evaluation. On 04/09/2025 at 11:08 AM the ADM was asked about the incident between RI #31 and RI #20. The ADM said, when RI #31 hit RI #20 in the back of the head with an open palm it was physical abuse. When asked how a reasonable person would feel about being hit in the back of the head with the palm of the hand, he said a reasonable person would have been surprised. The ADM said, RI #31 had increased agitation that week probably due to Dementia. 3.) Cross reference F609. On 05/20/2024 at 6:52 AM the State Agency received a Facility Reported Incident (FRI) alleging physical abuse occurred between roommates, when RI #219 told RI #42 to quit cussing and RI #42 got out of bed and assaulted RI #219 resulting in one having a bruise and the other having a cut, the victim was moved to another room and both residents were evaluated and monitored for injury and well being; family members were notified, physician was notified, and ongoing monitoring was being performed on both residents. RI #219 was admitted to the facility on [DATE] and had diagnoses that included Hypertensive Heart and Chronic Kidney Disease. RI #219's quarterly MDS assessment with an ARD of 04/26/2024 documented a BIMS score of 15 of 15 indicating RI #219 was cognitively intact. RI #42 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses to include Alzheimer's Disease. RI #42's quarterly MDS assessment with an ARD of 05/02/2024 documented a BIMS score of three of 15 indicating severely impaired cognition. RI #42 had a history of behavior included on a Behavioral Health (BH) assessment dated [DATE], that included: confusion, agitation, irritability, difficult to redirect, broken sleep, tends to be up all night, and fights with roommate. The facility investigative file contained a handwritten statement dated 05/19/2024 and signed by CNA #18 which documented: When I got to the room of (RI #219 and RI #42) around 11:45 pm. (RI #42) was standing beside (RI #219's) bed. The two . were hitting, yelling and cussing at one another. On 04/07/2025 at 2:38 PM CNA #18 was asked about the incident involving RI #42 and RI #219 that occurred on 05/20/2024. CNA #18 said she heard the residents arguing and yelling and went to the room. CNA #18 said, when she entered the room, RI #42 was over at RI #219's bed, they[TRUNCATED]

**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 ensure an allegation of sexual abuse was reported to the State Agency within two hours. Specifically, on 01/13/2025 around 2:00 AM, Licensed Practical Nurse (LPN) #13 called the Administrator/Abuse Coordinator (ADM) and reported RI #20 had been witnessed nude from the waist down in RI #44's room, sitting on Resident Identifier (RI) #44's bed next to RI #44 caressing RI #44's hip and thigh. The ADM failed report the allegation of sexual abuse to the State Agency until three days later on 01/16/2025. 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 at F609-Reporting of Alleged Violations. On 04/11/2025 at 5:26 PM, the ADM, the Director of Nursing (DON), the [NAME] President of Risk Management, the [NAME] President of Clinical Operations, and the Senior Regional Director of Clinical Operations were provided a copy of the IJ template and notified of the finding of immediate jeopardy and substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation at F609-Reporting of Alleged Violations. The IJ began on 01/13/2025 and continued until 04/14/2025 when the survey team verified onsite that corrective actions had been implemented. On 04/15/2025 the immediate jeopardy was removed, F609 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 #AL00049904. The facility further failed to ensure allegations of abuse that did not rise to the jeopardy level were immediately reported to the abuse coordinator and to the State agency within two hours. The allegations involved RI #3, RI #42, and RI #219. 2.) On 08/27/2023, staff failed to immediately report an allegation of verbal abuse involving RI #3 and a staff member to the Administrator/abuse coordinator and to the State Agency within two hours. 3.) On 05/27/2024 when bruising was found to RI #3's finger at 8:30 AM, the facility failed to immediately report the injury of unknown origin to the State Agency within two hours. 4.) On 05/20/2024, staff did not immediately report to the Administrator/abuse coordinator an allegation of physical abuse involving RI #219 and RI #42. Four of 27 residents sampled for abuse were found to have been affected due to late reporting of abuse allegations as determined by the investigations of facility reported incident (FRI)/complaint/report numbers AL00049904, AL00045410, AL00047974, and AL00047903. Findings include: Cross-reference F600, F835, and F867. Review of the facility's policy titled, Abuse, Neglect and Exploitation, with an implemented date of 11/16/2024, and a revised date of 11/18/2024, revealed: Policy: . VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency . and all other required agencies . within specified timeframes: a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . 1.) On 01/16/2025 at 01:30 PM, the State Survey Agency received an initial report from the facility regarding an allegation of sexual abuse between RI #20 and RI #44 that occurred on 01/13/2025 at approximately 2:00 AM. According to this initial report, the accusation of sexual assault was reported to the Administrator via resignation letter. The facility investigative file contained a handwritten witness statement dated 01/13/2025, signed by LPN #13 who witnessed the abuse, which documented . went to answer the light as nurse was approaching the room she was startled to see RI #20 without a brief sitting in the bed with RI #44 looking at him/her and caressing his/her hip and thigh. Administrator . was immediately called . Surveyors attempted and were unable to reach LPN #13 for interview during the survey. An interview was conducted with the Administrator/Abuse Coordinator (ADM) on 04/03/2025 at 3:30 PM. The ADM said on 01/13/2025 around 2:00 AM LPN #13 called him and reported the incident involving RI #20 and RI #44. The ADM said LPN #13 reported that she observed RI #20 sitting on the side of RI #44's bed naked from the waist down while touching RI #44's waist and thigh. The ADM said based on the information provided by LPN #13 at the time, the ADM concluded that he did not believe sexual abuse had occurred. The ADM said, on 01/16/2025, LPN #13 submitted a resignation email alleging that the facility had attempted to conceal sexual abuse and claimed that what she witnessed on 01/13/2025 was sexual abuse. When asked about the appropriate timeframe for reporting allegations of abuse to the state agency, the ADM stated that it should be done within two hours. When the ADM was questioned whether this particular incident warranted a report within that timeframe, he maintained that it did not, as he did not initially perceive it as abuse based on the information received from LPN #13. The ADM said if LPN #13 said RI #20 was masturbating or had an erection he would have reported the incident immediately. ********************************************** On 04/15/2025, the facility submitted an acceptable removal plan, which documented: 1. Immediate action(s) taken for the resident(s) found to have been potentially affected include: a. The facility failed to ensure an allegation of sexual abuse was reported to the State Agency within two hours. Specifically, on 01/13/2025 around 2:00 AM, LPN #13 called the Administrator/Abuse Coordinator and reported RI #20 had been found in RI #44's room, sitting on RI #44's bed next to RI #44. RI #20 was nude from the waist down and was caressing RI #44's hip and thigh. The ADM failed to immediately identify sexual abuse and report timely. RI #44 does not have the capacity to consent. The allegation of sexual abuse was not reported to the SA until 3 days later on 01/16/2025. b. Allegation was reported to Administrators, ADPH, law enforcement, physician, family, ombudsman 01/16/2025 c. On 04/11/2025, the [NAME] President of Risk Management conducted an in-service for the Administrator and Director of Nursing covering all types of abuse and the facility's responsibility to ensure all allegation are reported timely to the State Agency. 2. Identification of Other Residents Having the Potential to Be Affected a. All residents involved in an abuse allegation 3. Actions Taken / Systems to Be Put into Place to Reduce the Risk of Future Occurrences a. The [NAME] President of Risk Management reviewed all facility-initiated reports of abuse and confirmed that all incidents were reported timely. No additional incidents were identified as having been unreported or reported outside of the required timeframe. b. On 04/12/2025, the [NAME] President of Risk Management and the Regional Nurse Consultant provided one-on-one in-service training to the Administrator and Director of Nursing on the facility's 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 of residents when abuse is suspected, as well as reporting to state agency within the mandated time frame, and notification to Ombudsman, family, physician, and law enforcement. c. On 04/12/2025, a QAPI meeting was completed with the Administrator to ensure understanding of the Administrator's responsibility in implementing and enforcing facility policies. Moving forward, the Regional Nurse Consultant or the Regional Director of Operations will review and sign off on all facility reportable investigations, including those related to sexual abuse. This sign-off will verify that investigations are conducted in compliance with the facility's Abuse/Sexual Abuse Policy, QAPI Policy, Behavioral Health Services Policy, and Wandering Policy, and that all required procedures are properly implemented and followed. d. The facility investigative checklist was implemented on 4/12/25 as a guide on conducting abuse / sexual abuse investigations. Administrator (Abuse Coordinator) was in-serviced on 4/12/25 by VP of Risk Management on this form. This checklist will be completed by the abuse coordinator and verified for every reportable incident including sexual abuse investigations. Facility requests for IJ removal plan to be effective on 4/15/25 ****************************************************** 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 04/14/2025. 4.) Cross reference F600 On 05/20/2024 at 6:52 AM the State Agency received a Facility Reported Incident (FRI) alleging physical abuse occurred at 12:00 AM on 05/20/2024, between roommates, when RI #219 told RI #42 to quit cussing and RI #42 got out of bed and assaulted RI #219 resulting in one having a bruise and the other having a cut. The FRI documented the ADM had been made aware of the allegation at 5:00 AM, about five hours after the abuse had occurred. On 04/10/2025 at 5:58 PM, an interview was conducted with ADM. The ADM stated he was notified by the FDON #29 of the incident involving RI #42 and RI #219. The ADM said, the FDON #29 said she heard voices getting loud in the room, she entered the room and found RI #42 standing beside RI #219's bed pushing RI #219's head down in the pillow. The ADM said, the FDON #29 separated the residents. When asked if residents had any injuries, the ADM said RI #219 had a bruise to the left elbow and RI #42 had a scratch below the left eyes, skin tear to the left elbow and a skin tear to the right upper arm. The ADM said, the incident occurred at 12:00 AM but was not reported until 6:52 AM, so it was not reported within the two-hour time frame. The FDON was contacted during the survey on 04/07/2025 at 3:40 PM and asked about the abuse incident, but she said she had only worked at the facility three months and she did not remember the residents or the incident. 2.) On 08/29/2023 at 6:15 AM the State Agency received a Facility Incident Report (FRI) alleging verbal abuse had occurred when a Housekeeper (HK) #30 removed a tray from RI #3's room and was overheard in the hallway saying old bitch, by Certified Nursing Assistant (CNA) #21. The FRI documented the date and time of the alleged incident was 08/27/2023 at 8:00 AM and the date and time when the Administrator (ADM) was notified of the incident was 08/28/2023 at 9:30 AM. RI #3 was admitted to the facility on [DATE] with diagnoses to include Dementia with Behavioral Disturbances, Restlessness and Agitation, Age-Related Physical Debility, and Hypertension. RI #3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 08/16/2023 documented a Brief Interview for Mental States (BIMS) score of four out of fifteen which indicated severe cognitive impairment. RI #3 required extensive assistance with bed mobility and required total assistance with bathing and dressing. A review of RI #3's comprehensive care plan with an implementation date of 02/08/2023 revealed . RI #3 has behavior indicators . aggressive behaviors . hitting/ pinching .yells out instead of utilizing call light . also taps/bangs (his/her) fingers on (his/her) bedside at times to get staff attention . On 04/08/2025 at 5:42 PM an interview was conducted with the ADM regarding the FRI. The ADM said the allegation of abuse was reported to the State Agency on 08/29/2023 at 6:15 AM and the incident occurred on 08/27/2023 at 8:00 AM. When asked why the incident was reported late, the ADM said, he did not know why it was reported late. The ADM, said the previous DON completed the investigation/report, and he was unaware of the incident occurred. When asked if the report was submitted within the required two-hour time frame, the ADM said no. 3.) On 05/27/2024 at 5:39 PM the State Agency received a FRI alleging an Injury of Unknown Source involving RI #3 occurred that morning at 8:30 AM when bruising of the middle finger was discovered. A CNA notified the charge nurse Registered Nurse (RN) #14 of bruising to RI #3's middle finger. RN #14 then notified the DON (Former DON #29) of suspected a fracture and she ordered an X-ray, the Family was notified, and results were obtained at 4:30 PM with fracture to the middle finger. On 04/08/2025 at 3:08 PM an interview was conducted with the Administrator (ADM). The ADM said he was notified of the incident on 05/27/2024 by the Former Director of Nursing (FDON #29) at 10:00 AM. The ADM said he made the report to the state agency when the results came back regarding the fracture. The ADM said part of his job responsibilities as Abuse Coordinator was to report any abuse allegations within two hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of a facility policy titled Abuse Neglect and Exploitation the facility failed to conduct a thorough investigation to ensure appropriate corrective actions were taken to prevent recurrence following an allegation of sexual abuse that occurred on 01/13/2025, involving Resident Identifier (RI) #20 and RI #44. On 01/13/2025 at approximately 2:00 AM, Licensed Practical Nurse (LPN) #13 responded to a call light from RI #44's room and found RI #20 naked from the waist down, seated on RI #44's bed caressing RI #44's hip and thigh. The facility failed to ensure the investigation included and focused on whether abuse had occurred, the extent, and cause. The facility's investigation did not include when RI #20 entered RI #44's room, the duration of RI #20's presence in the room, details regarding what LPN #13 had witnessed, and RI #20's history of known behaviors of masturbation, watching others undress, and wandering. Additionally, the facility failed to determine when the residents were separated and how RI #44 and RI #20 were monitored immediately following the incident. The facility also failed to obtain thorough statements from staff who were working at the time. Further, the facility failed to ensure video recordings from the night of the incident were preserved and/or that a summary of the footage was documented. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was related to 483.12 Freedom from Abuse, Neglect, and Exploitation. On 04/11/2025 at 5:26 PM, the Administrator (ADM), the Director of Nursing (DON), the [NAME] President of Risk Management, the [NAME] President of Clinical Operations, and the Senior Regional director of Clinical Operations were provided a copy of the IJ template and notified of the finding of immediate jeopardy and substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation at F 610- Investigate/Prevent/Correct Alleged Violations. The IJ began on 01/13/2025 and continued until 04/14/2025 when the survey team verified onsite that corrective actions had been implemented. On 04/15/2025 the immediate jeopardy was removed, F610 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. The facility further failed to ensure allegations of injuries of unknown source that did not rise to the jeopardy level were thoroughly investigated, enabling the facility to correctly identify root causes and develop action plans for prevention of abuse and resident injury in the facility. 2.) On 05/27/2024 the facility failed to thoroughly investigate an injury of unknown origin to determine the root cause and rule out abuse, for RI #3, a resident who was found to have a bruised and fractured finger. 3.) On 07/15/2024 the facility failed to thoroughly investigate an injury of unknown origin to determine the root cause and rule out abuse, for RI #169, a resident who was found to have a bruised, swollen, and fractured foot/ankle. These failures affected RI #44, RI #3, and RI #169, three of 27 residents sampled for abuse and were cited as a result of the investigation of complaint/report numbers AL00049904, AL00047974, and AL00049295. Findings include: Cross-Reference F600, F609, F740, F835, and F867. Review of the facility's policy titled, Abuse, Neglect and Exploitation, with an implemented date of 11/16/2024, and a revised date of 11/18/2024, revealed: Policy: . V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include; 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation . 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved person, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation . On 01/16/2025 at 01:30 PM, the State Survey Agency received an initial report from the facility regarding an allegation of sexual abuse between RI #20 and RI #44 that occurred had on 01/13/2025 at approximately 2:00 AM. According to this initial report, the accusation of sexual assault was reported to the administrator via resignation letter. The facility investigative file contained a handwritten Nurse's Note dated 01/13/2025, signed by LPN #13 who witnessed the abuse, which documented . went to answer the light as nurse was approaching the room she was startled to see RI #20 without a brief sitting in the bed with RI #44 looking at him/her and caressing his/her hip and thigh. As RI #20 and the nurse made eye contact he/she was startled and immediately stopped touching RI #44. Nurse ran to the day room looking for RI #20's CNA and some assistance. RI #20 was immediately removed from RI #44's room . Head to toe assessments were immediately performed on RI #20 and RI #44. No broken skin, discolorations, or bruises were noted (RI #20) was immediately removed from (RI #44)'s room and returned to (his/her) room. (RI #20) . room is across the hall from (RI #44) . (ADM) was immediately called. Surveyors attempted and were unable to reach LPN #13 for interview during the survey. Further review of LPN #13's handwritten Nurse's Note dated 01/13/2025 revealed . CNA's were interviewed nurse determined no CNAs assigned were at fault but all were asked to provide statements. The facility's investigative file contained a Nurse's Note with CNA #23 dated 01/13 at 3:10 AM. CNA #23's note documented that she was the CNA assigned to RI #44's care and During the time of the incident . I was on lunch break. I was informed of what happened when I returned . The facility's investigative file contained a Nurse's Note dated 01/13/2025 that documented I (CNA #12) can not go into (RI #44's roommates) room . So I did not answer (his/her) light! . I did not know where (RI #20) was at or that (he/she) had entered (RI #20)'s room! The facility's investigative file contained a Nurse's Note dated 01/13/2025 that documented Around 2:30 AM, I was notified by primary nurse that she need help with a resident. Head to toe assessment performed. Proceed to move (male/female) resident to another room away from resident. Signed by LPN #22. No other interviews or statements from staff were included in the facility's investigation. A review of a document titled Investigation Conclusion dated 01/24/2025 signed by the Administrator documented: . The incident/allegation of sexual abuse is unsubstantiated. The report was generated after the nurse resigned based on the verbiage of her resignation letter. RI #20 was found sitting on the edge of RI #44's bed naked from waist down. When the nurse entered the room, she witnessed RI #20 touching RI #44 on the thigh and hip. RI #20 has wandering tendencies but has never had any issues nor sexual tendencies with any other male or female residents. RI #44's brief was secure and intact and no sign of displacement. RI #44 is non-verbal and RI #20 has severe short term memory. RI #20 was questioned and denied the allegations . (RI #20) was placed one-on-one . The facility form titled Resident Observation/Monitoring Tool dated 01/13/2025 had 1-1 observations and RI #20's name handwritten at the top. The tool documented observations began at 6:00 AM on 01/13/2025. A review of the facility's investigative file revealed that the facility's investigation did not include the time at which RI #20 accessed RI #44's room, the length of time RI #20 was in the room, nor details regarding exactly what LPN #13 had witnessed. The facility's investigative file did not include when the residents were separated and how and by whom RI #20 was monitored immediately following the incident. The investigation also did not include adequate details and comprehensive statements from the staff present at the time, who possessed relevant information regarding the response and protection of RI #44 and other residents. Statements included in the investigative file were documented on Nurse's Notes and dated 01/13/2025. During an interview with CNA #25 on 04/08/2025 at 2:17 PM, she said LPN #13 told her that RI #20 was found in RI #44's room sitting on RI #44's bed on top of the covers with his/her hand on RI #44's hip and a massaging motion was observed. CNA #25 said RI #20 was moved to the [NAME] Wing and CNA #12 provided one-on-one monitoring. A statement dated 04/06/2025 signed by CNA #41 revealed that he did not see RI #20 in RI #44's room because he was working on the other end. CNA #41 said LPN #13 came down to this end and called the ADM. The statement indicated that CNA #12 was sitting with RI #20 after RI #20 was moved to his unit. On 04/09/2025 at 6:10 PM during an interview with CNA #12, she said LPN #13 told her that RI #20 had been moved to the [NAME] Wing and she did not see him/her again that night. CNA #12 said she did not provide one-on-one care to RI #20 on 01/13/2025. An interview was conducted with the Administrator/Abuse Coordinator (ADM) on 04/03/2025 at 3:30 PM. The ADM stated LPN #13 gave two accounts, in one note she said she immediately separated the residents and in another she said she went and got help. A follow-up interview was conducted with the Administrator on 04/09/2025 at 12:21 PM. The ADM said based on the facility's investigation, he did not know the length of time that RI #20 was in RI #44's room. He said the investigation found that RI #20 got up and was found in RI #44's room with no clothes on from the waist down, touching RI #44's leg and a staff member witnessed this when she entered the room. When the video footage was requested during the survey, the facility provided a document that indicated that there was no video footage of the incident that occurred on 01/13/2025 because The footage was stored on a hard drive that [NAME] is unable to access. Additionally, it is believed that the video system operates on a loop that records over previous footage, which may have resulted in the footage being overwritten. The document was signed by the ADM. ************************************************ The facility submitted an acceptable removal plan, which documented: F610 Removal Plan 1. Immediate action(s) taken for the resident(s) found to have been potentially affected include: a. The facility failed to conduct a thorough investigation into a reported allegation of sexual abuse that occurred on 01/13/2025. The facility failed to determine when RI #20 entered RI #44's room and the duration of RI #20's presence in the room. Additionally, the facility failed to determine whether LPN #13 who observed the incident, took immediate action to protect RI #44, failed to collect details and thorough statements from staff who were working at the time and had information about the response and protection of RI #44. b. On 04/11/2025, the [NAME] President of Risk Management conducted an in-service for the Administrator and Director of Nursing addressing all types of abuse and the facility's responsibility to ensure resident safety. The training emphasized the importance of collecting and documenting detailed, thorough statements from all staff involved or present during an incident, including those with knowledge of the response and protective actions taken. It also included guidance on reviewing staff time sheets to ensure all potentially involved personnel or personnel with knowledge of the incident or contributing factors are identified and interviewed, with a focus on asking clarifying follow-up questions rather than relying solely on written statements. Investigative check list was implemented to ensure a through investigation is complete. The Tool was reviewed with the DON and Administrator to ensure understanding, regional nurse consultant was on site and completed an investigation with the DON and admin to verify understanding. Additionally, the Abuse Coordinator was trained to investigate for root cause and conduct a root cause analysis for each incident to identify contributing factors and implement appropriate corrective actions; and to notify Regional Nurse Consultant or the Regional Director of Operations of the incident occurrence. 2. Identification of other residents having the potential to be affected: a. This had the potential to affect all residents. Regional nurse consultant reviewed the complete investigation files of the facility reported incidents using the Investigation checklist form to identify other incidents of sexual abuse reported since 1/1/2025. None were identified. This was completed on 4/12/25. 3. Actions taken/systems to be put into place to reduce the risk of future occurrences include: a. On 04/12/2025, a QAPI meeting was completed with the Administrator to ensure understanding of the Administrator's responsibility in implementing and enforcing facility policies. The Administrator will notify Regional Nurse Consultant or the Regional Director of Operations of the incident occurrence. They will review and sign off on the Investigation check list prior to submission of the 5-day conclusion. This sign-off will verify that investigations are conducted in compliance with the facility's Abuse/Sexual Abuse Policy, QAPI Policy, Behavioral Health Services Policy, and Wandering Policy, and that all required procedures are properly implemented and followed. b. The facility investigative checklist was implemented on 4/12/25 as a guide on conducting abuse / sexual abuse investigations. Administrator (Abuse Coordinator) was in-serviced on 4/12/25 by VP of Risk Management. This checklist will be completed by the abuse coordinator and verified for every reportable incident including sexual abuse investigations. Facility requests IJ removal plan to be effective on 04/15/2025. ********************************************************* 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 04/14/2025. 2.) On 05/27/2024 at 5:39 PM the State Agency received a Facility Incident Report (FRI) alleging an injury of unknown source for RI #3 when a CNA notified the charge nurse of bruising to the middle finger approximately 8:30 AM and the Charge nurse then notified the (FDON) and she ordered an X-ray. The Family was notified, results were obtained at 4:30 PM with fracture to RI #3's middle finger; actions taken included immediately staff started investigation and notified family, getting witness statements and suspending CNA's that had contact with RI #3. RI #3 was admitted to the facility on [DATE] with diagnoses to include of Dementia with Behavioral Disturbances, Restlessness and Agitation, Age-Related Physical Debility, Primary Hypertension. A review of RI #3's comprehensive care plan with an implementation date of 02/08/2023 revealed . RI #3 has behavior indicators . aggressive behaviors . hitting/ pinching . yells out instead of utilizing call light . also taps/bangs (his/her) fingers on (his/her) bedside at times to get staff attention . A review of a document titled Mobile Images for RI #3 dated 05/28/2024 revealed: . PROCEDURE: X- RAY -RIGHT HAND . TECHNIQUE: 2 view (s) of the hand . FINDINGS: There is undisplaced fracture of distal metaphysics of middle phalanx of 3rd digit seen with sclerosis and soft tissue thickening. No callus formation seen. Reduced bone density seen . A review of RI #3's nursing progress notes dated 05/27/2024 from Former Director of Nursing (FDON) #29 revealed, . at 9:30 AM the charge nurse reported to this writer that resident may have a fracture to middle finger of right hand. (His/her) finger is bruised and swollen . The facility investigative file contained a handwritten statement signed by CNA #20 documented: . I noticed (his/her) arm and finger was (bruised) and swollen, I then proceeded to let the nurse know . On 04/07/2025 at 4:59 PM CNA #20 was asked about her handwritten statement in the facility investigative file. CNA #20 said, that day 05/27/2024, RI #3 was able to speak clearly, and told CNA #20, she hurt me and CNA #20 reported it. On 04/08/2025 at 10:05 AM the RR was asked about the incident with RI #3's finger. The RR said, that day RI #3 was distraught by it all, RI #3's speech was better so the RR spoke with RI #3 about it and RI #3 told the RR the aide hurt (him/her), but RI #3 did not know her name. The RR said, that day RI #3 was sobbing uncontrollably and grabbed her crying and upset. The RR stated she was not satisfied with the investigation outcome because no one ever told her anything other than they could not really determine what happened. The RR felt RI #3 had been physically and mentally abused. The facility investigative file for RI #3 did not contain interviews with staff who may have had knowledge of occurrences that could have caused or contributed to the injury of bruising and fracture prior to 05/26/2024 and it did not contain documentation that a skin or body assessment was completed on RI #3 after the injury was identified. The facility investigative file contained a typed document titled with RI #3's name and dated 05/26/2024, that was not signed and did not contain information about who created the document included the following: . The RP (Resident Representative) came in around (1:00 PM) to check on (him/her) and gave (FDON #29) additional information regarding the situation. (RI #3) gave information regarding the situation. The facility investigative file contained a sheet of white paper, unsigned and undated, with handwritten notes that included the following documentation: . (1:00 PM) . (RI #3's RR name) spoke to (CNA #20) . (4:30 PM) . spoke (with) (RI #3's RR) . says (he/she) was mishandled said a black woman was ugly to me I don't like you because you are white, she scratched me said, don't let her come back in here again. On 04/08/2025 at 3:08 PM an interview was conducted with the Administrator (ADM) who said he was notified on 05/27/2024 at 10:00 AM by FDON #29 of RI #3's bruising of the middle finger. The ADM said notifications were made, an X-Ray was ordered, and an investigation initiated. The ADM said interviews from staff who directly worked with RI #3 the day before the injury were obtained as part of the investigation. The ADM said staff denied having knowledge of anything occurring that could have caused an injury, and therefore the investigation was unsubstantiated. When asked why interviews were not obtained from staff who worked with RI #3 days prior to when injury was identified, the ADM said he only thought to interview direct care staff who worked with RI #3 the day before on 05/26/2024. The ADM said, he did not get interview with some nurses and CNAs who worked on 05/26/2024. The ADM said, he did not speak with or interview other residents to find out anything they might know. When asked about the note in the investigative file about CNA #20 and RI #3's RR and RI #3 being mishandled. The ADM said, he did not know where the note came from, and he was not aware of that information. The ADM continued to say he did not know where it came from or who wrote it because there was no signature. The ADM said, it was important to the investigation, and he should have been aware of the note. The ADM said, there was not any documentation of discussing the results of the investigation with the family. The ADM said, he did not see evidence of a body audit assessment after the incident until September 2024. The ADM said, the incident was discussed with the team in the morning meeting the next day but based on what he now knew, the allegation involving RI #3 was not thoroughly investigated. On 04/11/2025 at 10:41 AM during a follow-up interview the ADM, he was asked how was the facility able to determine the appropriate corrective action if an investigation did not include all witness statements. The ADM said, it would be hard to determine an appropriate corrective action plan. 3.) On 07/15/2024 at 3:21 PM the State Agency (SA) received a Facility Reported Incident (FRI) alleging Injury of Unknown Source involving RI #169 who had a large hematoma located on the right foot with swelling; actions taken by the facility in response to the incident included notified family, called for an X-ray, and assessed for pain. RI #169 was admitted to the facility on [DATE] with diagnoses to include Myocardial Infarction, Hypertension, Atrial Fibrillation, and Kidney Failure. RI #169's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/09/2024 documented a Brief Interview for Mental Status (BIMS) score of five out of 15 which indicated severe cognitive impairments and requirements of maximum assistance for toileting, bathing and dressing. A review of RI #169's Departmental Notes, dated 07/15/2024 at 10:21 AM, revealed called to resident room per CNA, upon assessment large hematoma noted to right foot with swelling. Range Of Motion Within Normal Limits, states (he/she) does not know what happened to (his/her) foot . A review of a x-ray results titled Mobile Images for RI #169, dated 07/15/2024 revealed . PROCEDURE: Right Foot, Complete, 3 Views HISTORY: Injury, swelling FINDINGS: Faint lucency across right 4th and 5th metatarsal heads noted . IMPRESSIONS: Suspect hairline nondisplaced fracture lucency across right 4th and 5th metatarsal heads, faintly visualized nondisplaced fracture lucency noted articular base of 5th metatarsal, extensive area of soft tissue swelling over foot and ankle noted. On 04/10/2025 at 11:27 AM an interview was conducted with the ADM who said he was notified of RI #169's injury of unknown origin on 07/15/2024. The ADM said RI #169 was interviewed and did not know how the injury occurred. The ADM said X-rays were ordered and revealed fractures, interventions were put in place for a boot and non-weight bearing status, an investigation was initiated, and interviews were conducted with staff. During the interview the facility investigative file for RI #169 was reviewed and revealed: 1) no documentation of staff interviews or any staff who may have had knowledge of occurrences that could have caused or contributed to the injury of bruising and fracture. 2) no documentation that a skin or body assessment was completed after the injury was identified. The ADM was asked about the documentation into RI #169's investigative file. The ADM said he did not know where the documentation was, and that the evidence of interviews should be in the file. When asked if RI #169's injury of unknown origin was thoroughly investigated, the ADM said based on the lack of documentation, no.

**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 prevent and protect other residents from being abused, and to ensure other residents' safety and privacy was protected from residents with combative, aggressive, wandering, and sexual behaviors. 1.) Specifically, on 01/13/2025 during the night, at approximately 2:00 AM, Licensed Practical Nurse (LPN) #13 found Resident Identifier (RI) #20 in another resident's room, sitting on RI #44's bed, without clothing from the waist down, and caressing RI #44's hip and thigh. Facility staff had knowledge of resident masturbating, family members witnessed RI #20 masturbating, and a Behavioral Health (BH) note dated 01/14/2025 documented family had reported resident would masturbate in front of others. The facility failed to communicate these behaviors to ensure interventions were developed and implemented to ensure RI #20 was supervised in a manner to prevent abuse and protect residents in the facility. 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 443.40 Behavioral Health Services. On 04/11/2025 at 5:26 PM, the Administrator (ADM), the Director of Nursing (DON), the [NAME] President of Risk Management, the [NAME] President of Clinical Operations, and the Senior Regional director of Clinical Operations were provided a copy of the IJ template and notified of the finding of immediate jeopardy in the area of Behavioral Health at F740-Behavioral Health Services. The IJ began on 01/13/2025 and continued until 04/14/2025 when the survey team verified onsite that corrective actions had been implemented. On 04/15/2025 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 complaint/report number AL00049904. The following deficiencies did not rise to the level of IJ. 2) The facility failed to manage RI #31's behavior on 06/13/2024 when RI #31 was very agitated and attempted to slap one resident and later hit another resident, RI #20, in the back of the head. The facility failed to provide supervision and interventions to protect residents in the facility from abuse by RI #31 who was exhibiting verbal and physical behaviors against others. 3.) The facility failed to manage RI #59's behaviors on 08/14/2024 when RI #59 entered RI #325's room, initiated an altercation with RI #325, and took RI #325's babydoll. The facility failed to provide supervision and interventions to protect residents from being affected by RI #59's aggressive, combative, and wandering behaviors. These deficiencies were cited as a result of the investigation of complaint/report number AL00048142 and AL00048960. These failures affected RI #44, RI #20, RI #31, RI #325, and RI #59, five of 41 sampled residents. Findings include: A facility policy titled Behavioral Health Care and Services with an implemented date of 11/2024 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 . RI #20 was admitted to the facility on [DATE] with diagnoses to include Intracranial injury with loss of consciousness. RI #20's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/06/2024 documented the resident had a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicted severe cognitive impairment. A review of RI #20's Care Plan Report revealed: . RI #20 has behavior indicators. (He/She) is sometimes aggressive toward peers and requires redirection. At risk for altercation, complications associated with behavior issues . start date 3/1/2024 . Status Active . When acute behaviors are noted, intervene promptly to manage/redirect . A review of RI #20's Comprehensive Care Plan submitted by the facility immediately following the survey revealed: . Behaviors will be identified and minimized or eliminated without causing harm to resident or staff during acute episode . with appropriate intervention . meds, redirection, diversional activities etc . The Care Plan included interventions and start dates including . (RI #20) has had episodes of being sexually inappropriate in the common areas of the facility. Staff is to redirect resident. Start Date 06/05/2024 . Further review of the Comprehensive Care Plan revealed that RI #20 had an intervention related to him/her wandering to roommates' side of room. The Care Plan did not include interventions to address RI #20 wandering into other residents' rooms. On 01/13/2025 LPN #13 documented that she witnessed RI #20 sitting on RI #44's bed. RI #20 was not wearing clothing from the waist down and was caressing RI #44's hip and thigh. RI #20's medical record included a Behavioral Health Progress Note signed by Family Nurse Practitioner (FNP) #40 dated 01/14/2025. The note documented: . History of Present Illness . Pt (patient) seen today for Initial televisit encounter for psychiatric evaluation and medication management. Resident seen today at the request of staff for inappropriate sexual behaviors . Staff reports that resident was found recently in another . residents room, sitting on the end of the bed, and rubbing (his/her) thigh. It was documented that (he/she) was indecently exposed from the waist down . Family has reported that (he/she) will masturbate in front of others. (He/She) does not appear to be a threat to (himself/herself) or others at this time. Again, (he/she) does display cognitive impairments . TBI (traumatic brain injury). 1:1 sitter could be discontinued with close observation of patient while medications have the time to become efficacious. Examination . Judgement Fair to Poor . Treatment . 2. Inappropriate sexual behavior . Attempts to interview FNP #40 during the survey were unsuccessful. On 04/04/2025 at 2:25 PM an interview was conducted with Certified Nursing Assistant (CNA) #23 who reported she was assigned to provide care to RI #44 on 01/13/2025 when the incident occurred. CNA #23 said she saw RI #20 sitting on the side of his/her bed when she took RI #44 to the shower. CNA #23 said RI #20 was dressed and he/she was looking out the door which faced RI #44's room. CNA #23 said it did seem unusual because RI #20 was normally asleep. CNA #23 said she was unaware that RI #20 had any sexual behaviors such as self-stimulation or masturbation. CNA #23 said another staff told her that RI #20 had previously went into another resident's room, but she had not witnessed RI #20 wandering. On 04/09/2025 at 6:10 PM an interview was conducted with CNA #12 who was assigned to RI #20's care on 01/13/2025 when the incident occurred. CNA #12 was asked what type of behaviors RI #20 had. CNA #12 said, she never knew RI #20 to have behaviors. CNA #12 said she saw RI #20 wandering/walking in the hall a few times. A statement dated 04/04/2025 signed by CNA #42 revealed that she was at lunch in the break room at about 2:00 AM on 01/13/2025 when RI #20 was found in RI #44's room. CNA #42 said she had seen RI #20 wander at times. During an interview on 04/08/2025 at 3:30 PM, LPN #26 reported that RI #20 wandered in the hallway and was easily redirected. An interview with LPN #17 was conducted on 04/07/2025 at 4:44 PM. LPN #17 reported that RI #20 tended to wander into other residents' rooms but would exit if requested. LPN #17 said that RI #20 occasionally masturbated in his/her own room, but to her knowledge, this occurred in no other locations. On 04/08/2025 at 9:15 AM an interview was conducted with CNA #16 who said that RI #20 wandered up and down the hallway but could be easily redirected. CNA #16 stated that she had observed RI #20 engaging in masturbation within his/her room. When asked how the staff managed RI #20's sexual behavior, she explained that if the door was open, they would close it and pull the privacy curtain if a roommate was present. During an interview with the Director of Nursing (DON) on 04/03/2024 at 4:45 PM, the DON was asked if RI #20 ever masturbated in front of other people. The DON said, no, she knew he/she had in his/her room. A follow-up interview was conducted on 04/10/2025 at 6:13 PM with the DON. During the interview, the DON was questioned about the measures staff were taking to prevent RI #20 from entering the rooms of other residents at the time of the incident on 01/13/2025. The DON indicated that staff would have made observations to ensure RI #20 did not wander into other residents' rooms. However, when asked about the actions of the staff on 01/13/2025 when RI #20 was discovered in RI #44's room, she said she was unaware of the actions. When asked whether staff should have been monitoring RI #20 on 01/13/2025, she said that they should have been attentive to the hallway. Regarding the care plan for RI #20 that was in effect on 01/13/2025, concerning behavioral issues, she referenced the care plan, which stated that RI #20 required redirection. When asked if any of the listed interventions could have prevented RI #20 from entering RI #44's room, she cited the guideline: When acute behaviors are noted, intervene promptly to reduce the risk of escalation, which may be more challenging to manage or redirect. On 04/11/2025 at 12:57 PM another follow-up interview was conducted with the DON regarding the Behavioral Health note dated 01/14/2025. The DON was asked which family reported that RI #20 was masturbating in front of others. The DON said the sister had reported to her during a meeting with the ADM and herself after the incident and she reported that he/she had masturbated in the shower but never in public places. The DON said that would be a problem. The DON said she was not sure when the meeting was held or if it was documented. The DON said the facility addressed the behavior in RI #20's behavior care plan, but it did not address specifically masturbation but did say inappropriate behaviors. On 04/03/2025 at 3:30 PM an interview was conducted with the ADM who said RI #20 did wander and had entered into other residents' room. The ADM said when RI #20 wandered staff redirected him/her. The ADM said RI #20 had no sexual behaviors in the past. On 04/09/2025 at 12:21 PM an interview was conducted with the ADM. During the interview, the ADM was asked about the management of RI #20's behavior on the morning of 01/13/2025, when RI #20 entered the room of RI #44. The ADM said he did not know why staff did not see RI #20 entering RI #44's room. When asked what could have prevented this incident, he stated that if staff had noticed RI #20, they could have redirected him/her away from the room. He said that one staff member was on break during the incident, and another might have been attending to other residents, although he could not confirm that. The ADM concluded by stating the negative consequence of RI #20 entering RI #44's room was RI #20 was discovered sitting on RI #44's bed without clothing from the waist down, touching RI #44's leg. On 04/04/2025 at 9:12 AM an interview was conducted with RI #44's Responsible Party (RP). The RP reported that on 12/10/2024 she was visiting and saw RI #20 masturbating while looking into RI #44's room. The RP said she told an unknown staff, and they apologized and closed RI #20's door. The RP said prior to that incident RI #44's roommate was RI #33. The RP reported that RI #33 would disrobe, and RI #20 would go into the room and look at RI #33. A review of RI #33's medical record indicated he/she was moved to the [NAME] Wing on 10/10/2024. On 04/04/2025 at 12:44 PM an interview was conducted with the Medical Director (MD), and she was asked about the incident of sexual abuse of RI #44 by RI #20. The MD said, she was aware of the incident of 01/13/2025 but was not aware RI #20 had any other sexual behaviors. The MD continued to say, another resident would at times take their clothes off and RI #20 would look in at the other resident who was undressing. The MD said, because RI #20 would watch the other resident undress, the other resident had been moved to another room. ****************************************************** On 04/15/2025, the facility submitted an acceptable removal plan, which documented: 1. Immediate action(s) taken for the resident(s) found to have been potentially affected include: a. The facility failed to ensure staff managed and addressed RI #20's behaviors including masturbation and wandering. Specifically, on 01/13/2025 at approximately 2:00 AM, LPN #13 witnessed RI #20 sitting on RI #44's bed, without clothing from the waist down, and making contact with RI #44's leg, caressing RI #44's hip and thigh. Facility staff had knowledge of resident masturbating, family members witnessed resident masturbating, a Behavioral Health note dated 1/14/2025 documented family had reported resident would masturbate in front of others. The facility failed to care plan these behaviors with interventions to protect other residents. b. LPN #13 removed Resident #20 from Resident #44's room on 1/13/25 at approximately 2 am and initiated 1:1 supervision for Resident #20 to ensure safety and prevent further incidents. c. RI #20 was relocated to room on the other end of the center. d. Behavioral Health was contacted and assessed resident on 1/14/25 - Recommendation was to discontinue 1:1 sitter and initiate Q 15-minute checks while medications have time to become efficacious. Q 15 min checks were initiated by the DON in alignment with nationally recognized nursing practice standards, close monitoring is defined as visual checks every 15 minutes. This frequency is commonly accepted in clinical practice for residents identified as high-risk, including during behavioral concerns, elopement risk, or post-incident observation. The assigned staff were to complete the documentation flow sheet. Charge nurses verified staff were monitoring and observing resident every 15 minutes, and staff submitted the flow sheet to the DON for review when completed. Recommendations from Behavioral Health (BH) are reviewed by the Director of Nursing (DON) or designee. The DON/designee followed the recommendations of the psych provider. The resident continues on Q 15-minute checks and has had no behaviors since 1/13/2025. e. RI #20 non-pharmacological intervention in place on 1/13/25 include explaining care prior to, engage in memory stimulating conversations, intervene and observe for pain, provide reorientation and redirection, offer simple choices, involve family, assess for unmet needs like hunger, thirst, toileting, and environmental stressors. f. RI #20 was started on Cimetidine 300 mg on 1/16/25, to reduce sexual desire by its anti-androgen effects. 2. Identification of other residents having the potential to be affected: a. Other residents with wandering and sexual behaviors in the center have the potential to be affected. b. All residents in the center were assessed using the Wandering Behavior Clinical form, by the Care Manger/designee on 04-12-2025 for wandering, going into others' rooms, pacing, exit seeking, shadowing, aimless walking, along with triggers and interventions. Regional Nurse consultant reviewed assessments for triggers and intervention to individualize their care plans. 8 found to have wandering tendencies, 6 had a known history of going into others' rooms. Noted of the 6 residents who enter others' rooms, their BIMs scores are low, indicating at least intermittent confusion, and they are redirectable. c. No other residents were reported to have sexually inappropriate behavior including masturbation. The regional Nurse consultant reviewed resident progress notes from 1/1/2025-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 4/12/25 [NAME] President of Risk Management provided in-service for the Administrator and Director of Nursing training on the facility's Behavioral Health Services Policy and facility's Elopement and Wandering Resident Policy to include management of wandering behaviors and entering other rooms and for behaviors that that increase residents risk of abuse like masturbation, wandering, cursing, shadowing, touching, calling out, and disrobing. b. Facility-wide staff training began on 04/11/2025, 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. 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 report by charge nurses. IDT team reviews documentation in clinical meeting for interventions/follow up. iii. Residents identified at risk for wandering into others' rooms will be reviewed during monthly risk meetings, by the interdisciplinary team. Residents at risk for wandering into resident's rooms will have, individualized, person-centered care plans will be developed by the MDS coordinator/designee, implemented by all staff providing care to the resident, the charge nurse will monitor to ensure care planned interventions are implemented and effective each shift, the charge nurses will communicate with the IDT team if care planned interventions are ineffective, and the MDS coordinator will revise CP as necessary. This is not a new process the MDS coordinator already performs this process. 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. 93 staff have been in-serviced, with 2 remaining to be trained. c. Care plans were reviewed by Regional Director of Clinical Reimbursement on 4/14/25 to ensure they were appropriate, and person centered and that they considered safety of the residents. d. QAPI Committee meeting was held 04-14-2025 to review allegations involving behaviors of wandering and sexual inappropriate behaviors including masturbation to include incidents originating 5/27/24 - current Investigations. The Interdisciplinary Team (IDT) identified eight residents requiring care plan reviews that were completed related to wandering and sexually inappropriate behaviors. The Quality Assurance and Performance Improvement (QAPI) team initiated a review to identify trends in wandering and sexual behaviors, assess potential behavioral triggers, and ensure that appropriate, individualized interventions were implemented and documented in the care plans. e. The regional nurse consultant in-serviced the DON 4/14/25 regarding the process to follow with psych provider recommendations. Upon receipt of the recommendation 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 approved the charge nurse will write an order in the resident's record. Facility requests IJ removal plan to be effective on 04-15-2025. ********************************************************* 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 04/14/2025. 2.) Cross reference F600. On 06/13/2024 the State Agency (SA) received an initial Facility Report Incident (FRI) alleging RI #20 was physically abused by RI #31 who approached RI #20 from behind, swatted RI #20 several times, hit RI #20 in the upper back and back of the head. The report included that RI #31 had demonstrated worsening agitation during the week and was being monitored. RI #20 was admitted to the facility on [DATE] and had diagnoses to include Epilepsy. RI #20's quarterly MDS assessment with an ARD of 06/07/2024 documented a BIMS score of three of 15 which indicated severe cognitive impairment. RI #31 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses to include Alzheimer's Disease. RI #31's quarterly MDS with an ARD of 05/28/2024 documented a BIMS score of three of 15 which indicated severe cognitive impairment. RI #31's care plan for a history of behaviors with a start date of 01/30/2024 described behaviors of being combative with caregivers and at risk for altercations. RI #31's progress notes were reviewed, and an entry dated 06/13/2024 at 1:59 PM documented: . (RI #31) HAS BEEN VERY AGITATED THIS SHIFT, (HE/SHE) HAS ATTEMPTED TO HAVE PHYSICAL ALTERCATIONS WITH TWO OTHER RESIDENTS, RESIDENT (referred) TO ONE RESIDENT AS THE BITCH WITH THE PIGTAIL AND TRIED TO SLAP (HIM/HER). (RI #31) WAS GIVEN PRN (as needed) ATIVAN, WHICH (WAS) INEFFECTIVE. (RI #31) BECAME AGITATED WITH ANOTHER RESIDENT BECAUSE (HE/SHE) THOUGHT (HE/SHE) WAS (HIS/HER) (child) AND HAD SPENT A LOT OF MONEY . (RI #31) JERKED A TOWEL OFF (HIS/HER) LAP AND (attempted) TO HIT (HIM/HER) WITH IT, NURSE REDIRECTED AND (asked) THE OTHER ONE TO GO DOWN THE HALL FOR A MOMENT AND (HE/SHE) FOLLOWED (HIM/HER) DOWN THE HALLWAY AND HIT (HIM/HER) ON THE BACK OF THE HEAD 3 TIMES. (HE/SHE) STATED (HE/SHE) IS A COMPLETE LIAR. NURSE REDIRECTED RESIDENT AND WALKED (HIM/HER) TO AN OFFICE WHERE (HE/SHE) CALMED DOWN . On 04/08/2025 at 10:26 AM an interview was conducted with Licensed Practical Nurse (LPN) #17 who was the nurse at the time of the incident on 06/13/2024. LPN #17 said, they were in the television room and RI #31 was agitated. LPN #17 said RI #31 thought RI #20 was his/her child, whom RI #31 thought (He/she) stole everything we had. LPN #17 said, she instructed RI #20 to go to his/her room. LPN #17 said as RI #20 began to go down the hall, RI #31 got up, walked quickly to behind RI #20, and hit RI #20 in the back of the head three times before they were separated. LPN #17 said, RI #31's increased behaviors and agitation that week could have been due to Dementia and some days RI #31's agitation was worse. On 04/08/2025 at 9:19 AM an interview was conducted with CNA #16 who witnessed the incident on 06/13/2024 between RI #20 and RI #31. CNA #16 said, RI #31 walked down the hallway toward RI #20, whom RI #31 thought was his/her child who had stolen money from him/her. RI #31 hit RI #20 in the back of the head three or four times with an open hand. CNA #16 said, she intervened to separate the residents. CNA #16 said, RI #31 would become agitated and combative with staff during care due to Dementia. On 04/10/2025 at 9:33 AM CNA #16 was asked follow-up questions. CNA #16 said, the abuse could have been prevented if they had moved RI #31 to the other hall. When asked about supervision level, CNA #16 said, they would check on RI #31 every two hours and monitor RI #31 when out of the room in the day area. RI #31's care plans did not include interventions, or the level of supervision RI #31 required to prevent other residents from being abused by RI #31's verbal and physical behaviors. 3.) On 08/14/2024 at 8:51 PM the State Agency received a Facility Reported Incident (FRI) alleging physical abuse when RI #325 was discovered in RI #59's room agitated and being aggressive, a family member tried to get him/her out, a nurse heard the incident, upon assessment there were no injuries noted, RI #325 was sent out for behavioral and threat issues. RI #325 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Acute Cystitis without Hematuria, Delirium due to known Physiological Condition, and Dementia with Behavioral Disturbance. A review of RI #325's annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/19/2024 revealed RI #325's ability to make daily decisions was severely impaired. RI #59 was admitted to the facility on [DATE] with diagnoses to include Dementia without Behavior and Schizoaffective Disorder. A review of RI #59's admission MDS with an ARD date of 07/10/2024 revealed RI #59's BIMS was 12 of 15 which indicated RI #59 had moderate cognitive impairment. The facility investigative file contained a handwritten statement dated 08/14/2024, signed by CNA #35 which documented: . I was in the Room . helping (with another resident) when I heard Screaming down the hall . I walked out with the other CNA and seen a visitor standing outside (another room) we went to check I seen (RI #325) yelling at (RI #59) and (RI #325) holding (RI #59's) babydoll (RI #59) then told me that (RI #325) had slapped (RI #59) and taken (his/her) babydoll. (RI #325) started cussing us out and yelling at other residents and going into other resident's rooms cussing at them. RI #325's medical record included Nurses Notes documenting a history of aggressive and combative behavior toward staff. Specifically, on 07/28/2024 an entry documented: . RESIDENT AGGRESSIVE TOWARDS STAFF, CURSING SLAPPING AND SPITTING, CHURCH LADY TRIED TALKING WITH (HIM/HER) DID NOT WORK . RESIDENT YELLING . HAD TO BACK AWAY FROM RESIDENT TRIED TO HIT ME . The facility investigative file contained a typed statement titled Office of Administrator dated 08/21/2024 which documented: . (RI #325) was demonstrating behavior issues prior to the incident . It appears (RI #325) was confused and confronted (RI #59) in (his/her) room across the hall and took (RI #59's) baby doll. (RI #59) claims that (he/she) was slapped in the forehead by (RI #325) . (RI #325) was removed from the room . (his/her) behavior was uncontrollable, . An emergency IDT (Interdisciplinary Team) meeting was done, and a Root Cause Analysis was done as well as a 4 Point Plan of Correction. On 04/10/2025 at 4:22 PM an interview was conducted with the ADM. When asked if RI #325 had any behaviors, the ADM said, RI #325 would wander but he did not recall any physical aggression. RI #59's care plans did not include interventions, or the level of supervision RI #59 required to prevent other residents from being affected by RI #'s 59's aggressive behaviors.

Based on interviews, record reviews, document review, and facility policy review, the facility failed to ensure residents who received mechanically altered diets were provided a meal consistent with their prescribed diet and of the appropriate texture and form to meet their individual needs. Further, the facility failed to ensure policies addressing the criteria for foods consistent with a mechanical soft diet were developed, implemented, and available to staff. Staff were not knowledgeable on what foods were acceptable for residents with orders for a mechanical soft diet. This failure affected 23 residents with orders for mechanical soft diets. Specifically, on 08/14/2023, the menu indicated the lunch meal for residents with mechanical soft diet orders would consist of ground pork, and the dinner meal would consist of a ground chicken salad plate. Instead, the facility prepared and served residents with orders for mechanical soft diets cubed pork tips cut into one (1) to one and one-half (1 1/2) inch cubes for lunch and a salad containing lettuce, dried croutons, and fried onion rings for dinner. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death of residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.60 (Food and Nutrition Services) at a scope and severity of K. On 08/16/2023 at 7:22 PM the Administrator and Director of Nursing (DON) were provided the IJ template and notified of the findings at the immediate jeopardy level in the area of Food and Nutrition Services at F805- Food in Form to Meet Individual Needs. The IJ began on 08/14/2023 and continued until 08/17/2023, when the facility implemented corrective actions to remove the immediacy and prevent further recurrences. Findings included: A review of the facility's Diet Master list, printed on 08/14/2023, identified 23 residents, including Resident #25 and Resident #58, that were prescribed a mechanical soft diet. A review of Resident #25's Facesheet revealed the facility admitted the resident on 06/30/2015 with diagnoses that included abnormal weight loss, and nutritional deficiency. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/05/2023, revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Per the MDS, Resident #25 received a mechanically altered diet. A review of Resident #25's Care Plan, with a start date of 04/28/2019, revealed the resident was at an increased nutritional risk for potential weight changes related to a history of weight loss, fluctuating appetite, and a mechanically altered and/or therapeutic diet. The Care Plan reflected a diet order of regular with chopped meats and aspiration precautions on 01/29/2023 and indicated on 06/27/2023 speech therapy would treat the resident for dysphagia. A review of a Dietary Note, dated 03/14/2023 and documented by the Registered Dietitian (RD), revealed Resident #25's diet consistency decreased in January 2023 from regular to mechanical soft due to reported coughing after eating. The note indicated the resident had difficulty swallowing. A review of a Speech Therapy SLP [speech language pathology] Evaluation & Plan of Treatment, revealed Resident #25 was placed on speech therapy caseload beginning on 06/27/2023 for Dysphagia [difficulty swallowing] Therapy. The reason for referral was documented as exacerbation of decreased oral/pharyngeal function, risk for aspiration, decreased functional activity tolerance, and dysphagia. A review of Resident #58's Facesheet revealed the facility admitted the resident on 12/22/2022 with diagnoses of Alzheimer's disease, dysphagia, and pulmonary fibrosis (scarring of the lungs). A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/29/2023, revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment. According to the MDS, the resident received a mechanically altered diet. A review of Resident #58's Care Plan, with a start date of 12/22/2022, revealed the resident was at an increased nutritional risk for potential weight changes related to fluctuating appetite and a mechanically altered and/or therapeutic diet. A review of Resident #58's August 2023 Physician Orders revealed an order dated 12/22/2022 for a mechanical soft diet. A review of the facility's week one 2023 Spring/Summer Menus, dated 08/14/2023, indicated the planned menu items for lunch for Mechanical Soft included ground pork tips with gravy. A review of the Recipe Summary Card for Braised Pork Tips in Gravy, dated 11/22/2015, revealed instructions to dice the pork into one-inch pieces. Per the recipe, Mechanical Soft Steps included, .Remove desired number of servings to chop for mechanical soft diets. Use a knife/fork or food processor to chop foods to the desired consistency . There were no further directions as to what the desired consistency was. During an observation on 08/14/2023 at 12:20 PM, Resident #25's meal meal included pork cut into one to one and one-half inch cubes. During the observation an interview was conducted with Nurse Aide (NA) #2 who described the food on Resident #25's tray as diced meat over noodles with gravy. NA #2 also stated the resident's meal ticket indicated MS (mechanical soft), but NA #2 was unable to say what MS stood for. NA #2 gave the resident a bite that consisted of one noodle and one piece of cubed meat but did not attempt to cut the piece of meat into smaller portions. NA #2 asked the resident if the uncut meat was ok, but the resident did not answer. At 12:27 PM, Resident #25 was observed coughing during the meal, and the resident asked for some milk. Resident #25 said they did not want any more of the meat, because it was tough to eat. During an interview on 08/14/2023 at 1:37 PM, LPN #13 was unable to state what type of diet/texture Resident #25 was supposed to have. She was unable to state what meats would not be appropriate for a MS diet. LPN #13 stated she observed the cubed meat that was served, and appeared like the all the meals that were served by the facility. During an interview on 08/14/2023 at 1:08 PM, [NAME] #1 stated the kitchen served three textures: regular, chopped, and pureed. The cook then stated the mechanical soft diet included chopped meats. The cook said raw fruits and vegetables were not allowed on the mechanical soft diet. The cook further stated that any other food was appropriate for the diet if it was soft. A review of the facility's week one 2023 Spring/Summer Menus, dated 08/14/2023, indicated the planned menu items for dinner for Mechanical Soft included a ground chicken salad plate and french fries. The planned menu items for dinner for Regular included onion rings. A review of the Recipe Summary Card for Chicken Caesar Salad, dated 06/05/2015, revealed instructions to cut chicken breasts into one-half-inch strips and to shred romaine lettuce. Mechanical Soft Steps included, .Remove desired number of servings to chop for mechanical soft diets. Use a knife/fork or food processor to chop foods to the desired consistency . There were no further directions as to what the desired consistency was. During an interview on 08/14/2023 at 2:24 PM, the Dietary Manager (DM) stated the facility served only regular, mechanical soft, and pureed textured diets. Per the DM, there was no diet manual for the kitchen staff to refer to on what different food textures were allowed on each diet. The DM stated no raw fruits or vegetables should be served on the mechanical soft diet, but then stated the residents on a mechanical soft diet would get processed chicken on romaine lettuce for dinner. During an interview on 8/14/2023 at 5:21 PM, the Speech Therapist (ST), stated foods such as raw vegetables, anything that was hard to chew, meats on the bone, and those meats that were not chopped up were not appropriate for the mechanical soft diet because they were hard to chew and could pose a choking risk. The ST confirmed chopped chicken on raw romaine lettuce with croutons and fried onion rings on the side were not appropriate textures for the mechanical soft diet. The ST then stated the facility did not have anything in writing for the employees to refer to on which foods were appropriate for each of the three textures served. During an interview on 08/14/2023 at 5:06 PM, [NAME] #3 stated he was serving the residents on a mechanical soft diet a plate of lettuce topped with chopped chicken and croutons with fried onion rings on the side. The cook then stated there was no separate menu he referred to when serving the mechanical soft diet. During a dinner meal observation on 08/14/2023 at 5:30 PM, Nurse Aide (NA) #14 described the meal for Resident #58 as chicken salad with fried onion rings, croutons, and iceberg lettuce with longer stems. NA #14 stated the meal ticket indicated the resident should receive a mechanical soft diet. NA #14 said she did not think the salad was appropriate for mechanical soft but stated staff served the residents the meal as prepared by the kitchen. On 08/14/2023 at 5:40 PM, the Administrator was notified of the concern with the mechanical soft diet meal and the need to stop the meal service. During an interview on 08/14/2023 at 5:59 PM, the Director of Nursing (DON) stated the facility stopped service to the residents on mechanical soft diets and indicated the kitchen would serve sloppy joes to those residents, instead of the chopped chicken on raw lettuce with croutons and fried onion rings as was prepared. During an interview on 08/15/2023 at 12:45 PM, Certified Nursing Assistant (CNA) #15 said the facility had been serving mechanical soft as chopped meats and indicated that staff were just learning that the meats were supposed to chopped smaller/finer than they had been serving. CNA #15 said staff had not received training on what foods were appropriate for each diet texture. During an interview on 08/15/2023 at 9:04 AM, the Medical Director (MD) stated the facility offered regular consistency, mechanical soft, and pureed textured diets. The MD said he was not aware of issues with the wrong texture diets being served. The MD stated raw lettuce or fried onion rings would not be appropriate, unless the onion rings were very soggy, due to concerns of choking or aspiration. The MD stated he was very concerned that residents prescribed a mechanical soft diet were being served lettuce and fried onion rings and agreed raw lettuce and fried onion rings should not have been served for the mechanical soft dinner meal. He stated he expected the RD to be involved in kitchen oversight. During an interview on 08/14/2023 at 2:40 PM, the Registered Dietitian (RD) stated she was primarily responsible for the residents' clinical assessments and was not involved in the kitchen unless requested. The RD further stated the facility utilized a pre-planned menu cycle which provided menus, recipes, tray tickets, and was approved by the menu company's corporate RD. Per the RD, through this menu system, the mechanical soft diet included chopped meats and only cooked vegetables, but there was no diet manual available for the kitchen to refer to on what specific foods were appropriate for each diet. On 08/15/2023 at 2:00 PM, the RD provided a copy of a diet manual but indicated the facility had not adopted it, so staff did not refer to it. During an interview on 08/15/2023 at 2:34 PM, the Assistant Director of Nursing (ADON) stated the facility had discussed implementing the diet manual associated with their menu system multiple times but had not yet implemented the manual. The ADON then stated the facility's kitchen served three diet consistencies, including regular, regular with chopped meats, and a pureed consistency. Per the ADON, the diet manual describing which foods were appropriate for each consistency had not been implemented because it was a big change for the kitchen staff. According to the ADON, the kitchen staff were used to country cooking and needed quite a bit of training to adhere to the diet manual. During an interview on 08/17/2023 at 10:59 AM, the ADON stated she expected staff to ensure the right diet was served to the residents. The ADON said if staff were not ensuring the correct foods were being served, they were putting residents at risk of choking and potential aspiration. During an interview on 08/17/2023 at 12:41 PM, the DON said there had been inconsistencies on what the different diets should look like and miscommunication between the dietary manager and other staff. The DON stated some of the nursing staff were not clear on what type of consistency the diets should look like, and the facility did not have a formal diet manual addressing the different diets. The DON stated she would expect for all the residents on mechanical soft diets to be served the mechanical soft ground consistencies and the CNAs should not have served the residents one-inch cubed pork. The CNAs should have returned the tray to the kitchen and requested a corrected diet tray with the correct texture/consistency. The DON stated serving salad with fried onion rings as well as cubed pork created a potential choking risk for all the residents on mechanical soft diets. During an interview on 08/17/2023 at 3:39 PM, the Administrator revealed he expected dietary staff to send out the correct diet during meals and the staff passing trays to ensure they were providing the correct diet to each resident. The Administrator stated if the correct food items and textures were not served, it put those residents at risk for aspiration, choking, or even death. He stated the residents should have received the correct diet and texture. ************************************************************************************************************ On 08/17/2023 at 1:39 PM, an acceptable Removal Plan was received which documented: Removal Plan: F805 The facility will ensure residents with orders for a mechanical soft diet will receive the appropriate diet texture and form to meet the individual needs. 1. 08/15/2023, through an impromptu QA, the facility adopted and implemented the newly approved diet texture policy that included guidelines for each texture type and has adopted and defined three texture types and forms to meet each resident's individual needs in accordance with the International Dysphagia Diet Standardization Initiative (IDDSI). This policy was approved by the Registered Dietitian and the Speech Therapist from the therapy department. The three texture types adopted are: a. Regular b. Mechanical Soft, which is identified as Level 6 Soft & Bite-sized foods in the IDDSI. c. Puree 2. On 08/15/2023, all resident diet orders reviewed by Director of Nursing, and textures clarified to the three adopted texture types: a. Regular b. Mechanical soft c. Puree 3. 08/16/2023 The Dietary Manager and cooks were trained by the DON on the new Diet Texture Policy. 4. On 08/15/2023 and 08/16/2023, all full time, part time, and prn, including all administrative, dietary, nursing, activity, and therapy department staff, hospice providers, and providers were trained by Director of Nursing, Administrator, Dietary Manager, and Staff Developer on the policy for what MS stands for (Mechanical Soft diet) to include what the texture looks like with visual and demonstration. Two associates (one out of the country and one on medical leave) who we were unable to contact. They will be educated in the same manner as all other staff by the Staff Developer prior to them being allowed to work. 5. On 08/15/2023 and 08/16/2023, all full time, part time, and prn, including all administrative, dietary, nursing, activity, and therapy department staff, hospice providers, and providers were trained by Director of Nursing, Administrator, Dietary Manager, and Staff Developer on the policy for what on what the mechanical soft diet looks like and what it consists of with a demonstration/visual. Two associates (one out of the country and one on medical leave) who we were unable to contact. They will be educated in the same manner as all other staff by the Staff Developer prior to them being allowed to work. 6. On 08/15/2023, IDDSI Level 6 Soft and Bite Sized visual aids were posted in the kitchen, dining areas, nurses' stations, activity room, therapy gym, and on the meal carts for staff references. 7. On 08/15/2023 and 08/16/2023, all full time, part time, and prn, including all administrative, dietary, nursing, activity, and therapy department staff, hospice providers, and providers were trained by Director of Nursing, Administrator, Dietary Manager, and Staff Developer on our policy to promptly return the meal to the dietary department and request the appropriate texture meal if the kitchen sends out the wrong texture diet. Two associates (one out of the country and one on medical leave), who we were unable to contact. They will be educated in the same manner as all other staff by the Staff Developer prior to them being allowed to work. 8. Dietary Manager and Contracted Registered Dietitian, with input from the Speech Therapist, will produce a Dietary Manual that will include resources on different diet textures that are appropriate for each diet type to guide the kitchen staff by 08/17/2023 and updated as needed. In the meantime, the visuals are readily available to all staff. 9. On 08/15/2023, the Register Dietitian adjusted the menus with input from the Speech Therapist, to reflect GBCH's adopted diet textures. The Speech Therapist agrees that these diet textures are appropriate for the residents with orders for Mechanical Soft diets. 08/16/2023 order obtained from physician for Speech Therapy evaluation to determine if the adjusted diet consistency is appropriate for each resident with order for mechanical soft diets. 10. 08/16/2023, A QAPI [quality assurance performance improvement] plan was implemented regarding the facility's meal service to include diet consistencies and following physician orders for modified diet consistencies. The Nursing staff will observe meals to ensure the residents are served the diet texture as ordered. 11. Immediate corrective actions for residents identified: a. On 08/14/2023, Resident #25 was provided a replacement mechanical soft meal. b. On 08/15/2023, Resident #31. The meal was replaced with an appropriate mechanical soft texture meal and the resident consumed 100% of the meal with no chewing, swallowing, or choking incidences. 12. All corrections were completed on 08/17/2023. 13. This immediacy of the IJ was removed on 08/17/2023. ***************************************** The IJ was removed on 08/17/2023 at 4:55 PM after the survey team performed onsite verification that the Removal Plan had been implemented. ******************************************************************************************************************************************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate corrective actions had been implemented, the scope/severity level of F805 was lowered to a lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy on 08/17/2023, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.