**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record, incident logs, policy and procedure review, interviews with administration, nursing and therapy staff, the resident's physician, and the resident's representatives, the facility failed to implement a systematic process to carry out their abuse policy for one Resident #17, who was cognitively intact and dependent on staff for incontinent care of two residents reviewed for abuse. The facility failed to take actions to report, thoroughly investigate, and take corrective action to prevent abuse to its residents. The facility failed to remove staff alleged to perpetrate the abuse and failed to thoroughly investigate the allegation to determine the root cause of the reported abuse to ensure the safety of the resident involved and ensure all facility residents would remain safe from a similar incident. On 11/24/2022 between 7:00 a.m. and 8:30 a.m. the Medical Director informed Staff A, Licensed Practical Nurse (LPN) that a male nurse had provided Resident #17 incontinent care, and she did not want a male nurse to provide the care. Between 9:00 a.m. and 9:30 a.m. Staff A, LPN stated she spoke to the Director of Nursing (DON) who had just arrived at the facility. Staff A said, I told her (DON) the Medical Director had concerns that the resident said she felt as though she was raped. Staff A said the Risk Manager called her back and I had told her I spoke to the Director of Nursing, she DON said she would handle it. Reports to the required abuse hotline showed the facility reported the verbal incident on 11/29/2022. The facility suspended two staff members (Staff C and Director of Nursing) on 11/29/2022. It was determined the investigation was not completed thoroughly and in a timely manner. This resulted in the findings of Immediate Jeopardy starting on 11/24/2022. The immediacy was removed on 12/02/2022 after verification of the implementation of removal action(s). The scope and severity was reduced to a D (no actual harm with potential for more than minimal harm). Findings included: Cross reference F609, F610, F699, and F835 On 11/29/2022 at 12:10 p.m. an interview was conducted with Resident #17. She was observed from the hallway lying in bed wearing a hospital gown. She made eye contact and was receptive to an interview. She said she was waiting to get dressed as she pulled at her hospital gown, and that she needed to get ready for therapy. When the resident was asked if she was treated with respect and dignity, she stated, A male aide (Staff C) started to perform incontinent care; I told him no. I told them (Staff C and D) before I only wanted females to care for me. But he proceeded to change my brief anyway. I told him no. At that time, she made eye contact with the surveyor and stated, No means no. She said she had cried and cried no, but he wouldn't stop. She stated, I felt like I was raped. When asked if she told anyone she stated, I told my doctor, and my doctor told them. She said it had occurred just a couple of days ago. She said she has not seen the male nurse since, but, she continued, I see those men walking past my room and looking in. They're just walking by with nothing to do. At that time the resident lowered her head slightly and stated, I don't want to answer any more questions. Resident #17's bed was positioned by the door and when the door is open, she is able see into the hallway. Review of Resident #17's admission Record revealed, she was geriatric in age and was transferred from a local hospital on [DATE] after having an altered mental status. Her admission Record showed she was admitted for short term rehabilitation with diagnoses that included atrial fibrillation, depression, wedge compression fracture of fourth lumbar vertebra, subsequential encounter for fracture with routine healing, generalized muscle weakness and abnormalities of gait and mobility. Review of Resident #17's admission Minimum Data Set (MDS), dated [DATE], Section C Cognitive Patterns showed the Brief Interview for Mental Status (BIMS) score coded as a 14. The code of 14 indicated cognitively intact. Further review of the MDS, Section G Functional Status showed toilet use coded as the number 3. The number 3 reflected extensive assistance. Support needed for toilet use mobility was coded as a 2 and indicated one-person physical assist. Review of the Medical Director's progress note, dated 11/24/2022 at 9:18 a.m., revealed S: [subjective] resident concern about a male nurse. Further record review of the facility Abuse and Neglect log for November 2022 did not reflect Resident #17's allegation. On 11/29/2022 at 2:04 p.m. an interview was conducted with the Nursing Home Administrator (NHA) related to Resident #17's allegation. The Nursing Home Administrator said the person the staff would contact would be him and the Director of Nursing (DON). Related to Resident #17's allegation, the NHA stated, No one called me on Thanksgiving Day. On 11/29/2022 at 2:26 p.m. a phone interview was conducted with the facility's Medical Director (MD), who confirmed he knew Resident #17 and saw her on 11/24/2022 between 7:00 a.m. and 8:30 a.m. He said she appeared agitated and told him that morning she had been wet and soiled. She said a nurse had cleaned her and that it was a male nurse. She said she didn't want a male nurse. The MD said the facility always honors resident preferences. He stated, That really troubled him. The MD said Resident #17 told him, A man wiped and cleaned me against my wishes. It was a male. I can't have males down there. She stated, He changed me, and he was not supposed to. I told him to stop, and he just kept going. The MD said she was agitated and asked not to be cleaned as he kept cleaning her and said she felt violated. The MD said he asked the resident if it was okay if he examined her. She told me that was different. The MD stated this was very concerning to him, and he immediately said something to nursing leadership. He said he was 100% confident he spoke to the nurse. The MD stated he reported to the charge nurse (Staff A) We have a potential situation here. The MD went on to state, I told them they had an issue that needed to be escalated to the Director of Nursing. The MD said the nurse (Staff A) confirmed to him that it would be escalated. He said he documented it and instructed the charge nurse (Staff A) to document it. He said he was told they were working on it and thought he heard them say the Director of Nursing was coming in. The MD stated, We have rules about this, no means no. When asked about his expectation he stated, Reporting is expected to be done. He confirmed this is the only facility he goes to, and he is the facility's Medical Director. The MD confirmed on 11/24/2022 Resident #17 was not doing well and said the resident was outside of her normal demeanor. He was informed the survey team was not able to locate documentation of Resident #17's allegation. The MD indicated he was surprised of this and repeated, They said they were going to escalate it. On 11/29/2022 at 2:35 p.m. an interview was conducted with the DON on the incident that occurred on 11/24/2022. The DON said she was aware the Medical Director spoke to Staff A (Licensed Practical Nurse) about his concern related to Resident #17. The DON said she was scheduled to work that day and she received a phone call from Staff A. She said at that time she was already in route to the facility. The DON said after she arrived at the facility she spoke to Staff A. The DON stated, [Staff A] told me that everything was fixed. She said Staff A stated that She had rearranged the aide assignment and had spoken to the resident. The resident was okay with the schedule change that no male aide would be providing her care. The DON denied she started a grievance. She denied she spoke to the resident. The DON stated, It was just a patient preference, and it was taken care of. On 11/29/2022 at 2:50 p.m. Staff C, Certified Nursing Assistant (CNA) was observed walking in the middle hallway. He stopped in the middle hall and then suddenly turned back around. As he turned, he was noted looking inside of the rooms. One of the rooms he looked into belonged to Resident #17. He then began to walk towards the nursing station. At that time, he was asked if he had time for an interview. He indicated a new admission had arrived, and he had a few minutes. Staff C, CNA said he had been a certified nursing assistant for thirteen years and only works at this facility. Staff C denied he worked the morning of Thanksgiving Day (11/24/2022). He said he worked the night shift on 11/23/2022, but then confirmed the shift ended on the morning of the 11/24/2022. Staff C said he knew Resident #17 and denied he assisted her with her incontinent care in the morning. He stated, I worked on the long hall and [Resident #17] did not reside on that hall. He then stated, I never worked with her. Staff C was asked to look at his documentation dated 11/24/2022. He looked at the report and confirmed he had documented in Resident #17's record which reflected bladder continence care had been provided on 11/24/2022 at 2:56 a.m. Staff C denied anyone spoke to him about an incident and went on to say he did not remember taking care of the resident and did not recall any objections or problems during the care. He did not recall the resident telling him she did not want a male to care for her. He then added I had taken care of her before. He said no one told him not to take care of her anymore. Staff C said typically, if someone would say they have preferences they don't assign the male aide to the room. He said there are no residents, that he is aware of, who do not want a male to take care of them. He said if there was one, he would get a female aide. Staff C confirmed he worked at the facility yesterday 11/28/2022 and assisted with new admissions. On 11/29/2022 at 3:22 p.m. an interview was conducted with the NHA who stated, No one knew she didn't want a male until Thanksgiving Day. He said, The aide is in the DON office right now and is being suspended. On 11/29/2022 at 3:14 p.m. an interview was conducted with the Social Service Director (SSD). She said she talked to the resident today (11/29/2022) and asked her if anything happened. The SSD said, She told me a couple days ago; a male aide came in to change her and she did not want him to change her. She said she cried and told the doctor, who told the nurse. The resident said she hadn't had a male aide since. The SSD said the resident reported that nothing inappropriate happened. The SSD said the resident's family member was in the room during that time and stated years ago she had a bad encounter with a male aide, stating, It happened somewhere else. The SSD said the resident said she has not had any male caregivers giving her care since the incident happened. She indicated on Thursday (11/24/2022) the resident's care plan had been updated to reflect no male aides. The SSD confirmed a grievance form was not filed. When asked what her expectation was, she stated I expect a male aide would stop and get a female. The NHA was present at the time of the interview and stated, Any concerns should be documented, and a grievance should be filed. He confirmed it was not transferred to paper and did not know why. On 11/29/2022 at 3:40 p.m. the NHA provided a copy of a form titled, Administrative Leave, dated 11/29/2022, Suspended pending abuse allegation that revealed Staff C's, CNA name. On 11/30/2022 at 12:25 p.m. a phone interview was conducted with Staff A, Licensed Practical Nurse (LPN). She confirmed she worked on 11/24/2022 and received a verbal report from the Medical Director. She stated, The MD came to me between 8:30 am and 9:30 a.m. and told me there was an issue that needed to be taken care of. He stated to me that [Resident #17] was very upset because she had been raped. I said, excuse me, did you say rape? He stated Yes. He said she used the word rape. Staff A stated, The MD told me he needed it handled right away. The MD said [Resident #17] told the male staff to stop. Staff A, LPN said she spoke to the resident and that she (Resident #17) said she was okay. I asked her, Do you want me to do anything different. She said that Resident #17 said, I'm fine I just don't want a male taking care of me. I do not want a male touching me down there. I told her that no male aide will take care of her and it will be in her plan of care. Continuing, Staff A stated, She told me that she wanted to be left alone, she did not want to be bothered. When asked what type of assessment was performed, she indicated a set of vital signs, and she observed the resident and did not see any bruising to her face or hands. Staff A confirmed she did not perform a full skin assessment. She said Resident #17's demeanor appeared calm, saying she was not disheveled, was alert and oriented, and her mood appeared okay. Staff A said it was her first time working with the resident. Staff A said the DON was in the building between 9:00 a.m. and 9:30 a.m. stating, I told her that the Medical Director had concerns and the resident said she felt as though she was raped. The DON said he does not like it when people throw that word around. Staff A said, I also told her that I had spoken to the [family member]. I told her the concerns of the resident not wanting a male aide. The [family member] said I don't know why she is like that lately but thank you for letting me know. Staff A continued, I additionally called the Risk Manager, who is also the Assistant Director of Nursing (ADON) and left her a message. Staff A said later that day she spoke to the ADON, and I told her I had informed the DON. Staff A said the DON told her she would handle it and take care of it. Staff A stated, The ADON had asked if I documented it, I told her the DON had said she would take care of it. Staff A denied seeing the DON going to the resident room after she had given her the report. Staff A confirmed she received abuse training in April 2022. She said, If someone alleges rape, we are to inform the parties that are involved, and that is what I did. If a resident alleges any form of abuse, the expectation is to call the hotline. Staff A stated she Figured the DON was handling it because she was here. On 11/30/2022 at 1:08 p.m. an interview was conducted with the ADON, who is the facility's Risk Manager (RM). She said she was not at the facility on Thanksgiving Day. She confirmed she received a call from Staff A, LPN in the morning, but did not answer the phone. The ADON said she called back later that afternoon and spoke to Staff A who told her a patient had a male CNA and didn't want a male CNA. The RM said, [Staff A] said the doctor had concerns. She told me that the DON was going to take care of it. The DON was at the facility and was taking care of it. The RM confirmed she deals with abuse and neglect allegations. Stating, It is a team process. When asked what she would do, she said she would not assign a male to the room, and she would go to the patient and see what her concerns were. She stated, I would want to know why she doesn't want a male. She said, I would investigate by starting the grievance process. I would speak to the resident to determine what had happened. She confirmed, An allegation of rape is immediately called in. The RM said part of her process would be to call the abuse hotline and perform a skin assessment of the resident. She went on to say, I would start a paper trail that would include witness statements from staff. The RM said she is responsible for training and had started abuse and neglect training yesterday (11/29/2022). On 11/30/2022 at 1:27 p.m. an interview was conducted with the Interim Director of Nursing (IDON). She said due to the investigation, she was asked last night around 6:00 p.m. if she could take the interim position. The IDON said the DON was aware of the incident and did not notify the NHA or start the abuse protocol. The IDON said Staff A was directly involved on that day and she was the one the doctor talked to. Staff A was informed by the doctor who used the word rape. Staff A then informed the DON of the doctor's statement. The IDON said if this had been reported to her, she would like to know first-hand information. She said it takes only a minute to see the patient and talk to the patient. The IDON stated, She would want firsthand information. She would have conducted an interview and would have assessed the patient. She would investigate why a resident wouldn't want a particular staff in the room. On 11/30/2022 at 1:41 p.m. an interview was conducted with Staff D, CNA. She confirmed she worked on Thanksgiving Day. She said she went into Resident #17's room with Staff A, LPN while she was gathering some bags. She said she overheard Resident #17 wanted a female instead of a male aide. Staff D said she had never mentioned that before, and had never mentioned anything about her past. Staff D said the resident seemed emotional and was upset a little. Staff D stated, She was telling the nurse she prefers a female over a male aide. Felt more comfortable with a female. Staff D said, I have taken care of her since then and has seemed normal since that day. Staff D continued, Later that same day a little after breakfast the resident told me that she had told the male aide she wanted a female, and said he kept going. She said she was crying and that she didn't want a male. She wanted a female. She said he just kept going. He just kept cleaning her and he kept going. She said the resident stated, You are a female like me would you want a male changing you. Staff D said the resident said she can't protect herself if something happens because she is an elderly old lady. Staff D said she did not notice any bruising and that she didn't seem frightened. Staff D said she told another aide (Staff E, CNA). Staff D said Resident #17 is alert and oriented and not forgetful or confused. On 11/30/2022 at 2:00 p.m. an interview was conducted with Staff E, CNA and she confirmed she worked on 11/24/2022 -Thanksgiving Day and knows Resident #17 stating, I take care of her all the time. She said she could not recall if the resident had voiced a concern to her about not having a male caregiver. She said on 11/24/2022 she was in Resident #17's room caring for her roommate when Staff A, LPN entered the room. Staff E said she could overhear Staff A ask Resident #17 if she preferred a female and Resident #17 responded, Yes. Staff E said she heard Staff A say, OK we won't have a male taking care of you. Staff E said Resident #17 was upset, she looked like she was just not happy. Staff E said on that day she noticed the resident was a little different and was upset. She did not verbalize to me what happened. Staff E said she remembered her and her roommate at the time both verbally said they didn't want a male in the room. Resident #17's roommate was discharged that day adding that she was an older resident also. She said Resident #17 was very alert. Staff E said most of the residents that are here are here for therapy and then go home. She noticed more of the women in therapy prefer not to have men in the room. Staff E said she talked to Staff C before, who is a male aide, about it and wanted to switch assignments. She said I told Staff C, CNA some of the women just don't feel comfortable with a man taking care of them. Staff C said she did not recall when it conversation occurred. On 11/30/22 at 3:12 p.m. an interview was conducted with Resident #17's family member who is her documented emergency contact. The family member said she visits the resident daily, and when she is not there another family member is. She stated, [Resident#17] and I are very close. The family member confirmed on 11/24/2022 she received a phone call from the facility nurse, Staff A. She said there was an incident that happened when (Resident #17) was being changed by a male CNA. She said [Resident #17] was very upset and had been crying all morning. Staff A, LPN had assured her [Resident #17] was okay, but she was upset because she did not want him to do it. The family member said she also spoke to the resident who told her the CNA was Staff C. The family member said on 10/26/2022 Staff C performed the resident's admission intake stating, We both remembered him. She said she told Staff C that she wanted a female caregiver for [ Resident #17], and he stated, Oh that's right you do not want a man to change you . The family member stated, He knew she did not want men providing her care. The family member said, I told [Resident #17] he did not care if she preferred female caregivers. Continuing, the family member stated, [Resident #17]said on 11/24/2022 [Staff C] told her if she did not let him change her brief then she had to wait until shift change. [Resident #17] told him fine. I will wait. [Resident #17] said then all of a sudden, he pulled her gown and continued to change her. She said she tried to reach for the buzzer to call staff and she could not reach it because he had moved the blanket to the side. The family member stated, [Resident #17] kept saying No but he would not listen. [Resident #17] told me she said she felt violated, it was her dignity and that she felt helpless. She said [Resident #17] thought she had a right not to have this man touching her. She said [Resident #17] did say she was not touched inappropriately but she did not want him providing care. The family member stated, The resident told her the doctor came in her room that morning and she was crying. [Resident #17] told me she had told him what had happened. The family member stated a couple weeks prior she spoke to Staff F, LPN a nurse who was working the weekend. He told me [Resident #17] said she did not want male staff providing her care. The family member stated that she shared with Staff F the resident's prior trauma, stating, [Resident #17] was married young, and her husband was very abusive. She said Staff F appeared uncomfortable when he heard her concerns. He said he would make note of it. The family member stated, He said word for word there was no reason why we can't make that accommodation here. This conversation happened a couple weeks prior to the incident. The family member said, [Resident #17] has always been independent and was in her right mind . and to have someone mock her feelings . saying oh yeah you are the one who doesn't want male caregivers, he was very condescending. The family member stated she did not realize the CNA would be like that with her. The family member reiterated the resident had past trauma related to being in an abusive marriage. She stated, Him forcing her during care caused her to be upset. The family member confirmed the resident had mentioned she did not feel comfortable with male caregivers several times to staff and to her. The family member confirmed she received a phone call from the DON on 11/29/2022 and stated, I was frustrated. She alleged that this was the first time she had been notified of the resident's preference. I asked the DON why this was not in her record . Why was it not reported? . Why wasn't there an incident report? The family member said, It bothers me. Where there is smoke there is fire. If they are working that hard to cover it up, what else are they hiding? What about residents who cannot speak for themselves? The family member said when she spoke with [Resident#17], she stated she was not going to allow this to happen. She felt helpless. She was crying. Resident #17 said, I told him to stop, and he ignored my request. The family member stated she felt Resident #17 was safe but was scared about the repercussions. She said, Even if that male caregiver is not here, he has his buddies. I just want [Resident #17] to be safe. The family member confirmed when Resident #17 was admitted [DATE] she informed Staff C, CNA of the resident's gender preference for care. On 11/30/2022 at 4:01 p.m. an interview was conducted with the NHA. He stated Staff C, CNA was interviewed on 11/29/2022. Staff C said he was providing care to Resident #17 on Thanksgiving morning and that she did not want him to do it, she kept saying No. He stated he felt he did not want to leave her without clothes on and wanted to make sure she was dry. The NHA stated they identified an educational opportunity. The NHA said, I let him know he should have left her, honor her request and let the nurse know. The NHA stated they initiated education and suspended the CNA. On 12/01/2022 at 11:27 a.m. a phone interview was conducted with Staff F, LPN. Staff F said he knew Resident #17 and indicated he worked on her unit a few times. He said he recalled speaking with the resident and her [family member]. He said he went into the room to inform the [family member] and the resident he had requested orders from the physician. He said they identified she had blood in her brief, and he was concerned about a gastroesophageal bleed. Staff F said when he was in the room the [family member] told him Resident #17 had a very abusive husband. She said she did not want any male aides to go in her room. Staff F could not recall the exact day of the conversation but stated, It was on the same day I received the order for the STAT (immediately) blood work. Staff F continued and said after he was informed by the [family member] of the resident's preference, he stated, I informed [Staff G Registered Nurse (RN)] the weekend supervisor about it right away. He said he then added it to the on shift report. He said the weekend reports are addressed on Monday mornings and indicated at that time the resident's care plan would be updated. Staff F denied he documented anything in Resident #17's medical record related to the conversation related to the resident's preference on the gender of caregivers. Medical record review revealed on 11/13/2022 Staff F, LPN requested and received orders for Resident #17 for a complete blood count (CBC) due to bright red blood in brief. Thus, indicating the facility staff were notified 12 days prior of the resident's gender preference on caregivers. On 12/02/2022 at 9:51 a.m. a return phone call was received from Staff G, RN Weekend Supervisor. Staff G said she heard about the allegation of abuse a couple of days ago when she was called and asked for a statement. She said, I did not know anything about the patient and was unaware of a patient preference related to not wanting a male aide. Staff G stated she did not recall Staff F, LPN telling her about a resident's preference for a caregiver. She denied she was notified. She stated, [Staff F LPN] does not let me know about his residents. She added last Saturday, 11/26/2022, at the nursing station, I had heard the aides, [Staff F] and [Staff A] talking about someone did not want a male aide. They did not mention the patient's name. Review of the facility policy titled, Abuse Prevention Program, dated 2017, showed 2. Orientation and Training of Employees b. To assist in identification of abuse, the following definitions of abuse are provided during training: Abuse is defined as the willful infliction of injury; unreasonable confinement; intimidation; punishment with resulting of physical harm, pain, or mental anguish; or deprivation by an individual, including a caretaker, of good or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Verbal abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. Sexual abuse is defined as, but not limited to, sexual harassment, sexual coercion, or sexual assault. 3. Preventing Resident Abuse- Establish a Resident Sensitive Environment: This Community desires to prevent abuse, neglect, or misappropriation of property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach including the following: 4. Concern Identification and Follow-up: Resident and family concerns will be recorded, reviewed, addressed, and responded to using the community's concern identification procedures. Residents and families will be informed of the community's concern identified. 6. Resident Assessment: as part of the resident social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, mistreatment, or who have needs and behaviors that might lead to conflict. 9. Identification of Allegation and Internal Reporting Requirements: Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, or misappropriation of property they observe, hear about, or suspect immediately to the administrator or the person in charge of the community, acting on behalf of the administrator, or an immediate supervisor who then must immediately report it to the administrator. If a crime, particularly involving physical or sexual abuse, is suspected, it must be reported to the State Survey Agency and local law enforcement under the following time frames All others -not later than 24 hours after forming the suspicion. Supervisors will immediately inform the administrator or in the absence of the administrator, the person in charge of the community, of all reports of incidents, allegations, or suspicion of potential abuse neglect or misappropriation of property. Upon learning of the report the administrator, or in the absence of the administrator, the person in charge of the community will initiate an incident investigation. 9. Protection of Residents: Employees of this community who have been accused of abuse, neglect, or mistreatment will be immediately suspended until the results of the investigation have been reviewed by the administrator or designee. 10. Investigation of Abuse, Neglect, or Misappropriation Allegation and Response: a. All incidents will be documented, whether or not abuse occurred, was alleged or suspected. B. Any incident or allegation involving abuse, neglect, or misappropriation will result in an abuse investigation. D. Following Abuse Investigation Procedures: The appointed investigator will follow the Abuse Investigation Procedures identified in this policy. Confidentiality: the investigator will do as much as possible to protect the identities of any employees and residents involved in the investigation, until the investigation is concluded. F. Updates to the Administrator: The person in charge of the investigation will update the administrator or designee during the progress of the investigation. The administrator or designee will keep the resident or resident representative informed of the progress of the investigation. G. Final Abuse Investigation Report: The investigator will report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident. 11. Reporting of Potential Abuse a. Initial Reporting of Allegations: Any allegations of abuse will be reported to the Administrator immediately and to the State Department of Health and the resident's representative as so[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews with the Nursing Home Administrator, the Director of Nursing, nursing staff, the resident's physician, and review of clinical and medical records, policies, and procedures, it was determined the facility failed to provide a systematic process to ensure residents were free from abuse and trauma for one resident (#17) of two residents reviewed for abuse by failing to report an allegation of abuse within the required timeframes to the required state agencies and authorities. On 11/24/2022 around 2:56 a.m. Resident #17 told Staff C, Certified Nursing Assistant (CNA) to stop performing incontinent care. The staff member refused to stop after being told multiple times no. On 11/24/2022 between 7:00 a.m. and 8:30 a.m. the Medical Director (MD) informed Staff A, Licensed Practical Nurse (LPN) that Resident #17 stated, I was raped after telling a male aide no. On 11/24/2022 between 9:00 a.m. and 9:30 a.m. the Director of Nursing (DON) was informed of the allegation and failed to follow the facility policy and procedure on abuse and neglect investigation and reporting. Reports to the required abuse hotline showed the facility reported the verbal incident on 11/29/2022. The facility suspended two staff members (Staff C and Director of Nursing) on 11/29/2022. This failure resulted in the determination of Immediate Jeopardy starting on 11/24/2022. The findings of Immediate Jeopardy were determined to be removed on 12/02/2022 after verification of the implementation of removal action(s). The scope and severity was reduced to a D (no actual harm with potential for more than minimal harm). Findings included: Cross reference F600, F610, F699, and F835 Review of the facility policy titled, Abuse Prevention Program, dated 2017, documented: 2. Orientation and Training of Employees b. To assist in identification of abuse, the following definitions of abuse are provided during training: Abuse is defined as the willful infliction of injury; unreasonable confinement; intimidation; punishment with resulting of physical harm, pain or mental anguish; or deprivation by an individual, including a caretaker, of good or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. Sexual abuse is defined as, but not limited to, sexual harassment, sexual coercion, or sexual assault. 3. Preventing Resident Abuse- Establish a Resident Sensitive Environment: This Community desires to prevent abuse, neglect, or misappropriation of property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach including the following: 4. Concern Identification and Follow-up: Resident and family concerns will be recorded, reviewed, addressed, and responded to using the community's concern identification procedures. Residents and families will be informed of the community's concern identified. 6. Resident Assessment: as part of the resident social history evaluation and MDS (minimum data set) assessments, staff will identify residents with increased vulnerability for abuse, neglect, mistreatment, or who have needs and behaviors that might lead to conflict. 9. Identification of Allegation and Internal Reporting Requirements: Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, or misappropriation of property they observe, hear about, or suspect immediately to the administrator or the person in charge of the community, acting on behalf of the administrator, or an immediate supervisor who then must immediately report it to the administrator. If a crime, particularly involving physical or sexual abuse, is suspected, it must be reported to the State Survey Agency and local law enforcement under the following time frames All others - not later than 24 hours after forming the suspicion. Supervisors will immediately inform the administrator or in the absence of the administrator, the person in charge of the community, of all reports of incidents, allegations, or suspicion of potential abuse neglect or misappropriation of property. Upon learning of the report, the administrator, or in the absence of the administrator, the person in charge of the community will initiate an incident investigation. 9. Protection of Residents: Employees of this community who have been accused of abuse, neglect, or mistreatment will be immediately suspended until the results of the investigation have been reviewed by the administrator or designee. 10. Investigation of Abuse, Neglect, or Misappropriation Allegation and Response: A. All incidents will be documented, whether or not abuse occurred, was alleged or suspected. B. Any incident or allegation involving abuse, neglect, or misappropriation will result in an abuse investigation. D. Following Abuse Investigation Procedures: The appointed investigator will follow the Abuse Investigation Procedures identified in this policy. Confidentiality: the investigator will do as much as possible to protect the identities of any employees and residents involved in the investigation, until the investigation is concluded. F. Updates to the Administrator: The person in charge of the investigation will update the administrator or designee during the progress of the investigation. The administrator or designee will keep the resident or resident representative informed of the progress of the investigation. G. Final Abuse Investigation Report: The investigator will report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident. 11. Reporting of Potential Abuse a. Initial Reporting of Allegations: Any allegations of abuse will be reported to the Administrator immediately and to the State Department of Health and the resident's representative as soon as possible within 24 hours. For reporting unusual occurrences or reasonable suspensions of a crime against a resident to the Department of Health, the community will utilize the incident report form provided by the Department. B. Five-day Final Abuse Investigation Report: Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including the steps the community has taken in response to the allegations, will be sent to the department of health. On 11/29/2022 at 12:10 p.m. an interview was conducted with Resident #17. She was observed from the hallway lying in bed wearing a hospital gown. She made eye contact and was receptive to an interview. When the resident was asked if she was treated with respect and dignity, she stated, A male aide (Staff C) started to perform incontinent care; I told him no. I told them (Staff C and D) before I only wanted females to care for me. But he proceeded to change my brief anyway. I told him no. At that time, she made eye contact with the surveyor and stated, No means no. She said she had cried and cried no, but he wouldn't stop. She stated, I felt like I was raped. When asked if she told anyone she stated, I told my doctor, and my doctor told them. She said it had occurred just a couple of days ago. She said she has not seen the male nurse since, but, she continued, I see those men walking past my room and looking in. They're just walking by with nothing to do. At that time the resident lowered her head slightly and stated, I don't want to answer any more questions. Resident #17's bed was positioned by the door and when the door is open, she is able see into the hallway. Review of Resident #17's admission Minimum Data Set (MDS), dated [DATE], Section C Cognitive Patterns showed the Brief Interview for Mental Status (BIMS) score coded as a 14. The code of 14 indicated cognitively intact. Further review of the MDS, Section G Functional Status showed toilet use coded as the number 3. The number 3 reflected extensive assistance. Support needed for toilet use mobility was coded as a 2 and indicated one-person physical assist. Review of the Medical Director's progress note, dated 11/24/2022 at 9:18 a.m., revealed S: [subjective] resident concern about a male nurse. Further record review of the facility Abuse and Neglect log for November 2022 did not reflect Resident #17's allegation. On 11/29/2022 at 2:04 p.m. an interview was conducted with the Nursing Home Administrator (NHA) related to Resident #17's allegation. The Nursing Home Administrator said the person the staff would contact would be him and the Director of Nursing (DON). Related to Resident #17's allegation, the NHA stated, No one called me on Thanksgiving Day. On 11/29/2022 at 2:26 p.m. a phone interview was conducted with the facility's Medical Director (MD), who confirmed he knew Resident #17 and saw her on 11/24/2022 between 7:00 a.m. and 8:30 a.m. He said she appeared agitated and told him that morning she had been wet and soiled. She said a nurse had cleaned her and that it was a male nurse. She said she didn't want a male nurse. The MD said the facility always honors resident preferences. He stated, That really troubled him. The MD said Resident #17 told him, A man wiped and cleaned me against my wishes. It was a male. I can't have males down there. She stated, He changed me, and he was not supposed to. I told him to stop, and he just kept going. The MD said she was agitated and asked not to be cleaned as he kept cleaning her and said she felt violated. The MD said he asked the resident if it was okay if he examined her. She told me that was different. The MD stated this was very concerning to him, and he immediately said something to nursing leadership. He said he was 100% confident he spoke to the nurse. The MD stated he reported to the charge nurse (Staff A) We have a potential situation here. The MD went on to state, I told them they had an issue that needed to be escalated to the Director of Nursing. The MD said the nurse (Staff A) confirmed to him that it would be escalated. He said he documented it and instructed the charge nurse (Staff A) to document it. He said he was told they were working on it and thought he heard them say the Director of Nursing was coming in. The MD stated, We have rules about this, no means no. When asked about his expectation he stated, Reporting is expected to be done. He confirmed this is the only facility he goes to, and he is the facility's Medical Director. The MD confirmed on 11/24/2022 Resident #17 was not doing well and said the resident was outside of her normal demeanor. He was informed that the survey team was not able to locate documentation of Resident #17's allegation. The MD indicated he was surprised of this and repeated, They said they were going to escalate it. On 11/29/2022 at 2:35 p.m. an interview was conducted with the DON on the incident that occurred on 11/24/2022. The DON said she was aware the Medical Director spoke to Staff A (Licensed Practical Nurse) about his concern related to Resident #17. The DON said she was scheduled to work that day and she received a phone call from Staff A. She said at that time she was already in route to the facility. The DON said after she arrived at the facility she spoke to Staff A. The DON stated, [Staff A] told me that everything was fixed. She said Staff A stated that She had rearranged the aide assignment and had spoken to the resident. The resident was okay with the schedule change that no male aide would be providing her care. The DON denied she started a grievance. She denied she spoke to the resident. The DON stated, It was just a patient preference, and it was taken care of. On 11/29/2022 at 2:50 p.m. Staff C, Certified Nursing Assistant (CNA) was observed walking in the middle hallway. He stopped in the middle hall and then suddenly turned back around. As he turned, he was noted looking inside of the rooms. One of the rooms he looked into belonged to Resident #17. He then began to walk towards the nursing station. At that time, he was asked if he had time for an interview. He indicated a new admission had arrived, and he had a few minutes. Staff C, CNA said he had been a certified nursing assistant for thirteen years and only works at this facility. Staff C denied he worked the morning of Thanksgiving Day (11/24/2022). He said he worked the night shift on 11/23/2022, but then confirmed the shift ended on the morning of the 11/24/2022. Staff C said he knew Resident #17 and denied he assisted her with her incontinent care in the morning. He stated, I worked on the long hall and [Resident #17] did not reside on that hall. He then stated, I never worked with her. Staff C was asked to look at his documentation dated 11/24/2022. He looked at the report and confirmed he had documented in Resident #17's record which reflected bladder continence care had been provided on 11/24/2022 at 2:56 a.m. Staff C denied anyone spoke to him about an incident and went on to say he did not remember taking care of the resident and did not recall any objections or problems during the care. He did not recall the resident telling him she did not want a male to care for her. He then added I had taken care of her before. He said no one told him not to take care of her anymore. Staff C said typically, if someone would say they have preferences they don't assign the male aide to the room. He said there are no residents, that he is aware of, who do not want a male to take care of them. He said if there was one, he would get a female aide. Staff C confirmed he worked at the facility yesterday 11/28/2022 and assisted with new admissions. On 11/29/2022 at 3:22 p.m. an interview was conducted with the NHA who stated, No one knew she didn't want a male until Thanksgiving Day. He said, The aide is in the DON office right now and is being suspended. On 11/29/2022 at 3:14 p.m. an interview was conducted with the Social Service Director (SSD). She said she talked to the resident today (11/29/2022) and asked her if anything happened. The SSD said, She told me a couple days ago; a male aide came in to change her and she did not want him to change her. She said she cried and told the doctor, who told the nurse. The resident said she hadn't had a male aide since. The SSD said the resident reported that nothing inappropriate happened. The SSD said the resident's family member was in the room during that time and stated years ago she had a bad encounter with a male aide, stating, It happened somewhere else. The SSD said the resident said she has not had any male caregivers giving her care since the incident happened. She indicated on Thursday (11/24/2022) the resident's care plan had been updated to reflect no male aides. The SSD confirmed a grievance form was not filed. When asked what her expectation was, she stated, I expect a male aide would stop and get a female. The NHA was present at the time of the interview and stated, Any concerns should be documented, and a grievance should be filed. He confirmed it was not transferred to paper and did not know why. On 11/29/2022 at 3:40 p.m. the NHA provided a copy of a form titled, Administrative Leave, dated 11/29/2022, Suspended pending abuse allegation that revealed Staff C's, CNA name. On 11/30/2022 at 12:25 p.m. a phone interview was conducted with Staff A, Licensed Practical Nurse (LPN). She confirmed she worked on 11/24/2022 and received a verbal report from the Medical Director. She stated, The MD came to me between 8:30 a.m. and 9:30 a.m. and told me there was an issue that needed to be taken care of. He stated to me that [Resident #17] was very upset because she had been raped. I said, Excuse me, did you say rape? He stated Yes. He said she used the word rape. Staff A stated, The MD told me he needed it handled right away. The MD said [Resident #17] told the male staff to stop. Staff A, LPN said she spoke to the resident and that she (Resident #17) said she was okay. I asked her, Do you want me to do anything different. She said that Resident #17 said, I'm fine I just don't want a male taking care of me. I do not want a male touching me down there. I told her that no male aide will take care of her and it will be in her plan of care. Continuing, Staff A stated, She told me that she wanted to be left alone, she did not want to be bothered. When asked what type of assessment was performed, she indicated a set of vital signs, and she observed the resident and did not see any bruising to her face or hands. Staff A confirmed she did not perform a full skin assessment. She said Resident #17's demeanor appeared calm, saying she was not disheveled, was alert and oriented, and her mood appeared okay. Staff A said it was her first time working with the resident. Staff A said the DON was in the building between 9:00 a.m. and 9:30 a.m. stating, I told her that the Medical Director had concerns and the resident said she felt as though she was raped. The DON said he does not like it when people throw that word around. Staff A said, I also told her that I had spoken to the [family member]. I told her the concerns of the resident not wanting a male aide. The [family member] said I don't know why she is like that lately but thank you for letting me know. Staff A continued, I additionally called the Risk Manager, who is also the Assistant Director of Nursing (ADON) and left her a message. Staff A said later that day she spoke to the ADON, and I told her I had informed the DON. Staff A said the DON told her she would handle it and take care of it. Staff A stated, The ADON had asked if I documented it, I told her the DON had said she would take care of it. Staff A denied seeing the DON going to the resident room after she had given her the report. Staff A confirmed she received abuse training in April 2022. She said, If someone alleges rape, we are to inform the parties that are involved, and that is what I did. If a resident alleges any form of abuse, the expectation is to call the hotline. Staff A stated she, Figured the DON was handling it because she was here. On 11/30/2022 at 1:08 p.m. an interview was conducted with the ADON, who is the facility's Risk Manager (RM). She said she was not at the facility on Thanksgiving Day. She confirmed she received a call from Staff A, LPN in the morning, but did not answer the phone. The ADON said she called back later that afternoon and spoke to Staff A who told her a patient had a male CNA and didn't want a male CNA. The RM said, [Staff A] said the doctor had concerns. She told me that the DON was going to take care of it. The DON was at the facility and was taking care of it. The RM confirmed she deals with abuse and neglect allegations. Stating, It is a team process. When asked what she would do, she said she would not assign a male to the room, and she would go to the patient and see what her concerns were. She stated, I would want to know why she doesn't want a male. She said, I would investigate by starting the grievance process. I would speak to the resident to determine what had happened. She confirmed, An allegation of rape is immediately called in. The RM said part of her process would be to call the abuse hotline and perform a skin assessment of the resident. She went on to say, I would start a paper trail that would include witness statements from staff. The RM said she is responsible for training and had started abuse and neglect training yesterday (11/29/2022). On 11/30/2022 at 1:27 p.m. an interview was conducted with the Interim Director of Nursing (IDON). She said due to the investigation, she was asked last night around 6:00 p.m. if she could take the interim position The IDON said the DON was aware of the incident and did not notify the NHA or start the abuse protocol. The IDON said Staff A was directly involved on that day and she was the one the doctor talked to. Staff A was informed by the doctor who used the word rape. Staff A then informed the DON of the doctor's statement. The IDON said if this had been reported to her, she would like to know first-hand information. She said it takes only a minute to see the patient and talk to the patient. The IDON stated, She would want firsthand information. She would have conducted an interview and would have assessed the patient. She would investigate why a resident wouldn't want a particular staff in the room. On 11/30/2022 at 1:41 p.m. an interview was conducted with Staff D, CNA. She confirmed she worked on Thanksgiving Day. She said she went into Resident #17's room with Staff A, LPN while she was gathering some bags. She said she overheard Resident #17 wanted a female instead of a male aide. Staff D said she had never mentioned that before, and had never mentioned anything about her past. Staff D said the resident seemed emotional and was upset a little. Staff D stated, She was telling the nurse she prefers a female over a male aide. Felt more comfortable with a female. Staff D said, I have taken care of her since then and has seemed normal since that day. Staff D continued, Later that same day a little after breakfast the resident told me that she had told the male aide she wanted a female, and said he kept going. She said she was crying and that she didn't want a male. She wanted a female. She said he just kept going. He just kept cleaning her and he kept going. She said the resident stated, You are a female like me would you want a male changing you. Staff D said the resident said she can't protect herself if something happens because she is an elderly old lady. Staff D said she did not notice any bruising and that she didn't seem frightened. Staff D said she told another aide (Staff E, CNA). Staff D said Resident #17 is alert and oriented and not forgetful or confused. On 11/30/2022 at 2:00 p.m. an interview was conducted with Staff E, CNA and she confirmed she worked on 11/24/2022 -Thanksgiving Day and knows Resident #17 stating, I take care of her all the time. She said she could not recall if the resident had voiced a concern to her about not having a male caregiver. She said on 11/24/2022 she was in Resident #17's room caring for her roommate when Staff A, LPN entered the room. Staff E said she could overhear Staff A ask Resident #17 if she preferred a female and Resident #17 responded, Yes. Staff E said she heard Staff A say, OK we won't have a male taking care of you. Staff E said Resident #17 was upset, she looked like she was just not happy. Staff E said on that day she noticed the resident was a little different and was upset. She did not verbalize to me what happened. Staff E said she remembered her and her roommate at the time both verbally said they didn't want a male in the room. Resident #17's roommate was discharged that day adding that she was an older resident also. She said Resident #17 was very alert. Staff E said she talked to Staff C before, who is a male aide, about it and wanted to switch assignments. She said I told Staff C, CNA some of the women just don't feel comfortable with a man taking care of them. Staff C said she did not recall when it conversation occurred. On 11/30/22 at 3:12 p.m. an interview was conducted with Resident #17's family member who is her documented emergency contact. The family member said she visits the resident daily, and when she is not there another family member is. She stated, [Resident#17] and I are very close. The family member confirmed on 11/24/2022 she received a phone call from the facility nurse, Staff A. She said there was an incident that happened when [Resident #17] was being changed by a male CNA. She said [Resident #17] was very upset and had been crying all morning. Staff A, LPN had assured her [Resident #17] was okay, but she was upset because she did not want him to do it. The family member said she also spoke to the resident who told her the CNA was Staff C. The family member said on 10/26/2022 Staff C performed the resident's admission intake stating, We both remembered him. She said she told Staff C that she wanted a female caregiver for [Resident #17], and he stated, Oh that's right you do not want a man to change you . The family member stated, He knew she did not want men providing her care. The family member said, I told [Resident #17] he did not care if she preferred female caregivers. Continuing, the family member stated, [Resident #17] said on 11/24/2022 [Staff C] told her if she did not let him change her brief then she had to wait until shift change. [Resident #17] told him fine. I will wait. [Resident #17] said then all of a sudden, he pulled her gown and continued to change her. She said she tried to reach for the buzzer to call staff and she could not reach it because he had moved the blanket to the side. The family member stated, [Resident #17] kept saying No but he would not listen. [Resident #17] told me she said she felt violated, it was her dignity and that she felt helpless. She said [Resident #17] thought she had a right not to have this man touching her. She said [Resident #17] did say she was not touched inappropriately but she did not want him providing care. The family member stated, The resident told her the doctor came in her room that morning and she was crying. [Resident #17] told me she had told him what had happened. The family member stated a couple weeks prior she spoke to Staff F, LPN a nurse who was working the weekend. He told me [Resident #17] said she did not want male staff providing her care. The family member stated that she shared with Staff F the resident's prior trauma, stating, [Resident #17] was married young, and her husband was very abusive. She said Staff F appeared uncomfortable when he heard her concerns. He said he would make note of it. The family member stated, He said word for word there was no reason why we can't make that accommodation here. This conversation happened a couple weeks prior to the incident. The family member said, [Resident #17] has always been independent and was in her right mind . and to have someone mock her feelings . saying oh yeah you are the one who doesn't want male caregivers, he was very condescending. The family member stated she did not realize the CNA would be like that with her. The family member reiterated the resident had past trauma related to being in an abusive marriage. She stated, Him forcing her during care caused her to be upset. The family member confirmed the resident had mentioned she did not feel comfortable with male caregivers several times to staff and to her. The family member confirmed she received a phone call from the DON on 11/29/2022 and stated, I was frustrated. She alleged that this was the first time she had been notified of the resident's preference. I asked the DON why this was not in her record . Why was it not reported? . Why wasn't there an incident report? The family member said, It bothers me. Where there is smoke there is fire. If they are working that hard to cover it up, what else are they hiding? What about residents who cannot speak for themselves? The family member said when she spoke with [Resident#17], she stated she was not going to allow this to happen. She felt helpless. She was crying. Resident #17 said, I told him to stop, and he ignored my request. The family member stated she felt Resident #17 was safe but was scared about the repercussions. She said, Even if that male caregiver is not here, he has his buddies. I just want [Resident #17] to be safe. The family member confirmed when Resident #17 was admitted [DATE] she informed Staff C, CNA of the resident's gender preference for care. On 11/30/2022 at 4:01 p.m. an interview was conducted with the NHA. He stated Staff C, CNA was interviewed on 11/29/2022. Staff C said he was providing care to Resident #17 on Thanksgiving morning and that she did not want him to do it, she kept saying No. He stated he felt he did not want to leave her without clothes on and wanted to make sure she was dry. The NHA stated they identified an educational opportunity. The NHA said, I let him know he should have left her, honor her request and let the nurse know. The NHA stated they initiated education and suspended the CNA. On 12/02/2022 at 9:51 a.m. a return phone call was received from Staff G, RN Weekend Supervisor. Staff G said she heard about the allegation of abuse a couple of days ago when she was called and asked for a statement. She said, I did not know anything about the patient and was unaware of a patient preference related to not wanting a male aide. Staff G stated she did not recall Staff F, LPN telling her about a resident's preference for a caregiver. She denied she was notified. She stated, [Staff F LPN] does not let me know about his residents. She added last Saturday, 11/26/2022, at the nursing station, I had heard the aides, [Staff F] and [Staff A] talking about someone did not want a male aide. They did not mention the patient's name. Facility Actions to Remove Immediate Jeopardy included: On 12/02/2022 at 4:45 p.m. a Removal Plan for F 609 was received which was verified and found to be acceptable. (Photographic Evidence Obtained) Review of the removal plan revealed: December 2,2022 in response to Immediate Jeopardy concerns identified during re-licensure survey F609- * 11/29/22 -At around 1:30 p.m. Surveyor brought to NHA attention a potential allegation of abuse that occurred on 11/24/2022 (Thanksgiving Day). Upon investigation, a physician progress note in [medical software] stated that resident had concerns with potential male C.N.A., note dated 11/24/22. * 11/29/22 investigation initiated; CNA suspended immediately pending investigation. * Investigation revealed on 11/24/22 physician communicated with licensed nurse (LPN) that there was potential issue occurring with a resident and to please escalate to clinical leadership. The LPN went immediately and talked to the resident about her concerns. The resident stated that a male C.N.A. came in to change her brief on 11-7 shift and she stated no and the C.N.A. proceeded, and she stated that No mean no and didn't want a male C.N.A. * That nurse then called the DCS around 10:30 a.m. on 11/24/22 and notified her of resident concerns. * 11/29/22-At around 6:00 p.m. with the presence of the HRD and administrator the DCS was suspended pending investigation due to failure to follow community reporting process pertain to abuse allegation. * 11/29/22-Immediate was submitted to AHCA (Agency for Health Care Administration). * 11/29/22 -Police notification * 11/29/22 DCF notification * On 11/29/2022 - Education was initiated with all staff by department leadership regarding Abuse, Neglect, Exploitation & Misappropriation, recognizing and reporting abuse per community policy/resident right, grievances and communication. * 11/30/2022- Acting Director of Nursing interviewed residents that were cared for by the alleged perpetrator. * On 11/30/2022 Resident who made allegation was seen by the psychologist however declined visit. He is to follow up week of 12/05/2022. * On 11/30/2022 ADHOC QAPI was completed with the Medical Director, NHA, acting DON, QA nurse, Unit Manager, SS, Clinical Re[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, incident logs, policy and procedure review, interviews with administration, nursing staff, the resident's physician, and the resident and the resident's representative, it was determined the facility failed to provide a systematic process to implement their abuse policy for one resident (#17) of two residents reviewed for abuse. The facility failed to thoroughly investigate to determine the root cause of a reported allegation of abuse and failed to remove staff alleged to perpetrate the abuse to ensure the safety of the resident involved and ensure all facility residents would remain safe from a similar incident. On 11/24/2022 around 2:56 a.m. Resident #17 told Staff C, Certified Nursing Assistant to stop performing incontinent care. The staff member refused to stop after being told multiple times no. On 11/24/2022 between 7:00 a.m. and 8:30 a.m. the Medical Director informed Staff A, Licensed Practical Nurse (LPN) that Resident #17 stated, I was raped after telling a male aide no. On 11/24/2022 between 9:00 a.m. and 9:30 a.m. the Director of Nursing (DON) was informed of the allegation and failed to follow the facility policy and procedure on abuse and neglect, investigation, implement strategies to protect resident(s) and reporting. It was confirmed through interview with Staff C, CNA and review of the working schedules that Staff C, CNA continued to work at the facility on the 2:45 p.m. to 11:15 p.m. shift on 11/28/2022 and part of the same shift on 11/29/2022. Review of reports to the required abuse hotline showed the facility reported the incident on 11/29/2022 and suspended two staff members (C and the Director of Nursing) on 11/29/2022. The investigation was not carried out in a consistent and thorough manner. This failure resulted in the determination of Immediate Jeopardy starting on 11/24/2022. The findings of Immediate Jeopardy were determined to be removed on 12/02/2022 after verification of the implementation of removal action(s). The scope and severity was reduced to a D (no actual harm with potential for more than minimal harm). Findings included: Cross reference F600, F609, F699, and F835 On 11/29/2022 at 12:10 p.m. an interview was conducted with Resident #17. She was observed from the hallway lying in bed wearing a hospital gown. She made eye contact and was receptive to an interview. She said she was waiting to get dressed as she pulled at her hospital gown, and that she needed to get ready for therapy. When the resident was asked if she was treated with respect and dignity, she stated, A male aide (Staff C) started to perform incontinent care; I told him no. I told them (Staff C and D) before I only wanted females to care for me. But he proceeded to change my brief anyway. I told him no. At that time, she made eye contact with the surveyor and stated, No means no. She said she had cried and cried no, but he wouldn't stop. She stated, I felt like I was raped. When asked if she told anyone she stated, I told my doctor, and my doctor told them. She said it had occurred just a couple of days ago. She said she has not seen the male nurse since, but, she continued, I see those men walking past my room and looking in. They're just walking by with nothing to do. At that time the resident lowered her head slightly and stated, I don't want to answer any more questions. Resident #17's bed was positioned by the door and when the door is open, she is able see into the hallway. Review of the facility Abuse and Neglect log for November 2022 did not reflect Resident #17's allegation. Review of Resident #17's admission Minimum Data Set (MDS), dated [DATE], Section C Cognitive Patterns showed the Brief Interview for Mental Status (BIMS) score coded as a 14. The code of 14 indicated cognitively intact. Further review of the MDS, Section G Functional Status showed toilet use coded as the number 3. The number 3 reflected extensive assistance. Support needed for toilet use mobility was coded as a 2 and indicated one-person physical assist. On 11/29/2022 at 2:35 p.m. an interview was conducted with the Director of Nursing (DON) on the incident that occurred on 11/24/2022. The DON said she was aware the Medical Director spoke to Staff A (Licensed Practical Nurse) about his concern related to Resident #17. The DON said she was scheduled to work that day and she received a phone call from Staff A. The DON said after she arrived at the facility, she spoke to Staff A. The DON stated, [Staff A] told me that everything was fixed. She said Staff A stated that She had rearranged the aide assignment and had spoken to the resident. The resident was okay with the schedule change that no male aide would be providing her care. The DON denied she started a grievance. She denied she spoke to the resident. The DON stated, It was just a patient preference, and it was taken care of. On 11/29/2022 at 2:04 p.m. an interview was conducted with the Nursing Home Administrator (NHA) related to Resident #17's allegation. The Nursing Home Administrator said the person the staff would contact would be him and the Director of Nursing (DON). Related to Resident #17's allegation, the NHA stated, No one called me on Thanksgiving Day. Review of the Medical Director's progress note, dated 11/24/2022 at 9:18 a.m., revealed S: [subjective] resident concern about a male nurse. On 11/29/2022 at 2:26 p.m. a phone interview was conducted with the facility's Medical Director (MD), who confirmed he knew Resident #17 and saw her on 11/24/2022 between 7:00 a.m. and 8:30 a.m. He said she appeared agitated and told him that morning she had been wet and soiled. She said a nurse had cleaned her and that it was a male nurse. She said she didn't want a male nurse. The MD said the facility always honors resident preferences. He stated, That really troubled me. The MD said Resident #17 told him, A man wiped and cleaned me against my wishes. It was a male. I can't have males down there. She stated, He changed me, and he was not supposed to. I told him to stop, and he just kept going. The MD said she was agitated and asked not to be cleaned as he kept cleaning her and said she felt violated. The MD said he asked the resident if it was okay if he examined her. She told me that was different. The MD stated this was very concerning to him, and he immediately said something to nursing leadership. He said he was 100% confident he spoke to the nurse. The MD stated he reported to the charge nurse (Staff A) We have a potential situation here. The MD went on to state, I told them they had an issue that needed to be escalated to the Director of Nursing. The MD said the nurse (Staff A) confirmed to him that it would be escalated. He said he documented it and instructed the charge nurse (Staff A) to document it. He said he was told they were working on it and thought he heard them say the Director of Nursing was coming in. The MD stated, We have rules about this, no means no. When asked about his expectation he stated, Reporting is expected to be done. He confirmed this is the only facility he goes to, and he is the facility's Medical Director. The MD confirmed on 11/24/2022 Resident #17 was not doing well and said the resident was outside of her normal demeanor. He was informed the survey team was not able to locate documentation of Resident #17's allegation. The MD indicated he was surprised of this and repeated, They said they were going to escalate it. On 11/29/2022 at 3:14 p.m. an interview was conducted with the Social Service Director (SSD). She said she talked to the resident today (11/29/2022) and asked her if anything happened. The SSD said, She told me a couple days ago; a male aide came in to change her and she did not want him to change her. She said she cried and told the doctor, who told the nurse. The resident said she hadn't had a male aide since. The SSD said the resident reported that nothing inappropriate happened. The SSD said the resident's family member was in the room during that time and stated years ago she had a bad encounter with a male aide, stating, It happened somewhere else. The SSD said the resident said she has not had any male caregivers giving her care since the incident happened. She indicated on Thursday (11/24/2022) the resident's care plan had been updated to reflect no male aides. The SSD confirmed a grievance form was not filed. When asked what her expectation was, she stated I expect a male aide would stop and get a female. The NHA was present at the time of the interview and stated, Any concerns should be documented, and a grievance should be filed. He confirmed it was not transferred to paper and did not know why. On 11/29/2022 at 2:50 p.m. Staff C, Certified Nursing Assistant (CNA) was observed walking in the middle hallway. He stopped in the middle hall and then suddenly turned back around. As he turned, he was noted looking inside of the rooms. One of the rooms he looked into belonged to Resident #17. He then began to walk towards the nursing station. At that time, he was asked if he had time for an interview. Staff C, CNA said he had been a certified nursing assistant for thirteen years and only works at this facility. Staff C denied he worked the morning of Thanksgiving Day (11/24/2022). He said he worked the night shift on 11/23/2022, but then confirmed the shift ended on the morning of the 11/24/2022. Staff C said he knew Resident #17 and denied he assisted her with her incontinent care in the morning. He stated, I worked on the long hall and [Resident #17] did not reside on that hall. He then stated, I never worked with her. Staff C was asked to look at his documentation dated 11/24/2022. He looked at the report and confirmed he had documented in Resident #17's record which reflected bladder continence care had been provided on 11/24/2022 at 2:56 a.m. Staff C denied anyone spoke to him about an incident and went on to say he did not remember taking care of the resident and did not recall any objections or problems during the care. He did not recall the resident telling him she did not want a male to care for her. He then added I had taken care of her before. He said no one told him not to take care of her anymore. Staff C said typically, if someone would say they have preferences they don't assign the male aide to the room. He said there are no residents, that he is aware of, who do not want a male to take care of them. He said if there was one, he would get a female aide. Staff C confirmed he worked at the facility yesterday 11/28/2022 and assisted with new admissions. On 11/29/2022 at 3:22 p.m. an interview was conducted with the NHA who stated, No one knew she didn't want a male until Thanksgiving Day. He said, The aide is in the DON office right now and is being suspended. On 11/29/2022 at 3:40 p.m. the NHA provided a copy of a form titled, Administrative Leave, dated 11/29/2022, Suspended pending abuse allegation that revealed Staff C's, CNA name. On 11/30/2022 at 12:25 p.m. a phone interview was conducted with Staff A, Licensed Practical Nurse (LPN). She confirmed she worked on 11/24/2022 and received a verbal report from the Medical Director. She stated, The MD came to me between 8:30 a.m. and 9:30 a.m. and told me there was an issue that needed to be taken care of. He stated to me that [Resident #17] was very upset because she had been raped. I said, Excuse me, did you say rape? He stated Yes. He said she used the word rape. Staff A stated, The MD told me he needed it handled right away. The MD said [Resident #17] told the male staff to stop. Staff A, LPN said she spoke to the resident and that she (Resident #17) said she was okay. I asked her, Do you want me to do anything different. She said that Resident #17 said, I'm fine I just don't want a male taking care of me. I do not want a male touching me down there. I told her that no male aide will take care of her and it will be in her plan of care. Continuing, Staff A stated, She told me that she wanted to be left alone, she did not want to be bothered. When asked what type of assessment was performed, she indicated a set of vital signs, and she observed the resident and did not see any bruising to her face or hands. Staff A confirmed she did not perform a full skin assessment. She said Resident #17's demeanor appeared calm, saying she was not disheveled, was alert and oriented, and her mood appeared okay. Staff A said it was her first time working with the resident. Staff A said the DON was in the building between 9:00 a.m. and 9:30 a.m. stating, I told her that the Medical Director had concerns and the resident said she felt as though she was raped. The DON said he does not like it when people throw that word around. Staff A said, I also told her that I had spoken to the [family member]. I told her the concerns of the resident not wanting a male aide. The [family member] said I don't know why she is like that lately but thank you for letting me know. Staff A continued, I additionally called the Risk Manager, who is also the Assistant Director of Nursing (ADON) and left her a message. Staff A said later that day she spoke to the ADON, and I told her I had informed the DON. Staff A said the DON told her she would handle it and take care of it. Staff A stated, The ADON had asked if I documented it, I told her the DON had said she would take care of it. Staff A denied seeing the DON going to the resident room after she had given her the report. Staff A confirmed she received abuse training in April 2022. She said, If someone alleges rape, we are to inform the parties that are involved, and that is what I did. If a resident alleges any form of abuse, the expectation is to call the hotline. Staff A stated she Figured the DON was handling it because she was here. On 11/30/2022 at 1:08 p.m. an interview was conducted with the ADON, who is the facility's Risk Manager (RM). She said she was not at the facility on Thanksgiving Day. She confirmed she received a call from Staff A, LPN in the morning, but did not answer the phone. The ADON said she called back later that afternoon and spoke to Staff A who told her a patient had a male CNA and didn't want a male CNA. The RM said, [Staff A] said the doctor had concerns. She told me that the DON was going to take care of it. The DON was at the facility and was taking care of it. The RM confirmed she deals with abuse and neglect allegations. Stating, It is a team process. When asked what she would do, she said she would not assign a male to the room, and she would go to the patient and see what her concerns were. She stated, I would want to know why she doesn't want a male. She said, I would investigate by starting the grievance process. I would speak to the resident to determine what had happened. She confirmed, An allegation of rape is immediately called in. The RM said part of her process would be to call the abuse hotline and perform a skin assessment of the resident. She went on to say, I would start a paper trail that would include witness statements from staff. The RM said she is responsible for training and had started abuse and neglect training yesterday (11/29/2022). On 11/30/2022 at 1:27 p.m. an interview was conducted with the Interim Director of Nursing (IDON). She said due to the investigation, she was asked last night around 6:00 p.m. if she could take the interim position The IDON said the DON was aware of the incident and did not notify the NHA or start the abuse protocol. The IDON said Staff A was directly involved on that day and she was the one the doctor talked to. Staff A was informed by the doctor who used the word rape. Staff A then informed the DON of the doctor's statement. The IDON said if this had been reported to her, she would like to know first-hand information. She said it takes only a minute to see the patient and talk to the patient. The IDON stated, She would want firsthand information. She would have conducted an interview and would have assessed the patient. She would investigate why a resident wouldn't want a particular staff in the room. On 11/30/2022 at 1:41 p.m. an interview was conducted with Staff D, CNA. She confirmed she worked on Thanksgiving Day. She said she went into Resident #17's room with Staff A, LPN while she was gathering some bags. She said she overheard Resident #17 wanted a female instead of a male aide. Staff D said she had never mentioned that before and had never mentioned anything about her past. Staff D said the resident seemed emotional and was upset a little. Staff D stated, She was telling the nurse she prefers a female over a male aide. Felt more comfortable with a female. Staff D said, I have taken care of her since then and has seemed normal since that day. Staff D continued, Later that same day a little after breakfast the resident told me that she had told the male aide she wanted a female, and said he kept going. She said she was crying and that she didn't want a male. She wanted a female. She said he just kept going. He just kept cleaning her and he kept going. She said the resident stated, You are a female like me would you want a male changing you. Staff D said the resident said she can't protect herself if something happens because she is an elderly old lady. Staff D said she did not notice any bruising and that she didn't seem frightened. Staff D said she told another aide (Staff E, CNA). Staff D said Resident #17 is alert and oriented and not forgetful or confused. On 11/30/2022 at 2:00 p.m. an interview was conducted with Staff E, CNA and she confirmed she worked on 11/24/2022 -Thanksgiving Day and knows Resident #17 stating, I take care of her all the time. She said she could not recall if the resident had voiced a concern to her about not having a male caregiver. She said on 11/24/2022 she was in Resident #17's room caring for her roommate when Staff A, LPN entered the room. Staff E said she could overhear Staff A ask Resident #17 if she preferred a female and Resident #17 responded, Yes. Staff E said she heard Staff A say, OK we won't have a male taking care of you. Staff E said Resident #17 was upset, she looked like she was just not happy. Staff E said on that day she noticed the resident was a little different and was upset. She did not verbalize to me what happened. Staff E said she remembered her and her roommate at the time both verbally said they didn't want a male in the room. Resident #17's roommate was discharged that day adding that she was an older resident also. She said Resident #17 was very alert. On 11/30/22 at 3:12 p.m. an interview was conducted with Resident #17's family member who is her documented emergency contact. The family member said she visits the resident daily, and when she is not there another family member is. She stated, [Resident#17] and I are very close. The family member confirmed on 11/24/2022 she received a phone call from the facility nurse, Staff A. She said there was an incident that happened when [Resident #17] was being changed by a male CNA. She said [Resident #17] was very upset and had been crying all morning. Staff A, LPN had assured her [Resident #17] was okay, but she was upset because she did not want him to do it. The family member said she also spoke to the resident who told her the CNA was Staff C. The family member said on 10/26/2022 Staff C performed the resident's admission intake stating, We both remembered him. She said she told Staff C that she wanted a female caregiver for [Resident #17], and he stated, Oh that's right you do not want a man to change you . The family member stated, He knew she did not want men providing her care. The family member said, I told [Resident #17] he did not care if she preferred female caregivers. Continuing, the family member stated, [Resident #17] said on 11/24/2022 [Staff C] told her if she did not let him change her brief then she had to wait until shift change. [Resident #17] told him fine. I will wait. [Resident #17] said then all of a sudden, he pulled her gown and continued to change her. She said she tried to reach for the buzzer to call staff and she could not reach it because he had moved the blanket to the side. The family member stated, [Resident #17] kept saying No but he would not listen. [Resident #17] told me she said she felt violated, it was her dignity and that she felt helpless. She said [Resident #17] thought she had a right not to have this man touching her. She said [Resident #17] did say she was not touched inappropriately but she did not want him providing care. The family member stated, The resident told her the doctor came in her room that morning and she was crying. [Resident #17] told me she had told him what had happened. The family member stated a couple weeks prior she spoke to Staff F, LPN a nurse who was working the weekend. He told me [Resident #17] said she did not want male staff providing her care. The family member stated that she shared with Staff F the resident's prior trauma, stating, [Resident #17] was married young, and her husband was very abusive. She said Staff F appeared uncomfortable when he heard her concerns. He said he would make note of it. The family member stated, He said word for word there was no reason why we can't make that accommodation here. This conversation happened a couple weeks prior to the incident. The family member said, [Resident #17] has always been independent and was in her right mind . and to have someone mock her feelings . saying oh yeah you are the one who doesn't want male caregivers, he was very condescending. The family member stated she did not realize the CNA would be like that with her. The family member reiterated the resident had past trauma related to being in an abusive marriage. She stated, Him forcing her during care caused her to be upset. The family member confirmed the resident had mentioned she did not feel comfortable with male caregivers several times to staff and to her. The family member confirmed she received a phone call from the DON on 11/29/2022 and stated, I was frustrated. She alleged that this was the first time she had been notified of the resident's preference. I asked the DON why this was not in her record . Why was it not reported? . Why wasn't there an incident report? The family member said, It bothers me. Where there is smoke there is fire. If they are working that hard to cover it up, what else are they hiding? What about residents who cannot speak for themselves? The family member said when she spoke with [Resident#17], she stated she was not going to allow this to happen. She felt helpless. She was crying. Resident #17 said, I told him to stop, and he ignored my request. The family member stated she felt Resident #17 was safe but was scared about the repercussions. She said, Even if that male caregiver is not here, he has his buddies. I just want [Resident #17] to be safe. The family member confirmed when Resident #17 was admitted [DATE] she informed Staff C, CNA of the resident's gender preference for care. On 11/30/2022 at 4:01 p.m. an interview was conducted with the NHA. He stated Staff C, CNA was interviewed on 11/29/2022. Staff C said he was providing care to Resident #17 on Thanksgiving morning and that she did not want him to do it, she kept saying No. He stated he felt he did not want to leave her without clothes on and wanted to make sure she was dry. The NHA stated they identified an educational opportunity. The NHA said, I let him know he should have left her, honor her request and let the nurse know. The NHA stated they initiated education and suspended the CNA. On 12/01/2022 at 11:27 a.m. a phone interview was conducted with Staff F, LPN. Staff F said he knew Resident #17 and indicated he worked on her unit a few times. He said he recalled speaking with the resident and her [family member]. He said he went into the room to inform the [family member] and the resident he had requested orders from the physician. He said they identified she had blood in her brief, and he was concerned about a gastroesophageal bleed. Staff F said when he was in the room the [family member] told him Resident #17 had a very abusive husband. She said she did not want any male aides to go in her room. Staff F could not recall the exact day of the conversation but stated, It was on the same day I received the order for the STAT (immediately) blood work. Staff F continued and said after he was informed by the [family member] of the resident's preference, he stated, I informed [Staff G Registered Nurse (RN)] the weekend supervisor about it right away. He said he then added it to the on shift report. He said the weekend reports are addressed on Monday mornings and indicated at that time the resident's care plan would be updated. Staff F denied he documented anything in Resident #17's medical record related to the conversation related to the resident's preference on the gender of caregivers. Medical record review revealed on 11/13/2022 Staff F, LPN requested and received orders for Resident #17 for a complete blood count (CBC) due to bright red blood in brief. Thus, indicating the facility staff were notified 12 days prior of the resident's gender preference on caregivers. Facility Actions to Remove Immediate Jeopardy: On 12/02/2022 at 4:45 p.m. a Removal Plan for F 610 was received which was verified and found to be acceptable. (Photographic Evidence Obtained) Review of the removal plan revealed: December 2,2022 in response to Immediate Jeopardy concerns identified during re-licensure survey F610 - * 11/29/22 -At around 1:30 p.m. Surveyor brought to NHA attention a potential allegation of abuse that occurred on 11/24/2022 (Thanksgiving Day). Upon investigation, a physician progress note in [medical software] stated that resident had concerns with potential male C.N.A, note dated 11/24/22. * 11/29/22 investigation initiated; CNA suspended immediately pending investigation. * Investigation revealed on 11/24/22 physician communicated with licensed nurse (LPN) that there was potential issue occurring with a resident and to please escalate to clinical leadership. The LPN went immediately and talked to the resident about her concerns. The resident stated that a male C.N.A. came in to change her brief on 11-7 shift and she stated no and the C.N.A proceeded, and she stated that No mean no and didn't want a male C.N.A. * That nurse then called the DCS around 10:30 a.m. on 11/24/22 and notified her of resident concerns. * 11/29/22-At around 6:00 p.m. with the presence of the HRD and administrator the DCS was suspended pending investigation due to failure to follow community reporting process pertain to abuse allegation. * 11/29/22-Immediate was submitted to AHCA (Agency for Health Care Administration). * 11/29/22 -Police notification * 11/29/22 DCF notification * On 11/29/2022 - Education was initiated with all staff by department leadership regarding Abuse, Neglect, Exploitation & Misappropriation, recognizing and reporting abuse per community policy/resident right, grievances and communication. * 11/30/2022- Acting Director of Nursing interviewed residents that were cared for by the alleged perpetrator. * On 11/30/2022 Resident who made allegation was seen by the psychologist however declined visit. He is to follow up week of 12/05/2022. * On 11/30/2022 ADHOC QAPI was completed with the Medical Director, NHA, acting DON, QA nurse, Unit Manager, SS, Clinical Records, Admissions, Business Office Manager, Rehab Manager, Dining Manager, MDS, Housekeeping, Maintenance, Activities, Human Recourses were present. * 12/01/2022 Education provided to acting Director of Nursing and NHA Trauma Informed Care/Brief Trauma Questionnaire/Behavioral and Emotional status by Regional Nurse. * 12/01/2022 Education has been completed for all SNF staff recognizing and reporting abuse per community policy/residents' rights, grievances, and communication. * 12/1/2022 Reviewed and revised Community Specific Brief Trauma Questionnaire. * 12/1/2022 Education conducted by acting DON with licensed nursing staff pertaining to: o Change in condition o Trauma Informed Care/Behavioral and Emotional Status o Brief Trauma Questionnaire o Resident Preference Interview * 12/02/2022 Education conducted with IDT by NHA & Acting DON o Change in condition o Trauma Informed Care/Behavioral and Emotional Status o Brief Trauma Questionnaire o Resident Preference interview with all new admissions * 12/02/2022- ADHOC QAPI (Quality Assessment Performance Improvement) * 12/2/22 New Brief Trauma Questionnaire to be completed with all current residents. * 12/2/22 Abuse investigation finalized by NHA. 12/2/22 Immediate Action: Education as noted above and DON/Designee will conducted a weekly quality review of 5 residents/responsible party weekly for 4 weeks, and then every 2 weeks for 2 months. Questions to include: 1. Has anyone mistreated you, or loved one since a resident here? 2. Has anyone threatened your or your loved one since a resident here? 3. Are you fearful of anyone while residing here? 4. For residents what are not interviewable, complete a skin evaluation and answer, does the resident present with any of the following: a. Distress b. Unusual/suspicious injuries c. Interview with family using above questions. Verification of the facility's removal plan was conducted by the survey team on 12/02/2022. Interviews were conducted with Staff A, Licensed Practical Nurse-First Shift (FS), Staff H Business office Manager, Staff I, CNA (FS), Staff J, CNA(FS), Staff K, CNA (FS), Staff L, CNA(FS), Staff N, CNA(FS) Staff M, Life Enrichment Manager, Staff O, Physical Therapist Assistant (PTA), Staff T, Director of Rehab, Staff U, PTA, Staff V, Occupational Therapy Assistant (COTA), Staff W, OTA, Staff X, Speech Therapist, Staff Y, Dietary Clerk, Staff Z, Dietary Clerk, Staff AA, Housekeeping Supervisor, Staff BB, Receptionist, Staff CC, Maintenance Manager, Staff DD, CNA(FS), Staff EE, CNA(FS), Staff FF, CNA(FS), Staff GG Licensed Practical (LPN/FS), Staff HH, CNA Second shift (SS), Staff II, CNA (SS), Staff JJ, CNA(SS), Staff KK, CNA(SS), Staff LL, CNA(SS), Staff MM, CNA(SS) Third shift (TS), Staff NN, CNA(SS/TS), Staff OO, Licensed Practical Nurse (PM), Staff PP, LPN (SS), Staff QQ, LPN/SS at the facility regarding the policies and procedures on Abuse, Neglect, and Misappropriation, resident rights and resident preferences. All staff were able to define abuse, neglect and misappropriation, and resident rights. They knew who the allegation should be reported to stating, the NHA, SSD, RM, and their direct supervisor. They knew the hotline abuse phone number and where the number [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record, incident logs, policy and procedure review, interviews with administration, nursing staff, Resident #17, the resident's physician, and the resident's representative, the facility failed to follow professional standards of practice to maintain the resident's highest practical and psychosocial well-being by not ensuring their Behavioral Health Services for Trauma Informed Care was followed for one resident (#17) of two residents reviewed for abuse. The facility failed to take actions and respond to a family member and cognitively intact resident's request for female caregivers only. The first request was made on 10/26/2022 by the family member and the resident to the Staff C, Certified Nursing Assistant (CNA), who performed the admission intake; the second request was made on 11/13/2022 by the family member and the resident to a Staff F, Licensed Practical Nurse (LPN), who assured the resident and family member a male aide would not provide care. At that time, the LPN was informed of the resident's past traumatic history by the family member, which spanned over twenty-five years and consisted of physical abuse by a spouse who used her as a punching bag. On 11/24/2022 at 2:56 a.m., eleven days after Staff F, LPN was notified of the resident's past traumatic history, a male aide entered her bedroom to provide incontinence care. The resident told him she would wait, but the male aide failed to honor the resident's rights, dignity, and psychosocial well-being. As he pushed back her gown and provided incontinent care, she cried out repeatedly for him to stop; the aide did not stop. As he continued, the resident continued to cry telling him no, resulting in physical abuse, and re-traumatization. The resident informed her Medical Doctor, stating, I was raped, violated. No means no. Resident #17's admission Record revealed she was in her early nineties, cognitively intact, and was admitted for short term rehabilitation with a discharge plan to go back to her own home, where she had previously been independent. Interviews with the resident's family member revealed the resident was a trauma survivor, with a history that included over 25 years of physical abuse. This failure resulted in the determination of Immediate Jeopardy starting on 11/24/2022. The findings of Immediate Jeopardy were determined to be removed on 12/02/2022 after verification of the implementation of removal action(s). The scope and severity was reduced to a D (no actual harm with potential for more than minimal harm). Findings included: Cross reference F600, F609, F610, and F835 Review of a policy titled, Subject: Trauma Informed Care Approved: ADHOC QAPI 12/02/2022 revealed: Intent: It is the policy of the facility to ensure each resident receives the care and services to attain and maintain the highest practicable psycho-social well-being. Procedure: 1. The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care, in accordance with professional standards of practice and accounting for residents' experiences and preferences, in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Review of a policy titled, Program, dated 12/02/2022, revealed: Subject: Trauma Informed Care Program Intent: it is the policy of the facility to ensure residents receives care and services to attain and maintain the highest practicable psycho-social well-being. Procedure: 1. All residents admitted to facility will have a Brief Trauma Questionnaire (BTQ) preformed at the time of admission. 2. When trauma has been identified the Social Service Director or Designee will inform the resident's attending physician and request both Psychiatry and Psychology Services for the resident. 4. Through resident interview and Psych Services, a comprehensive Plan of Care will be developed with the Interdisciplinary Team to reduce the risk of re-traumatization. 5. All staff will receive education in Orientation upon hire and annually. Review of the policy titled, Behavioral Health Services, revision date February 2017, revealed: Policy Statement 1. The facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable, physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Policy Interpretation and Implementation 1. Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care. 2. Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care. 3. Residents who do not display symptoms of, or have not been diagnosed with, mental, psychiatrist, psychosocial adjustment, substance abuse or post-traumatic stress disorder(s) will not develop behavioral disturbances that cannot be attributed to a specific clinical condition that makes the pattern unavoidable. 4. Staff must promote dignity, autonomy, privacy, socialization and safety as appropriate for each resident and are trained in ways to support residents in distress. 5. Behavioral health services are provided by staff who are qualified and competent in behavioral health and trauma-informed care. 6. Staff are scheduled in sufficient numbers to manage resident needs throughout the day, evening, and night. On 11/29/2022 at 12:10 p.m. an interview was conducted with Resident #17. She was observed from the hallway lying in bed wearing a hospital gown. She made eye contact and was receptive to an interview. She said she was waiting to get dressed as she pulled at her hospital gown, and that she needed to get ready for therapy. When the resident was asked if she was treated with respect and dignity, she stated, A male aide (Staff C) started to perform incontinent care; I told him no. I told them (Staff C and D) before I only wanted females to care for me. But he proceeded to change my brief anyway. I told him no. At that time, she made eye contact with the surveyor and stated, No means no. She said she had cried and cried no, but he wouldn't stop. She stated, I felt like I was raped. When asked if she told anyone she stated, I told my doctor, and my doctor told them. She said it had occurred just a couple of days ago. She said she has not seen the male nurse since, but, she continued, I see those men walking past my room and looking in. They're just walking by with nothing to do. At that time the resident lowered her head slightly and stated, I don't want to answer any more questions. Resident #17's bed was positioned by the door and when the door is open, she is able see into the hallway. On 11/30/22 at 3:12 p.m. an interview was conducted with Resident #17's family member who is her documented emergency contact. The family member said she visits the resident daily, and when she is not there another family member is. She stated, [Resident#17] and I are very close. The family member confirmed on 11/24/2022 she received a phone call from the facility nurse, Staff A, LPN. She said there was an incident that happened when [Resident #17] was being changed by a male CNA (Staff C, CNA). She said [Resident #17] was very upset and had been crying all morning. Staff A, LPN had assured her [Resident #17] was okay, but she was upset because she did not want him to do it. The family member said she also spoke to the resident who told her the CNA was Staff C. The family member said on 10/26/2022 Staff C performed the resident's admission intake stating, We both remembered him. The family member reiterated the resident had past trauma related to being in an abusive marriage. She stated, [Resident #17] was in an abusive marriage for twenty-five years, he used her as his own punching bag. She stated, Him (Staff C) forcing her during care caused her to be upset. The family member confirmed the resident had mentioned she did not feel comfortable with male caregivers several times to staff and to her. She said she told Staff C that she wanted a female caregiver for [Resident #17], and he stated, Oh that's right you do not want a man to change you . The family member stated, He knew she did not want men providing her care. The family member said, I told [Resident #17] he did not care if she preferred female caregivers. Continuing, the family member stated, [Resident #17] said on 11/24/2022 [Staff C] told her if she did not let him change her brief then she had to wait until shift change. [Resident #17] told him fine. I will wait. [Resident #17] said then all of a sudden, he pulled her gown and continued to change her. She said she tried to reach for the buzzer to call staff and she could not reach it because he had moved the blanket to the side. The family member stated, [Resident #17] kept saying No but he would not listen. [Resident #17] told me she said she felt violated, it was her dignity and that she felt helpless. She said [Resident #17] thought she had a right not to have this man touching her. She said [Resident #17] did say she was not touched inappropriately but she did not want him providing care. The family member stated, The resident told her the doctor came in her room that morning and she was crying. [Resident #17] told me she had told him what had happened. The family member stated a couple weeks prior she spoke to Staff F, LPN a nurse who was working the weekend. He told me [Resident #17] said she did not want male staff providing her care. The family member stated that she shared with Staff F, LPN the resident's prior trauma, stating, [Resident #17] was married young, and her husband was very abusive. She said Staff F appeared uncomfortable when he heard her concerns. He said he would make note of it. The family member stated, He said word for word there was no reason why we can't make that accommodation here. This conversation happened a couple weeks prior to the incident. The family member said, [Resident #17] has always been independent and was in her right mind . and to have someone mock her feelings . saying oh yeah you are the one who doesn't want male caregivers, he was very condescending. The family member stated she did not realize the CNA would be like that with her. The family member reiterated the resident had past trauma related to being in an abusive marriage. She stated, Him forcing her during care caused her to be upset. The family member confirmed she received a phone call from the Director of Nursing (DON) on 11/29/2022 and stated, I was frustrated. She alleged that this was the first time she had been notified of the resident's preference. I asked the DON why this was not in her record . Why was it not reported? . Why wasn't there an incident report? The family member said, It bothers me. Where there is smoke there is fire. If they are working that hard to cover it up, what else are they hiding? What about residents who cannot speak for themselves? The family member said when she spoke with [Resident#17], she stated she was not going to allow this to happen. She felt helpless. She was crying. Resident #17 said, I told him to stop, and he ignored my request. The family member stated she felt Resident #17 was safe but was scared about the repercussions. She said, Even if that male caregiver is not here, he has his buddies. I just want [Resident #17] to be safe. The family member confirmed when Resident #17 was admitted on [DATE] she informed Staff C, CNA of the resident's gender preference for care. Review of the Medical Director's progress note, dated 11/24/2022 at 9:18 a.m., revealed S: [subjective] resident concern about a male nurse. On 11/29/2022 at 2:26 p.m. a phone interview was conducted with the facility's Medical Director (MD), who confirmed he knew Resident #17 and saw her on 11/24/2022 between 7:00 a.m. and 8:30 a.m. He said she appeared agitated and told him that morning she had been wet and soiled. She said a nurse had cleaned her and that it was a male nurse. She said she didn't want a male nurse. The MD said the facility always honors resident preferences. He stated, That really troubled me. The MD said Resident #17 told him, A man wiped and cleaned me against my wishes. It was a male. I can't have males down there. She stated, He changed me, and he was not supposed to. I told him to stop, and he just kept going. The MD said she was agitated and asked not to be cleaned as he kept cleaning her and said she felt violated. The MD said he asked the resident if it was okay if he examined her. She told me that was different. The MD stated this was very concerning to him, and he immediately said something to nursing leadership. He said he was 100% confident he spoke to the nurse. The MD stated he reported to the charge nurse (Staff A) We have a potential situation here. The MD went on to state, I told them they had an issue that needed to be escalated to the Director of Nursing. The MD said the nurse (Staff A) confirmed to him that it would be escalated. He said he documented it and instructed the charge nurse (Staff A) to document it. He said he was told they were working on it and thought he heard them say the Director of Nursing was coming in. The MD stated, We have rules about this, no means no. When asked about his expectation he stated, Reporting is expected to be done. He confirmed this is the only facility he goes to, and he is the facility's Medical Director. The MD confirmed on 11/24/2022 Resident #17 was not doing well and said the resident was outside of her normal demeanor. He was informed that the survey team was not able to locate documentation of Resident #17's allegation. The MD indicated he was surprised of this and repeated, They said they were going to escalate it. Review of Resident #17's admission Record revealed, she was geriatric in age and was transferred from a local hospital on [DATE] after having an altered mental status. Her admission Record showed she was admitted for short term rehabilitation with diagnoses that included depression. Review of Resident #17's admission Minimum Data Set (MDS), dated [DATE], Section C Cognitive Patterns showed the Brief Interview for Mental Status (BIMS) score coded as a 14. The code of 14 indicated cognitively intact. Medical record was omitted of documentation related to Resident #17 preference on a caregiver gender. On 11/29/2022 at 2:35 p.m. an interview was conducted with the DON on the incident that occurred on 11/24/2022. The DON said she was aware the Medical Director spoke to Staff A (Licensed Practical Nurse) about his concern related to Resident #17. The DON said she was scheduled to work that day and she received a phone call from Staff A. She said at that time she was already in route to the facility. The DON said after she arrived at the facility, she spoke to Staff A. The DON stated, [Staff A] told me that everything was fixed. She said Staff A stated that She had rearranged the aide assignment and had spoken to the resident. The resident was okay with the schedule change that no male aide would be providing her care. The DON denied she started a grievance. She denied she spoke to the resident. The DON stated, It was just a patient preference, and it was taken care of. On 11/30/2022 at 12:25 p.m. a phone interview was conducted with Staff A, LPN. She confirmed she worked on 11/24/2022 and received a verbal report from the Medical Director. She stated, The MD came to me between 8:30 a.m. and 9:30 a.m. and told me there was an issue that needed to be taken care of. He stated to me that [Resident #17] was very upset because she had been raped. I said, Excuse me, did you say rape? He stated Yes. He said she used the word rape. Staff A stated, The MD told me he needed it handled right away. The MD said [Resident #17] told the male staff to stop. Staff A, LPN said she spoke to the resident and that she (Resident #17) said she was okay. I asked her, Do you want me to do anything different. She said that Resident #17 said, I'm fine I just don't want a male taking care of me. I do not want a male touching me down there. I told her that no male aide will take care of her and it will be in her plan of care. Continuing, Staff A stated, She told me that she wanted to be left alone, she did not want to be bothered. When asked what type of assessment was performed, she indicated a set of vital signs, and she observed the resident and did not see any bruising to her face or hands. Staff A confirmed she did not perform a full skin assessment. She said Resident #17's demeanor appeared calm, saying she was not disheveled, was alert and oriented, and her mood appeared okay. Staff A said it was her first time working with the resident. Staff A said the DON was in the building between 9:00 a.m. and 9:30 a.m. stating, I told her that the Medical Director had concerns and the resident said she felt as though she was raped. The DON said he does not like it when people throw that word around. Staff A said, I also told her that I had spoken to the [family member]. I told her the concerns of the resident not wanting a male aide. The [family member] said I don't know why she is like that lately but thank you for letting me know. Staff A continued, I additionally called the Risk Manager, who is also the Assistant Director of Nursing (ADON) and left her a message. Staff A said later that day she spoke to the ADON, and I told her I had informed the DON. Staff A said the DON told her she would handle it and take care of it. Staff A stated, The ADON had asked if I documented it, I told her the DON had said she would take care of it. Staff A denied seeing the DON going to the resident room after she had given her the report. Staff A confirmed she received abuse training in April 2022. She said, If someone alleges rape, we are to inform the parties that are involved, and that is what I did. If a resident alleges any form of abuse, the expectation is to call the hotline. Staff A stated she Figured the DON was handling it because she was here. On 11/29/2022 at 3:14 p.m. an interview was conducted with the Social Service Director (SSD). She said she talked to the resident today (11/29/2022) and asked her if anything happened. The SSD said, She told me a couple days ago; a male aide came in to change her and she did not want him to change her. She said she cried and told the doctor, who told the nurse. The resident said she hadn't had a male aide since. The SSD said the resident reported that nothing inappropriate happened. The SSD said the resident's family member was in the room during that time and stated years ago she had a bad encounter with a male aide, stating, It happened somewhere else. The SSD said the resident said she has not had any male caregivers giving her care since the incident happened. She indicated on Thursday (11/24/2022) the resident's care plan had been updated to reflect no male aides. The SSD confirmed a grievance form was not filed. When asked what her expectation was, she stated, I expect a male aide would stop and get a female. The NHA (Nursing Home Administrator) was present at the time of the interview and stated, Any concerns should be documented, and a grievance should be filed. He confirmed it was not transferred to paper and did not know why. On 11/30/2022 at 1:27 p.m. an interview was conducted with the Interim Director of Nursing (IDON). Staff A was informed by the doctor who used the word rape. Staff A then informed the DON of the doctor's statement. On 11/30/2022 at 1:41 p.m. an interview was conducted with Staff D, CNA. She confirmed she worked on Thanksgiving Day. She said she went into Resident #17's room with Staff A, LPN while she was gathering some bags. She said she overheard Resident #17 wanted a female instead of a male aide. Staff D said she had never mentioned that before and had never mentioned anything about her past. Staff D said the resident seemed emotional and was upset a little. Staff D stated, She was telling the nurse she prefers a female over a male aide. Felt more comfortable with a female. Staff D said, I have taken care of her since then and has seemed normal since that day. Staff D continued, Later that same day a little after breakfast the resident told me that she had told the male aide she wanted a female, and said he kept going. She said she was crying and that she didn't want a male. She wanted a female. She said he just kept going. He just kept cleaning her and he kept going. She said the resident stated, You are a female like me would you want a male changing you. Staff D said the resident said she can't protect herself if something happens because she is an elderly old lady. Staff D said she did not notice any bruising and that she didn't seem frightened. Staff D said she told another aide (Staff E, CNA). Staff D said Resident #17 is alert and oriented and not forgetful or confused. On 11/30/2022 at 2:00 p.m. an interview was conducted with Staff E, CNA and she confirmed she worked on 11/24/2022 -Thanksgiving Day and knows Resident #17 stating, I take care of her all the time. She said on 11/24/2022 she was in Resident #17's room caring for her roommate when Staff A, LPN entered the room. Staff E said she could overhear Staff A ask Resident #17 if she preferred a female and Resident #17 responded, Yes. Staff E said she heard Staff A say, OK we won't have a male taking care of you. Staff E said Resident #17 was upset, she looked like she was just not happy. Staff E said on that day she noticed the resident was a little different and was upset. She did not verbalize to me what happened. Staff E said she remembered her and her roommate at the time both verbally said they didn't want a male in the room. She said Resident #17 was very alert. She noticed more of the women in therapy prefer not to have men in the room. Staff E said she talked to Staff C, before about it and wanted to switch assignments. She said I told Staff C, CAN, Some of the women just don't feel comfortable with a man taking care of them. Staff C said she did not recall when it conversation occurred. On 11/30/2022 at 4:01 p.m. an interview was conducted with the NHA. He stated Staff C, CNA was interviewed on 11/29/2022. Staff C said he was providing care to Resident #17 on Thanksgiving morning and that she did not want him to do it, she kept saying No. He stated he felt he did not want to leave her without clothes on and wanted to make sure she was dry. The NHA stated they identified an educational opportunity. The NHA said, I let him know he should have left her, honor her request and let the nurse know. The NHA stated they initiated education and suspended the CNA. On 12/01/2022 at 11:27 a.m. a phone interview was conducted with Staff F, LPN. Staff F said he knew Resident #17 and indicated he worked on her unit a few times. He said he recalled speaking with the resident and her [family member]. He said he went into the room to inform the [family member] and the resident he had requested orders from the physician. Staff F said when he was in the room the [family member] told him Resident #17 had a very abusive husband. She said she did not want any male aides to go in her room. Staff F could not recall the exact day of the conversation but stated, It was on the same day I received the order for the STAT (immediately) blood work. Staff F continued and said after he was informed by the [family member] of the resident's preference, he stated, I informed [Staff G Registered Nurse (RN)] the weekend supervisor about it right away. He said he then added it to the on shift report. He said the weekend reports are addressed on Monday mornings and indicated at that time the resident's care plan would be updated. Staff F denied he documented anything in Resident #17's medical record related to the conversation related to the resident's preference on the gender of caregivers. Medical record review revealed on 11/13/2022 Staff F, LPN requested and received orders for Resident #17 for a complete blood count (CBC). Thus, indicating the facility staff were notified 12 days prior of the resident's gender preference on caregivers. On 12/02/2022 at 9:51 a.m. a return phone call was received from Staff G, RN Weekend Supervisor. She said, I did not know anything about the patient and was unaware of a patient preference related to not wanting a male aide. Staff G stated she did not recall Staff F, LPN telling her about a resident's preference for a caregiver. She denied she was notified. She stated, [Staff F LPN] does not let me know about his residents. She added last Saturday, 11/26/2022, at the nursing station, I had heard the aides, [Staff F] and [Staff A] talking about someone did not want a male aide. They did not mention the patient's name. Facility Actions to Remove Immediate Jeopardy: On 12/02/2022 at 4:45 p.m. a Removal Plan for F 699 was received which was verified and found to be acceptable. (Photographic Evidence Obtained) Review of the removal plan revealed: December 2, 2022 in response to Immediate Jeopardy concerns identified during re-licensure survey F699 * 11/29/22 -At around 1:30 p.m. Surveyor brought to NHA attention a potential allegation of abuse that occurred on 11/24/2022 (Thanksgiving Day). Upon investigation, a physician progress note in [medical software] stated that resident had concerns with potential male C.N.A, note dated 11/24/22. * 11/29/22 investigation initiated; CNA suspended immediately pending investigation. * Investigation revealed on 11/24/22 physician communicated with licensed nurse (LPN) that there was potential issue occurring with a resident and to please escalate to clinical leadership. The LPN went immediately and talked to the resident about her concerns. The resident stated that a male C.N.A. came in to change her brief on 11-7 shift and she stated no and the C.N.A proceeded, and she stated that No mean no and didn't want a male C.N.A. * That nurse then called the DCS around 10:30 a.m. on 11/24/22 and notified her of resident concerns. * 11/29/22-At around 6:00 p.m. with the presence of the HRD and administrator the DCS was suspended pending investigation due to failure to follow community reporting process pertain to abuse allegation. * 11/29/22-Immediate was submitted to AHCA (Agency for Health Care Administration). * 11/29/22 -Police notification * 11/29/22 DCF notification * On 11/29/2022 - Education was initiated with all staff by department leadership regarding Abuse, Neglect, Exploitation & Misappropriation, recognizing and reporting abuse per community policy/resident right, grievances and communication. * 11/30/2022- Acting Director of Nursing interviewed residents that were cared for by the alleged perpetrator. * On 11/30/2022 Resident who made allegation was seen by the psychologist however declined visit. He is to follow up week of 12/05/2022. * On 11/30/2022 ADHOC QAPI was completed with the Medical Director, NHA, acting DON, QA nurse, Unit Manager, SS, Clinical Records, Admissions, Business Office Manager, Rehab Manager, Dining Manager, MDS, Housekeeping, Maintenance, Activities, Human Recourses were present. * 12/01/2022 Education provided to acting Director of Nursing and NHA Trauma Informed Care/Brief Trauma Questionnaire/Behavioral and Emotional status by Regional Nurse. * 12/01/2022 Education has been completed for all SNF staff recognizing and reporting abuse per community policy/residents' rights, grievances, and communication. * 12/1/2022 Reviewed and revised Community Specific Brief Trauma Questionnaire. * 12/1/2022 Education conducted by acting DON with licensed nursing staff pertaining to: o Change in condition o Trauma Informed Care/Behavioral and Emotional Status o Brief Trauma Questionnaire o Resident Preference Interview * 12/02/2022 Education conducted with IDT by NHA & Acting DON o Change in condition o Trauma Informed Care/Behavioral and Emotional Status o Brief Trauma Questionnaire o Resident Preference interview with all new admissions * 12/02/2022- ADHOC QAPI (Quality Assessment Performance Improvement) * 12/2/22 New Brief Trauma Questionnaire to be completed with all current residents. * 12/2/22 Abuse investigation finalized by NHA. 12/2/22 Immediate Action: Education as noted above and DON/Designee to be completed by 12/2/22 with licensed nursing associates. New residents will be evaluated utilizing the Brief Trauma Questionnaire with care plan update as required. The DON/designee will conduct audit of new admission daily x 12 weeks to review for questionnaire being completed and care plan updated. Verification of the facility's removal plan was conducted by the survey team on 12/02/2022. Interviews were conducted with Staff A, Licensed Practical Nurse-First Shift (FS), Staff H Business office Manager, Staff I, CNA (FS), Staff J, CNA(FS), Staff K, CNA (FS), Staff L, CNA(FS), Staff N, CNA(FS) Staff M, Life Enrichment Manager, Staff O, Physical Therapist Assistant (PTA), Staff T, Director of Rehab, Staff U, PTA, Staff V, Occupational Therapy Assistant (COTA), Staff W, OTA, Staff X, Speech Therapist, Staff Y, Dietary Clerk, Staff Z, Dietary Clerk, Staff AA, Housekeeping Supervisor, Staff BB, Receptionist, Staff CC, Maintenance Manager, Staff DD, CNA(FS), Staff EE, CNA(FS), Staff FF, CNA(FS), Staff GG Licensed Practical Nurse (LPN/FS), Staff HH, CNA Second shift (SS), Staff II, CNA (SS), Staff JJ, CNA(SS), Staff KK, CNA(SS), Staff LL, CNA(SS), Staff MM, CNA(SS) Third shift (TS), Staff NN, CNA(SS/TS), Staff OO, Licensed Practical Nurse (PM), Staff PP, LPN (SS), Staff QQ, LPN/SS at the facility regarding the policies and procedures on Abuse, Neglect, and Misappropriation, resident rights and resident preferences. All staff were able to define abuse, neglect and misappropriation, and resident rights. They knew who the allegation should be reported to stating, the NHA, SSD, RM, and their direct supervisor. They knew the hotline abuse phone number and where the number could be located within the facility. They verbalized knowing the need for timely reporting of an allegation and verbalized knowledge on the facility policies. They confirmed if a resident has a specific preference their preference would be honored by communicating to the nurse. Nurses indicated it would be documented and addressed immediately to ensure the interdisciplinary team were aware of it. The staff members confirmed the education had included trauma-based care. If the any staff were informed of would immediately report it to their supervisor. On 12/02/2022 after interview and review of the Training log it was determined prior to the exit the facility had conducted 100% of education to their employees. Based on verification of the facility's Immediate Jeopardy removal plan the Immediate Jeopardy was determined to be removed on 12/02/2022 and the non-compliance was reduced to a s[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews with nursing and administrative staff, the resident and the resident's physician, the resident's representative, the resident's psychiatric practitioner, and the facility's Medical Director, the facility Administration failed to use its resources effectively to lead and direct the overall operations of the facility in accordance with resident needs, regulations, and company policies related to abuse for one resident (#17) of two residents reviewed for abuse. On 11/24/2022, Resident #17, an elderly female who was cognitively intact and dependent on staff for incontinent care and services, reported a male Certified Nursing Assistant (Staff C, CNA) performed incontinence care that she had repeatedly refused. Resident #17 reported the event to the Medical Director, who then reported it to the supervising nursing staff. The supervising staff (Staff A, Licensed Practical Nurse) immediately reported to the Director of Nursing (DON). The DON failed to investigate, report, protect and take corrective action to prevent similar occurrence. Facility administration determined this was not abuse, did not fully investigate, report, protect, and take corrective action to prevent a similar occurrence. The failure of the Administration to follow the Centers for Medicare and Medicaid Services (CMS) guidelines and to implement their abuse policies created a likelihood that placed all residents at risk of a similar occurrence, and which could lead to serious injury or serious harm such as serious psychosocial harm and re-traumatization. This resulted in the findings of Immediate Jeopardy starting on 11/24/2022. The immediacy was removed on 12/02/2022 after verification of the implementation of removal actions. The scope and severity was reduced to a D (no actual harm with potential for more that minimal harm). Findings included: Cross reference F600, F609, F610 and F699. Review of the Job Description Position Title: Director of Nursing, Department: Health Center, Supervisor: Executive Director Revision Date: 1/2/2022. General Summary: The Director of Nursing is responsible for the overall supervision, provision, and quality of nursing care in the Health Center, and residential apartments. He/she is responsible for the selection, training, discipline, and supervision for all nursing related Health Center personnel. He/she is responsible for the procurement of appropriate supplies and equipment and operating within the department budget. Principle Duties, Essential Job Duties: 1. Responsible for the development, organization and operation of nursing services and supportive services for the Health Care and residential apartments. 3. Responsible for the coordination and direction of the total planning for nursing services including recommendation through a staffing plan. 11. Participates in the coordination of resident care services through department staff meeting. 16. Ensures that significant clinical developments of residents are reported to their families and /or responsible party, physicians, the Medical Director, the Executive Director, and State, as necessary. 17. Review the nursing requirements of each resident admitted to the Health Care Center and assists the attending in planning care. 19. If necessary, acts on behalf of the Administrator in his/her absence. 20. Ensures compliance with all federal, state, and local regulations including corporate compliance and HIPPA Privacy Standards. 28. Services as Manager on Duty on scheduled weekends. Wellness Function: The [Community name] employees are expected to promote a health community culture for all residents and employees. This is a whole person approached to health and wellness which includes eight dimensions of wellness: Emotional, Environmental, Health Services, Intellectual, Physical, Social, Spiritual and Vocational through these efforts we can ensure and exceed residents' wellness needs related to their mind, body, and soul, which may also have a positive effect on the employees, as a result. Review of the Administrator Job Description, dated August 03, 2021, General Summary/Major Function: The Administrator is responsible for assisting the Chief Administrative Officer/Executive Director in the overall administration of the Community. S/he supervises over operation of the service departments as directed by the Executive Director, with primary emphasis on the health center. S/he also handles special projects for the Board of Directors and the Executive Director. In the Executive Director's absence, the Administrator can assume responsibility for all Community operations. Essential Duties and Responsibilities Health Care Management Assist Chief Administrative Officer/Executive Director in maintaining licensure and certification of Community; ensure compliance with state and federal regulations; maintain personal Administrator's license. Maintain current knowledge of applicable laws and regulations. On 11/29/2022 at 12:10 p.m. an interview was conducted with Resident #17. She was observed from the hallway lying in bed wearing a hospital gown. She made eye contact and was receptive to an interview. She said she was waiting to get dressed as she pulled at her hospital gown, and that she needed to get ready for therapy. When the resident was asked if she was treated with respect and dignity, she stated, A male aide (Staff C) started to perform incontinent care; I told him no. I told them (Staff C and D) before I only wanted females to care for me. But he proceeded to change my brief anyway. I told him no. At that time, she made eye contact with the surveyor and stated, No means no. She said she had cried and cried no, but he wouldn't stop. She stated, I felt like I was raped. When asked if she told anyone she stated, I told my doctor, and my doctor told them. She said it had occurred just a couple of days ago. She said she has not seen the male nurse since, but, she continued, I see those men walking past my room and looking in. They're just walking by with nothing to do. At that time the resident lowered her head slightly and stated, I don't want to answer any more questions. Resident #17's bed was positioned by the door and when the door is open, she is able see into the hallway. Review of Resident #17's admission Minimum Data Set (MDS), dated [DATE], Section C Cognitive Patterns showed the Brief Interview for Mental Status (BIMS) score coded as a 14. The code of 14 indicated cognitively intact. Further review of the MDS, Section G Functional Status showed toilet use coded as the number 3. The number 3 reflected extensive assistance. Support needed for toilet use mobility was coded as a 2 and indicated one-person physical assist. Review of the Medical Director's progress note, dated 11/24/2022 at 9:18 a.m., revealed S: [subjective] resident concern about a male nurse. Further record review of the facility Abuse and Neglect log for November 2022 did not reflect Resident #17's allegation. On 11/29/2022 at 2:04 p.m. an interview was conducted with the Nursing Home Administrator (NHA) related to Resident #17's allegation. The Nursing Home Administrator said the person the staff would contact would be him and the Director of Nursing (DON). Related to Resident #17's allegation, the NHA stated, No one called me on Thanksgiving Day. On 11/29/2022 at 2:26 p.m. a phone interview was conducted with the facility's Medical Director (MD), who confirmed he knew Resident #17 and saw her on 11/24/2022 between 7:00 a.m. and 8:30 a.m. He said she appeared agitated and told him that morning she had been wet and soiled. She said a nurse had cleaned her and that it was a male nurse. She said she didn't want a male nurse. The MD said the facility always honors resident preferences. He stated, That really troubled me. The MD said Resident #17 told him, A man wiped and cleaned me against my wishes. It was a male. I can't have males down there. She stated, He changed me, and he was not supposed to. I told him to stop, and he just kept going. The MD said she was agitated and asked not to be cleaned as he kept cleaning her and said she felt violated. The MD said he asked the resident if it was okay if he examined her. She told me that was different. The MD stated this was very concerning to him, and he immediately said something to nursing leadership. He said he was 100% confident he spoke to the nurse. The MD stated he reported to the charge nurse (Staff A) We have a potential situation here. The MD went on to state, I told them they had an issue that needed to be escalated to the Director of Nursing. The MD said the nurse (Staff A) confirmed to him that it would be escalated. He said he documented it and instructed the charge nurse (Staff A) to document it. He said he was told they were working on it and thought he heard them say the Director of Nursing was coming in. The MD stated, We have rules about this, no means no. When asked about his expectation he stated, Reporting is expected to be done. He confirmed this is the only facility he goes to, and he is the facility's Medical Director. The MD confirmed on 11/24/2022 Resident #17 was not doing well and said the resident was outside of her normal demeanor. He was informed the survey team was not able to locate documentation of Resident #17's allegation. The MD indicated he was surprised of this and repeated, They said they were going to escalate it. On 11/29/2022 at 2:35 p.m. an interview was conducted with the DON on the incident that occurred on 11/24/2022. The DON said she was aware the Medical Director spoke to Staff A (Licensed Practical Nurse) about his concern related to Resident #17. The DON said she was scheduled to work that day and she received a phone call from Staff A. She said at that time she was already in route to the facility. The DON said after she arrived at the facility, she spoke to Staff A. The DON stated, [Staff A] told me that everything was fixed. She said Staff A stated that She had rearranged the aide assignment and had spoken to the resident. The resident was okay with the schedule change that no male aide would be providing her care. The DON denied she started a grievance. She denied she spoke to the resident. The DON stated, It was just a patient preference, and it was taken care of. On 11/29/2022 at 2:50 p.m. Staff C, Certified Nursing Assistant (CNA) was observed walking in the middle hallway. He stopped in the middle hall and then suddenly turned back around. As he turned, he was noted looking inside of the rooms. One of the rooms he looked into belonged to Resident #17. He then began to walk towards the nursing station. At that time, he was asked if he had time for an interview. Staff C, CNA said he had been a certified nursing assistant for thirteen years and only works at this facility. Staff C denied he worked the morning of Thanksgiving Day (11/24/2022). He said he worked the night shift on 11/23/2022, but then confirmed the shift ended on the morning of the 11/24/2022. Staff C said he knew Resident #17 and denied he assisted her with her incontinent care in the morning. He stated, I worked on the long hall and [Resident #17] did not reside on that hall. He then stated, I never worked with her. Staff C was asked to look at his documentation dated 11/24/2022. He looked at the report and confirmed he had documented in Resident #17's record which reflected bladder continence care had been provided on 11/24/2022 at 2:56 a.m. Staff C denied anyone spoke to him about an incident and went on to say he did not remember taking care of the resident and did not recall any objections or problems during the care. He did not recall the resident telling him she did not want a male to care for her. He then added I had taken care of her before. He said no one told him not to take care of her anymore. Staff C said typically, if someone would say they have preferences they don't assign the male aide to the room. He said there are no residents, that he is aware of, who do not want a male to take care of them. He said if there was one, he would get a female aide. Staff C confirmed he worked at the facility yesterday 11/28/2022 and assisted with new admissions. On 11/29/2022 at 3:22 p.m. an interview was conducted with the NHA who stated, No one knew she didn't want a male until Thanksgiving Day. He said, The aide is in the DON office right now and is being suspended. On 11/29/2022 at 3:14 p.m. an interview was conducted with the Social Service Director (SSD). She said she talked to the resident today (11/29/2022) and asked her if anything happened. The SSD said, She told me a couple days ago; a male aide came in to change her and she did not want him to change her. She said she cried and told the doctor, who told the nurse. The resident said she hadn't had a male aide since. The SSD said the resident reported that nothing inappropriate happened. The SSD said the resident's family member was in the room during that time and stated years ago she had a bad encounter with a male aide, stating, It happened somewhere else. The SSD said the resident said she has not had any male caregivers giving her care since the incident happened. She indicated on Thursday (11/24/2022) the resident's care plan had been updated to reflect no male aides. The SSD confirmed a grievance form was not filed. When asked what her expectation was, she stated I expect a male aide would stop and get a female. The NHA was present at the time of the interview and stated, Any concerns should be documented, and a grievance should be filed. He confirmed it was not transferred to paper and did not know why. On 11/29/2022 at 3:40 p.m. the NHA provided a copy of a form titled, Administrative Leave, dated 11/29/2022, Suspended pending abuse allegation that revealed Staff C's, CNA name. On 11/30/2022 at 12:25 p.m. a phone interview was conducted with Staff A, Licensed Practical Nurse (LPN). She confirmed she worked on 11/24/2022 and received a verbal report from the Medical Director. She stated, The MD came to me between 8:30 a.m. and 9:30 a.m. and told me there was an issue that needed to be taken care of. He stated to me that [Resident #17] was very upset because she had been raped. I said, excuse me, did you say rape? He stated Yes. He said she used the word rape. Staff A stated, The MD told me he needed it handled right away. The MD said [Resident #17] told the male staff to stop. Staff A, LPN said she spoke to the resident and that she (Resident #17) said she was okay. I asked her, Do you want me to do anything different. She said that Resident #17 said, I'm fine I just don't want a male taking care of me. I do not want a male touching me down there. I told her that no male aide will take care of her, and it will be in her plan of care. Continuing, Staff A stated, She told me that she wanted to be left alone, she did not want to be bothered. When asked what type of assessment was performed, she indicated a set of vital signs, and she observed the resident and did not see any bruising to her face or hands. Staff A confirmed she did not perform a full skin assessment. She said Resident #17's demeanor appeared calm, saying she was not disheveled, was alert and oriented, and her mood appeared okay. Staff A said it was her first time working with the resident. Staff A said the DON was in the building between 9:00 a.m. and 9:30 a.m. stating, I told her that the Medical Director had concerns and the resident said she felt as though she was raped. The DON said he does not like it when people throw that word around. Staff A said, I also told her that I had spoken to the [family member]. I told her the concerns of the resident not wanting a male aide. The [family member] said I don't know why she is like that lately but thank you for letting me know. Staff A continued, I additionally called the Risk Manager, who is also the Assistant Director of Nursing (ADON) and left her a message. Staff A said later that day she spoke to the ADON, and I told her I had informed the DON. Staff A said the DON told her she would handle it and take care of it. Staff A stated, The ADON had asked if I documented it, I told her the DON had said she would take care of it. Staff A denied seeing the DON going to the resident room after she had given her the report. Staff A confirmed she received abuse training in April 2022. She said, If someone alleges rape, we are to inform the parties that are involved, and that is what I did. If a resident alleges any form of abuse, the expectation is to call the hotline. Staff A stated she Figured the DON was handling it because she was here. On 11/30/2022 at 1:08 p.m. an interview was conducted with the ADON who is the facility's Risk Manager (RM). She confirmed she received a call from Staff A, LPN in the morning, but did not answer the phone. The ADON said she called back later that afternoon and spoke to Staff A who told her a patient had a male CNA and didn't want a male CNA. The RM said, [Staff A] said the doctor had concerns. She told me that the DON was going to take care of it. The DON was at the facility and was taking care of it. The RM confirmed she deals with abuse and neglect allegations. Stating, It is a team process. When asked what she would do, she said she would not assign a male to the room, and she would go to the patient and see what her concerns were. She stated, I would want to know why she doesn't want a male. She said, I would investigate by starting the grievance process. I would speak to the resident to determine what had happened. She confirmed, An allegation of rape is immediately called in. The RM said part of her process would be to call the abuse hotline and perform a skin assessment of the resident. She went on to say, I would start a paper trail that would include witness statements from staff. The RM said she is responsible for training and had started abuse and neglect training yesterday (11/29/2022). On 11/30/2022 at 1:27 p.m. an interview was conducted with the Interim Director of Nursing (IDON). She said due to the investigation, she was asked last night around 6:00 p.m. if she could take the interim position The IDON said the DON was aware of the incident and did not notify the NHA or start the abuse protocol. The IDON said Staff A was directly involved on that day and she was the one the doctor talked to. Staff A was informed by the doctor who used the word rape. Staff A then informed the DON of the doctor's statement. The IDON said if this had been reported to her, she would like to know first-hand information. She said it takes only a minute to see the patient and talk to the patient. The IDON stated, She would want firsthand information. She would have conducted an interview and would have assessed the patient. She would investigate why a resident wouldn't want a particular staff in the room. On 11/30/2022 at 1:41 p.m. an interview was conducted with Staff D, CNA. She confirmed she worked on Thanksgiving Day. She said she went into Resident #17's room with Staff A, LPN while she was gathering some bags. She said she overheard Resident #17 wanted a female instead of a male aide. Staff D said she had never mentioned that before and had never mentioned anything about her past. Staff D said the resident seemed emotional and was upset a little. Staff D stated, She was telling the nurse she prefers a female over a male aide. Felt more comfortable with a female. Staff D said, I have taken care of her since then and has seemed normal since that day. Staff D continued, Later that same day a little after breakfast the resident told me that she had told the male aide she wanted a female, and said he kept going. She said she was crying and that she didn't want a male. She wanted a female. She said he just kept going. He just kept cleaning her and he kept going. She said the resident stated, You are a female like me would you want a male changing you. Staff D said the resident said she can't protect herself if something happens because she is an elderly old lady. Staff D said she did not notice any bruising and that she didn't seem frightened. Staff D said she told another aide (Staff E, CNA). Staff D said Resident #17 is alert and oriented and not forgetful or confused. On 11/30/2022 at 2:00 p.m. an interview was conducted with Staff E, CNA and she confirmed she worked on 11/24/2022 -Thanksgiving Day and knows Resident #17 stating, I take care of her all the time. She said she could not recall if the resident had voiced a concern to her about not having a male caregiver. She said on 11/24/2022 she was in Resident #17's room caring for her roommate when Staff A, LPN entered the room. Staff E said she could overhear Staff A ask Resident #17 if she preferred a female and Resident #17 responded, Yes. Staff E said she heard Staff A say, OK we won't have a male taking care of you. Staff E said Resident #17 was upset, she looked like she was just not happy. Staff E said on that day she noticed the resident was a little different and was upset. She did not verbalize to me what happened. Staff E said she remembered her and her roommate at the time both verbally said they didn't want a male in the room. Resident #17's roommate was discharged that day adding that she was an older resident also. She said Resident #17 was very alert. Staff E said most of the residents that are here are here for therapy and then go home. She noticed more of the women in therapy prefer not to have men in the room. Staff E said she talked to Staff C, before who is male aide, about it and wanted to switch assignments. She said I told Staff C, CNA some of the women just don't feel comfortable with a man taking care of them. Staff C said she did not recall when the conversation occurred. On 11/30/22 at 3:12 p.m. an interview was conducted with Resident #17's family member who is her documented emergency contact. The family member said she visits the resident daily, and when she is not there another family member is. She stated, [Resident#17] and I are very close. The family member confirmed on 11/24/2022 she received a phone call from the facility nurse, Staff A. She said there was an incident that happened when [Resident #17] was being changed by a male CNA. She said [Resident #17] was very upset and had been crying all morning. Staff A, LPN had assured her [Resident #17] was okay, but she was upset because she did not want him to do it. The family member said she also spoke to the resident who told her the CNA was Staff C. The family member said on 10/26/2022 Staff C performed the resident's admission intake stating, We both remembered him. She said she told Staff C that she wanted a female caregiver for [Resident #17], and he stated, Oh that's right you do not want a man to change you . The family member stated, He knew she did not want men providing her care. The family member said, I told [Resident #17] he did not care if she preferred female caregivers. Continuing, the family member stated, [Resident #17] said on 11/24/2022 [Staff C] told her if she did not let him change her brief then she had to wait until shift change. [Resident #17] told him fine. I will wait. [Resident #17] said then all of a sudden, he pulled her gown and continued to change her. She said she tried to reach for the buzzer to call staff and she could not reach it because he had moved the blanket to the side. The family member stated, [Resident #17] kept saying No but he would not listen. [Resident #17] told me she said she felt violated, it was her dignity and that she felt helpless. She said [Resident #17] thought she had a right not to have this man touching her. She said [Resident #17] did say she was not touched inappropriately but she did not want him providing care. The family member stated, The resident told her the doctor came in her room that morning and she was crying. [Resident #17] told me she had told him what had happened. The family member stated a couple weeks prior she spoke to Staff F, LPN a nurse who was working the weekend. He told me [Resident #17] said she did not want male staff providing her care. The family member stated that she shared with Staff F the resident's prior trauma, stating, [Resident #17] was married young, and her husband was very abusive. She said Staff F appeared uncomfortable when he heard her concerns. He said he would make note of it. The family member stated, He said word for word there was no reason why we can't make that accommodation here. This conversation happened a couple weeks prior to the incident. The family member said, [Resident #17] has always been independent and was in her right mind . and to have someone mock her feelings . saying oh yeah you are the one who doesn't want male caregivers, he was very condescending. The family member stated she did not realize the CNA would be like that with her. The family member reiterated the resident had past trauma related to being in an abusive marriage. She stated, Him forcing her during care caused her to be upset. The family member confirmed the resident had mentioned she did not feel comfortable with male caregivers several times to staff and to her. The family member confirmed she received a phone call from the DON on 11/29/2022 and stated, I was frustrated. She alleged that this was the first time she had been notified of the resident's preference. I asked the DON why this was not in her record . Why was it not reported? . Why wasn't there an incident report? The family member said, It bothers me. Where there is smoke there is fire. If they are working that hard to cover it up, what else are they hiding? What about residents who cannot speak for themselves? The family member said when she spoke with [Resident#17], she stated she was not going to allow this to happen. She felt helpless. She was crying. Resident #17 said, I told him to stop, and he ignored my request. The family member stated she felt Resident #17 was safe but was scared about the repercussions. She said, Even if that male caregiver is not here, he has his buddies. I just want [Resident #17] to be safe. The family member confirmed when Resident #17 was admitted [DATE] she informed Staff C, CNA of the resident's gender preference for care. On 11/30/2022 at 4:01 p.m. an interview was conducted with the NHA. He stated Staff C, CNA was interviewed on 11/29/2022. Staff C said he was providing care to Resident #17 on Thanksgiving morning and that she did not want him to do it, she kept saying No. He stated he felt he did not want to leave her without clothes on and wanted to make sure she was dry. The NHA stated they identified an educational opportunity. The NHA said, I let him know he should have left her, honor her request and let the nurse know. The NHA stated they initiated education and suspended the CNA. On 12/01/2022 at 11:27 a.m. a phone interview was conducted with Staff F, LPN. Staff F said he knew Resident #17 and indicated he worked on her unit a few times. He said he recalled speaking with the resident and her [family member]. He said he went into the room to inform the [family member] and the resident he had requested orders from the physician. He said they identified she had blood in her brief, and he was concerned about a gastroesophageal bleed. Staff F said when he was in the room the [family member] told him Resident #17 had a very abusive husband. She said she did not want any male aides to go in her room. Staff F could not recall the exact day of the conversation but stated, It was on the same day I received the order for the STAT (immediately) blood work. Staff F continued and said after he was informed by the [family member] of the resident's preference, he stated, I informed [Staff G Registered Nurse (RN)] the weekend supervisor about it right away. He said he then added it to the on shift report. He said the weekend reports are addressed on Monday mornings and indicated at that time the resident's care plan would be updated. Staff F denied he documented anything in Resident #17's medical record related to the conversation related to the resident's preference on the gender of caregivers. Medical record review revealed on 11/13/2022 Staff F, LPN requested and received orders for Resident #17 for a complete blood count (CBC). Thus, indicating the facility staff were notified 12 days prior of the resident's gender preference on caregivers. On 12/02/2022 at 9:51 a.m. a return phone call was received from Staff G, RN Weekend Supervisor. Staff G said she heard about the allegation of abuse a couple of days ago when she was called and asked for a statement. She said, I did not know anything about the patient and was unaware of a patient preference related to not wanting a male aide. Staff G stated she did not recall Staff F, LPN telling her about a resident's preference for a caregiver. She denied she was notified. She stated, [Staff F LPN] does not let me know about his residents. She added last Saturday, 11/26/2022, at the nursing station, I had heard the aides, [Staff F] and [Staff A] talking about someone did not want a male aide. They did not mention the patient's name. Facility Actions to Remove Immediate Jeopardy: On 12/02/2022 at 4:45 p.m. a Removal Plan for F 835 was received which was verified and found to be acceptable. (Photographic Evidence was Obtained) Review of the removal plan revealed: December 2, 2022. In response to Immediate Jeopardy concerns identified during re-licensure survey F835- * 11/29/22 -At around 1:30 p.m. Surveyor brought to NHA attention a potential allegation of abuse that occurred on 11/24/2022 (Thanksgiving Day). Upon investigation, a physician progress note in [medical software] stated that resident had concerns with potential male C.N.A, note dated 11/24/22. *11/29/22 investigation initiated; CNA suspended immediately pending investigation. *Investigation revealed on 11/24/22 physician communicated with licensed nurse (LPN) that there was potential issue occurring with a resident and to please escalate to clinical leadership. The LPN went immediately and talked to the resident about her concerns. The resident stated that a male C.N.A. came in to change her brief on 11-7 shift and she stated no and the C.N.A proceeded, and she stated that No mean no and didn't want a male C.N.A. *That nurse then called the DCS around 10:30 a.m. on 11/24/22 and notified her of resident concerns. *11/29/22-At around 6:00 p.m. with the presence of the HRD and administrator the DCS was suspended pending investigation due to failure to follow community reporting process pertain to abuse allegation. *11/29/22-Immediate was submitted to AHCA (Agency for Health Care Administration). *11/29/22 -Police notification *11/29/22 DCF notification *On 11/29/2022 - Education was initiated with all staff by department leadership regarding Abuse, Neglect, Exploitation & Misappropriation, recognizing and reporting abuse per community policy/resident right, grievances and communication. *11/30/2022- Acting Director of Nursing interviewed residents that were cared for by the alleged perpetrator. *On 11/30/2022 Resident who made allegation was seen by the psychologist however declined visit. He is to follow up week of 12/05/2022. *On 11/30/2022 ADHOC QAPI was completed with the Medical Director, NHA, acting DON, QA nurse, Unit