**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A review of the facility's abuse log revealed Resident #164 made an allegation of abuse on 9/19/23. During an interview on 01/10/24 at 12:16 p.m. the Nursing Home Administrator (NHA) confirmed an allegation of abuse was made by Resident #164 on 09/19/23 and a federal report was completed. The resident reported his Certified Nursing Assistant (CNA), Staff R poisoned his coffee. The resident stated he witnessed the CNA remove his coffee and put an unknown substance in his coffee. An investigation was initiated. The NHA stated she could not find the statements she obtained from the CNA. She stated she spoke to the nurse who worked that day as well but could not find that statement either. A follow-up interview with the NHA on 01/10/24 at 12:38 p.m., revealed she misplaced the entire file related to Resident #164's abuse investigation to include witness statements. The NHA said Staff R, CNA was suspended for 5 days and education was conducted for all staff on Abuse and Neglect but no documentation of the training could be provided. Review of Resident #164's admission Record revealed he was admitted on [DATE] with diagnoses to include muscle wasting and atrophy, epilepsy, unspecified dementia with agitation, and adult failure to thrive. The resident's admission Minimum Data Set assessment dated [DATE] revealed a BIMS score of 7, indicating severe cognitive impairment. The resident exhibited no signs of psychosis or behaviors. The resident had no new orders received on 9/19/23 following the allegation and no pain assessments completed. The admission record revealed the resident was discharged on 09/30/23 with no discharge location documented. On 01/09/24 at 3:43 p.m., an interview was conducted with Resident #36. She reported she was verbally abused by a staff member. Resident #36 stated a staff member yelled at her. She was scared to report the incident, but she told the Social Services Director (SSD) the first time it happened. She stated this happened before Christmas. Resident #36 said, The CNA yelled at me because of a fan. She called me out. Her name is [Staff T, CNA]. She stated she spoke to the DON and SSD about it. Resident #36 stated [Staff T] had gotten into her face about a fan at night. She said, She was just rude and disrespectful. She called me names. I don't want to say much about it. I don't want them to come after me. Then today, it's [Staff R, CNA]. This morning she [Staff R] came up again and said she will not assist me with my shower, and she won't change me. She said if you don't stop that [expletive] you will get into more trouble. Review of a grievance/concern report dated 12/23/23 for Resident #36 completed by Staff R, CNA revealed, Resident was upset when I came in this morning. I asked her what was wrong. She said an overnight CNA [Staff T, CNA] came in her room and took her fan out of her room. She told her to shut up she is tired of her shit and that it was her fan. Review of the grievance completed by the DON showed under facility follow-up Resident was informed the fan was the CNA's. A section on the form asked if this was an allegation of abuse. The box was left blank, indicating facility did not consider verbal abuse towards the resident abuse. The resolution of grievance /concerns section showed the grievance was not confirmed. Under the findings summary it showed, Resident voiced understanding the fan was not hers. The SSD signed off the grievance and indicated the resident was satisfied with the grievance resolution. On 01/09/24 at 4:09 p.m., an interview was conducted with Staff R, CNA with the DON present. Staff R stated she worked the back hall where Resident #36's room is located. She stated she had not had any negative interaction with the resident. She stated the previous week, Resident #36 reported someone took her fan. Resident #36 reported the staff member walked into the room to get her fan and that she used some words to her and her roommate, Resident #81. Staff R said, I submitted a grievance to the DON because the two residents [#36 and #81] were upset. Staff R stated Resident #36 was upset. She said, I asked her, and she said a CNA [Staff T] told her to shut up and mind her own business. Staff R stated the CNA Resident #36 was referring to was Staff T, CNA who worked the same assignment area during the 3 p.m. to 11 p.m. shift. Staff R said, This morning, she did not want to get out of bed, she was upset. She first told me she said she did not want to shower. I left her and then came back and took care of her. I was not rude or mean to her. She was upset with [Staff T]. On 01/09/24 at 4:15 p.m., an interview was conducted with the DON. She said, When the fan was taken, I questioned [Staff T, CNA] regarding the fan. Staff T said the fan was hers, and she was letting the resident borrow the fan. She stated the resident reported [Staff T] was rude to her when she took the fan back. The DON said, It was the way she took the fan. She [Staff T] told her she was taking it because it was not hers. She apparently told her to shut up. We questioned her [Resident #36] about the incident. It was a couple days after the grievance was documented. I went there with the SSD. Her other roommates were in the room. Resident #36 denied the abuse incident at that time. She did not say [Staff T] used choice words. I don't know why she changed her story. She had first reported the incident to [Staff R] the morning it happened. The DON stated she did not initiate abuse allegation for Resident #36 related to the 12/23/23 grievance because when she went to question the resident, she denied the abuse even though it was already documented. The DON stated she focused on the fan. The DON stated she did not talk to the resident privately. She stated she did not obtain witness statements from other residents or staff regarding the verbal abuse because the resident withdrew her statement. She stated, I don't know why she would have reported abuse and then withdrew it. I did not follow-up. I did not ask other staff about it. On 01/09/24 at 04:55 p.m., an interview was conducted with the NHA and the DON. The NHA stated regarding the fan incident on 12/23/23 with Staff T, the DON resolved the grievance after she spoke to the resident and the resident denied any abuse related to this incident. The NHA stated she did not have any witness statements. The DON stated she did not speak to the nurse who worked that night. She did not interview the roommates. The DON stated she did not document the resident's response related to denying that someone abused her verbally. She stated she did not document any of the interviews. She stated she did not know that she needed to document any of that information. The DON stated she did not know she needed to ask other staff or other residents about the verbal abuse allegations. The DON stated she did not follow-up with Staff R regarding the initial grievance submitted on 12/23/23 on Resident #36's behalf. A follow-up interview was conducted on 01/10/24 at 4:26 p.m. with the DON and the NHA. The DON said, at the time of my investigation they said it did not occur. I did not revisit the issue. I did not think to look further. I did not focus on the verbiage used when the grievance was documented because the residents said it did not happen. I don't know why they changed their story. Now I see how I should have investigated it further. I did not interview other staff or residents. I did not know she still had issues with that incident. Review of the facility's incident log showed Resident #12, a vulnerable resident had a fall on 12/4/23. Review of Hospital records dated 12/4/23 at 7:51 p.m. revealed a [AGE] year-old female with past medical history of congestive heart failure (CHF), cerebral vascular accident (CVA), hypertension (HTN), and renal failure presents to Emergency Department (ED) via Emergency Management Services (EMS) from nursing home with complaints of severe right leg pain due to fracture and fever. Patient's temperature was 100 degrees Fahrenheit on arrival. Patient states she does not know when the fracture happened. Patient reports she had her left leg amputated in 1992. Patient documentation from nursing home shows fracture of proximal fibular and tibial meta diaphysis. Hospital X-rays obtained on 12/04/23 at 9:20 p.m. showed minimally displaced fracture of the proximal tibial metaphysis. Review of the admission Record revealed Resident #12 was originally admitted to the facility on [DATE] and readmitted on [DATE] following a 10-day hospitalization. The resident was re-admitted with a primary diagnosis of unspecified fracture of upper end or right tibia, sequela and additional diagnoses to include legal blindness, end stage renal disease (ESRD), contracture of right hand, contracture of right wrist, hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, unspecified convulsions, and psychotic disorder with delusions due to unknown physiological condition. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] showed Resident #12 had a BIMS of 14, indicating intact mental cognition. Section G showed the resident had upper and lower extremity impairment and was totally dependent on staff for all ADLS (activities of daily living). On 01/12/24 at 11:01 a.m., an interview was conducted with Resident #12's RP regarding the fall and hospitalization. She said, They said they called me, and they left a voice mail. They did not leave any voicemails. If they couldn't reach me, they could have reached other family members. They have contacts. They sent her out [referring to the 12/4/23 hospitalization] and they did not tell me. I did her washing and when I dropped it off that was when I found out she was gone. The RP stated the NHA told her the resident was sent out because her wound was infected. The RP said, She [NHA] did not say her leg was broken. They did not tell me how the injury happened. They did not tell me her leg was broken or how it broke. The RP stated she went to the hospital to visit Resident #12 and when another family member, who accompanied her, touched the resident's leg, she hollered. The RP said, She was in pain. The doctor said she had broken her leg. That was when I found out. I called the facility. The [NHA] told me it may have happened during dialysis. She said I could call them and ask them. I was upset. The RP stated Resident #12 needed more supervision because she was blind and was dependent on staff. The RP said, They should know who dropped her. All I know is she has a broken leg that is infected, and I don't know how the leg broke. I am afraid she will lose her only leg. Review of progress notes for Resident #12 showed: 12/4/23 Note Text: CNA notified this writer that during care resident c/o pain to right knee. Resident stated her right knee hurts with movement and repositioning, swelling noted, MD notified with new order for x-ray to right knee, RP notified, will continue to monitor. 12/4/23 Note documented by NHA on 12/5/23, Spoke with resident concerning positive x-ray results. Resident denies harm and states she experienced a fall at dialysis. 12/4/23 Note Text: X-ray results received showing There are fractures of the proximal right fibula and tibia. PCP notified, left VM [voicemail] with RP. DON and Administrator notified. 12/4/23 Note Text: Resident alert and oriented. Complaints of pain in right leg. Scheduled pain medication was given. X- ray was completed to the right femur. Due to pending/preliminary results new orders were given to send resident out to the emergency room to be further evaluated. Power of Attorney was notified x 3 via Voicemail & was notified to call the facility's nursing team back regarding resident's plan of care. 12/4/23: Note Text: PCP [Primary Care Physician] notified of results, orders to send patient to ER for further evaluation. On 01/08/24 at 9:45 a.m., Resident #12 was noted with an undated dressing on her left arm. The dressing around the left upper arm area was observed with blood. Resident #12 stated she did not know she had been bleeding and did not know the cause. The resident made no mention of her leg injuries. On 01/12/24 at 10:16 a.m., an interview was conducted with the ESRD facility's Clinical Manager where Resident #12 received dialysis. She confirmed Resident #12 was their resident and attended dialysis at their facility every Monday, Wednesday, and Friday. The Clinical Manager stated, She [Resident #12] arrived at the facility on 12/4/23. She had no incidents. Patient comes to our facility under the care of the transport company. She arrives in a stretcher, and then they transfer her into a chair. She never ambulates. The transport puts her in the treatment chair. She never gets out of the treatment chair. The Clinical Manager stated she never received a phone call from the facility. She stated , I was told on 12/6/23 that she was not coming to dialysis because she was hospitalized for a wound infection. The Clinical Manager stated she did not know anything about the patient falling. She said, She probably fell at [name of the nursing home]. She never walks. I received a call from some insurance people while she was at the hospital. They wanted to know the date of the incident. I told them, she did not fall at dialysis. I have not heard from them again. The Clinical Manager confirmed the facility never contacted her to inquire about the resident's fall or an injury she may have sustained at the ESRD facility. On 01/12/24 at 2:15 p.m., an attempt to reach Resident #12's dialysis transportation company was unsuccessful. Review of a Radiology report for Resident #12 dated 12/04/23 at 6:27 p.m., showed: Knee 1 0f 2 views, right. Results: There are moderately displaced fractures of the proximal right fibular and tibial metadiaphyses with medialization of the proximal fracture fragments. Bones are osteopenic. Soft tissue overlies the fracture. Conclusion: There are fractures of the proximal right fibula and tibia On 01/12/24 12:37 p.m. an interview was conducted with the Risk Manager Consultant (RMC), and the Regional Nurse Clinical (RNC). The RMC stated he had reviewed the investigation file. He stated it showed resident had a BIMS 14 and she reported that she fell at the dialysis center. He stated the paper he was reviewing was undated. He confirmed Resident #12 was transferred out because her X-rays came back positive for a leg fracture. The RMC read a progress note dated 12/4/23 showing, the resident said nobody hurt her and no one abused her. He stated there were two notes from the nurse which read, On 12/4/23 resident alert, she complained of leg pain and pain medication given. Right leg was not swollen but she did complain when I moved it through ROM (range of motion). CNA made me aware she was complaining of pain in her right leg. A CNA report read, I was giving care to [Resident #12] when I moved her leg, she was in pain. I informed the nurse who was on duty. The RMC stated the NHA Investigation summary showed the resident's knee x-ray results showed fracture of right fibula and tibia. It showed the PCP, DON and NHA were notified. The NHA interviewed the patient and she denied anybody was abusing her. She admits to falling at dialysis center. Medical Doctor (MD) ordered transfer to the ED. She left a voice mail with patient's mother and was waiting for a call back. The RMC said, I cannot conclude what happened. I agree there is an incomplete investigation. On 01/12/24 12:48 p.m. The RNC stated, The NHA talked to the patient who has a BIMS of 14 there does not seem a reason why we would not trust that patient. I did not know she was blind. I do understand that the patient suffered a significant injury. She reported it happened at dialysis. I agree, there is no evidence that follow-up calls were made to figure out what happened. Further investigation should have been conducted. You are right, dialysis or dialysis company should have been contacted. I don't know if the incident was reported. 01/12/24 at 3:16 p.m., an interview was conducted with the facility's Medical Director (MD), who is also Resident #12's PCP. The MD stated he did not have any recollection of any recent injury reports that resulted in a hospitalization. He could not recollect a fall with injury for Resident #12 and stated I would know. The MD did not remember being notified. The MD stated if there was a significant injury, he would have expected to be notified. The MD said, I would remember if a resident had significant injuries. It should be documented if I had a follow-up visit. Review of physician notes showed Resident #12 was seen by the MD on 04/12/23, 04/26/23 and 09/09/23. There were no physician notes documented on or around the time of Resident #12's injury on 12/04/23 or after she returned from the hospital on [DATE]. Based on interviews with residents, staff and administrative staff, and Medical Director, and review of the clinical record, incident log, and policy and procedure, it was determined the facility failed to protect residents' right to be free from physical, verbal, psychological, psychosocial and sexual abuse, and neglect by failing to implement a systematic process to carry out their abuse policy to ensure witnessed or reported abusive interactions, neglect and injuries were fully investigated and addressed for nine residents (#164, #6, #36, #90,#32, #100, #308, #106, #12) of 12 residents sampled. Incidents occurred between residents (#164, #6, #36) and staff members and between a resident (#90) and two other residents (#32, and #100). The facility failed to identify and prevent neglect by failing to ensure wound care orders were implemented for two residents (#308 and #106) and failed to investigate the cause of a fracture for one resident (#12) who stated they fell. These failures resulted in Immediate Jeopardy which began on 09/19/23 and was ongoing at the time of survey exit on 01/12/2024. Findings included: Cross reference F610, F726, F835, and F867. A review of the facility's Abuse Prevention Program with an effective date of 2012 and a most recent change date of August 2022 revealed: POLICY: The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment and misappropriation of resident's property. These policies guide the identification, management and reporting of suspected, or alleged, abuse, neglect, mistreatment and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burnout, or resident behavior which may increase the likelihood of such events. DEFINITIONS: Abuse - Includes Verbal, Physical, Sexual, and Mental/Emotional Abuse Abuse o Willful infliction of injury upon a resident by a staff member, another resident, a vendor, a visitor, or other individual. o Unreasonable confinement/Involuntary seclusion o Separation of a resident from other residents, or from their room or other area, against the resident's will or the will of the resident's representative. o Intimidation with resulting physical harm, or pain, or mental anguish. o Punishment with resulting physical harm, or pain, or mental anguish. o Deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well being. o Corporal punishment and any physical or chemical restraint not required to treat the resident's symptoms. o Instances of abuse of residents, irrespective of any mental or physical condition, that causes physical harm, pain or mental anguish to include verbal, sexual, physical, & mental abuse. o Abuse that includes that which is facilitated or enabled using technology. o Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal Abuse o Oral, written, or gestured language that includes disparaging and derogatory terms to the residents or their families to describe the resident within their hearing distance, regardless of their age &/or ability to comprehend or disability. Physical Abuse o Includes hitting, slapping, pinching, scratching, spitting, holding roughly, etc. o Also includes controlling behavior through corporal punishment or a restraint not required to treat the resident's symptoms. Sexual Abuse o Includes but is not limited to, humiliation, harassment, coercion, or sexual assault. Sexual abuse is non-consensual sexual contact of any type with a resident. Mental/Emotional Abuse o Includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. o During the delivery of personal care, staff must remove residents from public view & provide clothing or draping to prevent unnecessary exposure of body parts. o The taking of unauthorized photographs may constitute mental, physical, and/or sexual abuse. o Whether mental abuse has occurred is determined by a reasonable person standard and does not require a specific response from the resident. o Mental abuse related to photographs and/or audio/video recordings is prohibited; staff are prohibited from taking, keeping &/or distributing photographs that demean or humiliate residents. NOTE: If the facility has reason to believe that a resident representative is making decisions or taking actions that are not in the best interests of a resident, the facility shall report such concerns when indicated and, in the manner, required under state law. Residents must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, or other individuals. Neglect o Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Exploitation/Misappropriation of Resident/Patient Property o Deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident/patient's belongings or money without the resident's consent. o Taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion. Mistreatment o Inappropriate treatment or exploitation of a resident. Injury of Unknown Source o An injury that is suspicious for abuse, or neglect due to the severity of the injury, the site of the injury, the number of injuries at one time, or the number of injuries over time. o An injury should be classified as an injury of unknown source when all of the following criteria are met: o The source of the injury was not observed by any person; and o The source of the injury could not be explained by the resident; and o The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. Serious Bodily Injury An injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization, or physical rehabilitation; or an injury resulting from criminal sexual abuse. Alleged Violation o A situation or occurrence that is observed or reported by staff, resident, relative, visitor of others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Suspected Crime (Elder Justice Act Reporting) o A report from a resident, representative or other relater that an event has occurred which is defined by law of the applicable political subdivision where the facility is located, involving individuals aged 60 or older. This may include, but may not be limited to, allegations of sexual assault, theft, and abuse. o Criminal sexual abuse: In the case of criminal sexual abuse which is defined in section 2011(l9)(B) of the Act (as added by section 6703(a)(l)(C) of the Affordable Care Act), serious bodily injury/harm shall be considered to have occurred if the conduct causing the injury is conduct described in section 2241 (relating to aggravated sexual abuse) or section 2242 (relating to sexual abuse) of Title 18, United States Code, or any similar offense under State law. In other words, serious bodily injury includes sexual intercourse with a resident by force or incapacitation or through threats of harm to the resident or others or any sexual act involving a child. Serious bodily injury also includes sexual intercourse with a resident who is incapable of declining to participate in the sexual act or lacks the ability to understand the nature of the sexual act. Review of the facility's abuse log revealed a resident to resident incident occurred on 11/21/23 involving Resident #32 and Resident #90. Review of Resident # 32's progress note, dated 11/21/2023 at 9:04 p.m., signed by Staff L, Licensed Practical Nurse (LPN), revealed, Resident reported that another resident touched her inappropriately. States that while at the smoking area on Saturday [11/18/23], a male resident approached her and asked her if she would like to be sexually harassed, she agreed to it thinking it was a joke and he went ahead and touched her breast. Review of Resident #32's most recent Quarterly Minimum Data Set Assessment (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. During an interview on 01/10/24 at 3:05 p.m. Resident #32 said Resident #90 came up and asked if I wanted to be sexually harassed. I thought he was joking and then he groped my breast. When asked if she thought the touch on her breast could have been an accident, Resident #32 replied, I never told anyone it was an accident. Resident #32 continued to describe the events and said, Staff I, Certified Nursing Assistant (CNA) overheard me say to Resident #90, there will be no more of that, and asked what I was talking about. Resident #32 reported she told Staff I, CNA about Resident #90 touching her breast. Staff I then came to my room and helped me write a grievance. This was all reported to Staff I, CNA on the day it occurred, but I found out about four days after the incident, on 11/21/2023, that the grievance had been lost. I became hysterical and called the police. The police came and talked to me. This was on 11/21/2023, four days after the incident, and four days after Staff I, CNA helped me write the grievance. When I called the police, I heard Resident #90 was immediately placed on 1:1 (one to one) supervision, but I heard he got caught with someone else and was put on 1:1 again. During an interview on 01/10/24 at 3:15 p.m., Staff I, CNA reported she remembered Resident #32 reporting the allegation of sexual abuse. She said she reported the incident but was not sure who she had reported it to. Staff I was aware law enforcement was called but was not present at the facility when law enforcement came. Staff I said Resident #90 was placed on 1:1 supervision immediately after she reported it. Resident #90 was taken off of the 1:1 supervision (date unknown) but was placed back on 1:1, maybe less than two weeks later. A follow-up interview was conducted with Staff I, CNA on 01/11/24 at 1:17 p.m. She recalled reporting the event with Residents #32 and #90 on a Saturday (11/18/21) to the weekend nurse supervisor, Staff N, Registered Nurse (RN). Staff I, CNA did not know if Staff N, RN called the Director of Nursing (DON) or the Nursing Home Administrator (NHA) to report the event but remembered they wanted a statement. They had Resident #32 write the statement and Staff I, CNA signed under Resident #32's statement. The weekend supervisor (Staff N, RN) was sick the next day and I made a copy of the statement, but I can't find the copy. I slid the statement under the NHA's door on Sunday before I left the facility. On Monday, the NHA said the housekeeper must have swept up the statement because she did not see it. I came in that Tuesday, 11/21/2023 and went to the NHA's office. I attempted to give the NHA a copy of the statement, and the NHA didn't take it from me. The NHA said that she had it handled. An interview was conducted with the NHA on 01/11/2024 at 5:58 p.m. to discuss the incident between Resident #32 and #90 and the investigation of the incident. The NHA said she first learned of the incident when Resident #32 called law enforcement on 11/21/2023 and the evening unit manager, Staff L, LPN called her. The NHA said she came to the building and talked to both residents and staff but did not document any of the interviews. She said no staff witnessed the incident and neither resident involved remembered what date the event took place. Resident #32 did not report telling any other staff, so no other staff were interviewed. The NHA said she did not receive a written statement from Staff I, CNA. The NHA expressed that Resident #32 and Resident #90 stated this incident was consensual. The NHA said the 1:1 supervision was for a short period of time. When asked if Resident #32's call to 911 to report the event as a crime on 11/21/2023 indicated a consensual event took place for Resident #32, the NHA did not respond. On 01/11/24 at 1:15 p.m. a telephone call was made to Staff L, LPN who documented the report of abuse on 11/21/2023. Staff L, LPN did not answer and a message stating the phone number was not accepting messages received. Due to this, no voicemail could be left for a return call. On 01/11/24 at 1:36 p.m. a telephone call was placed to the weekend nurse supervisor/Staff N, RN related to Staff I, CNA's report to her of a sexual abuse allegation by Resident #32 on 11/18/23. A voicemail message was left but no return call was received prior to exiting the facility on 1/12/24. Review of Resident #90's progress note, dated 11/21/2023 at 8:38 p.m. and signed by Staff L, LPN revealed, this resident was reported by another resident of inappropriately touching her. Resident #90 stated that he accidentally brushed his hand against a female resident's breast. He explained that he jokingly asked the resident if she would like to be harassed, and she answered yes. He then reached to touch her shoulder and he accidentally touched her breast. The incident was reported as per facility policy. skin check completed. patient placed on 1:1 for safety. Review of Resident #90's most recent Quarterly MDS, dated [DATE], revealed a BIMS score of 15, indicating cognitively intact. The MDS did not reveal any behaviors. Resident #90's clinical record was void of any documentation of 1:1 supervision in November 2023 or December 2023 and no orders for 1:1 supervision for this time frame could be found. Continued review of the abuse log revealed Resident #90 had another resident to resident incident on 12/26/23 involving Resident #100. Review of Resident #90's progress note, dated 12/26/2023 at 3:13 p.m., indicated resident [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the facility's incident log showed Resident #12, a vulnerable resident had a fall on 12/4/23. Review of Hospital records dated 12/4/23 at 7:51 p.m. revealed a [AGE] year-old female with past medical history of congestive heart failure (CHF), cerebral vascular accident (CVA), hypertension (HTN), and renal failure presents to Emergency Department (ED) via Emergency Management Services (EMS) from nursing home with complaints of severe right leg pain due to fracture and fever. Patient's temperature was 100 degrees Fahrenheit on arrival. Patient states she does not know when the fracture happened. Patient reports she had her left leg amputated in 1992. Patient documentation from nursing home shows fracture of proximal fibular and tibial meta diaphysis. Hospital X-rays obtained on 12/04/23 at 9:20 p.m. showed minimally displaced fracture of the proximal tibial metaphysis. Review of the admission Record revealed Resident #12 was originally admitted to the facility on [DATE] and readmitted on [DATE] following a 10-day hospitalization. The resident was re-admitted with a primary diagnosis of unspecified fracture of upper end or right tibia, sequela and additional diagnoses to include legal blindness, end stage renal disease (ESRD), contracture of right hand, contracture of right wrist, hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, unspecified convulsions, and psychotic disorder with delusions due to unknown physiological condition. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] showed Resident #12 had a BIMS of 14, indicating intact mental cognition. Section G showed the resident had upper and lower extremity impairment and was totally dependent on staff for all ADLS (activities of daily living). On 01/12/24 at 11:01 a.m., an interview was conducted with Resident #12's RP regarding the fall and hospitalization. She said, They said they called me, and they left a voice mail. They did not leave any voicemails. If they couldn't reach me, they could have reached other family members. They have contacts. They sent her out [referring to the 12/4/23 hospitalization] and they did not tell me. I did her washing and when I dropped it off that was when I found out she was gone. The RP stated the NHA told her the resident was sent out because her wound was infected. The RP said, She [NHA] did not say her leg was broken. They did not tell me how the injury happened. They did not tell me her leg was broken or how it broke. The RP stated she went to the hospital to visit Resident #12 and when another family member, who accompanied her, touched the resident's leg, she hollered. The RP said, She was in pain. The doctor said she had broken her leg. That was when I found out. I called the facility. The [NHA] told me it may have happened during dialysis. She said I could call them and ask them. I was upset. The RP stated Resident #12 needed more supervision because she was blind and was dependent on staff. The RP said, They should know who dropped her. All I know is she has a broken leg that is infected, and I don't know how the leg broke. I am afraid she will lose her only leg. Review of progress notes for Resident #12 showed: 12/4/23 Note Text: CNA notified this writer that during care resident c/o pain to right knee. Resident stated her right knee hurts with movement and repositioning, swelling noted, MD notified with new order for x-ray to right knee, RP notified, will continue to monitor. 12/4/23 Note documented by NHA on 12/5/23, Spoke with resident concerning positive x-ray results. Resident denies harm and states she experienced a fall at dialysis. 12/4/23 Note Text: X-ray results received showing There are fractures of the proximal right fibula and tibia. PCP notified, left VM [voicemail] with RP. DON and Administrator notified. 12/4/23 Note Text: Resident alert and oriented. Complaints of pain in right leg. Scheduled pain medication was given. X- ray was completed to the right femur. Due to pending/preliminary results new orders were given to send resident out to the emergency room to be further evaluated. Power of Attorney was notified x 3 via Voicemail & was notified to call the facility's nursing team back regarding resident's plan of care. 12/4/23: Note Text: PCP [Primary Care Physician] notified of results, orders to send patient to ER for further evaluation. On 01/08/24 at 9:45 a.m., Resident #12 was noted with an undated dressing on her left arm. The dressing around the left upper arm area was observed with blood. Resident #12 stated she did not know she had been bleeding and did not know the cause. The resident made no mention of her leg injuries. On 01/12/24 at 10:16 a.m., an interview was conducted with the ESRD facility's Clinical Manager where Resident #12 received dialysis. She confirmed Resident #12 was their resident and attended dialysis at their facility every Monday, Wednesday, and Friday. The Clinical Manager stated, She [Resident #12] arrived at the facility on 12/4/23. She had no incidents. Patient comes to our facility under the care of the transport company. She arrives in a stretcher, and then they transfer her into a chair. She never ambulates. The transport puts her in the treatment chair. She never gets out of the treatment chair. The Clinical Manager stated she never received a phone call from the facility. She stated , I was told on 12/6/23 that she was not coming to dialysis because she was hospitalized for a wound infection. The Clinical Manager stated she did not know anything about the patient falling. She said, She probably fell at [name of the nursing home]. She never walks. I received a call from some insurance people while she was at the hospital. They wanted to know the date of the incident. I told them, she did not fall at dialysis. I have not heard from them again. The Clinical Manager confirmed the facility never contacted her to inquire about the resident's fall or an injury she may have sustained at the ESRD facility. On 01/12/24 at 2:15 p.m., an attempt to reach Resident #12's dialysis transportation company was unsuccessful. Review of a Radiology report for Resident #12 dated 12/04/23 at 6:27 p.m., showed: Knee 1 of 2 views, right. Results: There are moderately displaced fractures of the proximal right fibular and tibial metadiaphyses with medialization of the proximal fracture fragments. Bones are osteopenic. Soft tissue overlies the fracture. Conclusion: There are fractures of the proximal right fibula and tibia On 01/12/24 12:37 p.m. an interview was conducted with the Risk Manager Consultant (RMC), and the Regional Nurse Clinical (RNC). The RMC stated he had reviewed the investigation file. He stated it showed resident had a BIMS 14 and she reported that she fell at the dialysis center. He stated the paper he was reviewing was undated. He confirmed Resident #12 was transferred out because her X-rays came back positive for a leg fracture. The RMC read a progress note dated 12/4/23 showing, the resident said nobody hurt her and no one abused her. He stated there were two notes from the nurse which read, On 12/4/23 resident alert, she complained of leg pain and pain medication given. Right leg was not swollen but she did complain when I moved it through ROM (range of motion). CNA made me aware she was complaining of pain in her right leg. A CNA report read, I was giving care to [Resident #12] when I moved her leg, she was in pain. I informed the nurse who was on duty. The RMC stated the NHA Investigation summary showed the resident's knee x-ray results showed fracture of right fibula and tibia. It showed the PCP, DON and NHA were notified. The NHA interviewed the patient and she denied anybody was abusing her. She admits to falling at dialysis center. Medical Doctor (MD) ordered transfer to the ED. She left a voice mail with patient's mother and was waiting for a call back. The RMC said, I cannot conclude what happened. I agree there is an incomplete investigation. On 01/12/24 12:48 p.m. The RNC stated, The NHA talked to the patient who has a BIMS of 14 there does not seem a reason why we would not trust that patient. I did not know she was blind. I do understand that the patient suffered a significant injury. She reported it happened at dialysis. I agree, there is no evidence that follow-up calls were made to figure out what happened. Further investigation should have been conducted. You are right, dialysis or dialysis company should have been contacted. I don't know if the incident was reported. 01/12/24 at 3:16 p.m., an interview was conducted with the facility's Medical Director (MD), who is also Resident #12's PCP. The MD stated he did not have any recollection of any recent injury reports that resulted in a hospitalization. He could not recollect a fall with injury for Resident #12 and stated I would know. The MD did not remember being notified. The MD stated if there was a significant injury, he would have expected to be notified. The MD said, I would remember if a resident had significant injuries. It should be documented if I had a follow-up visit. Review of physician notes showed Resident #12 was seen by the MD on 04/12/23, 04/26/23 and 09/09/23. There were no physician notes documented on or around the time of Resident #12's injury on 12/04/23 or after she returned from the hospital on [DATE]. On 01/09/24 at 3:43 p.m., an interview was conducted with Resident #36. She reported she was verbally abused by a staff member. Resident #36 stated a staff member yelled at her. She was scared to report the incident, but she told the Social Services Director (SSD) the first time it happened. She stated this happened before Christmas. Resident #36 said, The CNA yelled at me because of a fan. She called me out. Her name is [Staff T, CNA]. She stated she spoke to the DON and SSD about it. Resident #36 stated [Staff T] had gotten into her face about a fan at night. She said, She was just rude and disrespectful. She called me names. I don't want to say much about it. I don't want them to come after me. Then today, it's [Staff R, CNA]. This morning she [Staff R] came up again and said she will not assist me with my shower, and she won't change me. She said if you don't stop that [expletive] you will get into more trouble. Review of a grievance/concern report dated 12/23/23 for Resident #36 completed by Staff R, CNA revealed, Resident was upset when I came in this morning. I asked her what was wrong. She said an overnight CNA [Staff T, CNA] came in her room and took her fan out of her room. She told her to shut up she is tired of her shit and that it was her fan. Review of the grievance completed by the DON showed under facility follow-up Resident was informed the fan was the CNA's. A section on the form asked if this was an allegation of abuse. The box was left blank, indicating facility did not consider verbal abuse towards the resident abuse. The resolution of grievance /concerns section showed the grievance was not confirmed. Under the findings summary it showed, Resident voiced understanding the fan was not hers. The SSD signed off the grievance and indicated the resident was satisfied with the grievance resolution. On 01/09/24 at 4:09 p.m., an interview was conducted with Staff R, CNA with the DON present. Staff R stated she worked the back hall where Resident #36's room is located. She stated she had not had any negative interaction with the resident. She stated the previous week, Resident #36 reported someone took her fan. Resident #36 reported the staff member walked into the room to get her fan and that she used some words to her and her roommate, Resident #81. Staff R said, I submitted a grievance to the DON because the two residents [#36 and #81] were upset. Staff R stated Resident #36 was upset. She said, I asked her, and she said a CNA [Staff T] told her to shut up and mind her own business. Staff R stated the CNA Resident #36 was referring to was Staff T, CNA who worked the same assignment area during the 3 p.m. to 11 p.m. shift. Staff R said, This morning, she did not want to get out of bed, she was upset. She first told me she said she did not want to shower. I left her and then came back and took care of her. I was not rude or mean to her. She was upset with [Staff T]. On 01/09/24 at 4:15 p.m., an interview was conducted with the DON. She said, When the fan was taken, I questioned [Staff T, CNA] regarding the fan. Staff T said the fan was hers, and she was letting the resident borrow the fan. She stated the resident reported [Staff T] was rude to her when she took the fan back. The DON said, It was the way she took the fan. She [Staff T] told her she was taking it because it was not hers. She apparently told her to shut up. We questioned her [Resident #36] about the incident. It was a couple days after the grievance was documented. I went there with the SSD. Her other roommates were in the room. Resident #36 denied the abuse incident at that time. She did not say [Staff T] used choice words. I don't know why she changed her story. She had first reported the incident to [Staff R] the morning it happened. The DON stated she did not initiate abuse allegation for Resident #36 related to the 12/23/23 grievance because when she went to question the resident, she denied the abuse even though it was already documented. The DON stated she focused on the fan. The DON stated she did not talk to the resident privately. She stated she did not obtain witness statements from other residents or staff regarding the verbal abuse because the resident withdrew her statement. She stated, I don't know why she would have reported abuse and then withdrew it. I did not follow-up. I did not ask other staff about it. On 01/09/24 at 04:55 p.m., an interview was conducted with the NHA and the DON. The NHA stated regarding the fan incident on 12/23/23 with Staff T, the DON resolved the grievance after she spoke to the resident and the resident denied any abuse related to this incident. The NHA stated she did not have any witness statements. The DON stated she did not speak to the nurse who worked that night. She did not interview the roommates. The DON stated she did not document the resident's response related to denying that someone abused her verbally. She stated she did not document any of the interviews. She stated she did not know that she needed to document any of that information. The DON stated she did not know she needed to ask other staff or other residents about the verbal abuse allegations. The DON stated she did not follow-up with Staff R regarding the initial grievance submitted on 12/23/23 on Resident #36's behalf. A follow-up interview was conducted on 01/10/24 at 4:26 p.m. with the DON and the NHA. The DON said, at the time of my investigation they said it did not occur. I did not revisit the issue. I did not think to look further. I did not focus on the verbiage used when the grievance was documented because the residents said it did not happen. I don't know why they changed their story. Now I see how I should have investigated it further. I did not interview other staff or residents. I did not know she still had issues with that incident. A review of the facility's abuse log revealed Resident #164 made an allegation of abuse on 9/19/23. During an interview on 01/10/24 at 12:16 p.m. the Nursing Home Administrator (NHA) confirmed an allegation of abuse was made by Resident #164 on 09/19/23 and a federal report was completed. The resident reported his Certified Nursing Assistant (CNA), Staff R poisoned his coffee. The resident stated he witnessed the CNA remove his coffee and put an unknown substance in his coffee. An investigation was initiated. The NHA stated she could not find the statements she obtained from the CNA. She stated she spoke to the nurse who worked that day as well but could not find that statement either. A follow-up interview with the NHA on 01/10/24 at 12:38 p.m., revealed she misplaced the entire file related to Resident #164's abuse investigation to include witness statements. The NHA said Staff R, CNA was suspended for 5 days and education was conducted for all staff on Abuse and Neglect but no documentation of the training could be provided. Review of Resident #164's admission Record revealed he was admitted on [DATE] with diagnoses to include muscle wasting and atrophy, epilepsy, unspecified dementia with agitation, and adult failure to thrive. The resident's admission Minimum Data Set assessment dated [DATE] revealed a BIMS score of 7, indicating severe cognitive impairment. The resident exhibited no signs of psychosis or behaviors. The resident had no new orders received on 9/19/23 following the allegation and no pain assessments completed. The admission record revealed the resident was discharged on 09/30/23 with no discharge location documented Review of the facility's abuse log revealed a resident to resident incident occurred on 11/21/23 involving Resident #32 and Resident #90. Review of Resident # 32's progress note, dated 11/21/2023 at 9:04 p.m., signed by Staff L, Licensed Practical Nurse (LPN), revealed, Resident reported that another resident touched her inappropriately. States that while at the smoking area on Saturday [11/18/23], a male resident approached her and asked her if she would like to be sexually harassed, she agreed to it thinking it was a joke and he went ahead and touched her breast. Review of Resident #32's most recent Quarterly Minimum Data Set Assessment (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. During an interview on 01/10/24 at 3:05 p.m. Resident #32 said Resident #90 came up and asked if I wanted to be sexually harassed. I thought he was joking and then he groped my breast. When asked if she thought the touch on her breast could have been an accident, Resident #32 replied, I never told anyone it was an accident. Resident #32 continued to describe the events and said, Staff I, Certified Nursing Assistant (CNA) overheard me say to Resident #90, there will be no more of that, and asked what I was talking about. Resident #32 reported she told Staff I, CNA about Resident #90 touching her breast. Staff I then came to my room and helped me write a grievance. This was all reported to Staff I, CNA on the day it occurred, but I found out about four days after the incident, on 11/21/2023, that the grievance had been lost. I became hysterical and called the police. The police came and talked to me. This was on 11/21/2023, four days after the incident, and four days after Staff I, CNA helped me write the grievance. When I called the police, I heard Resident #90 was immediately placed on 1:1 (one to one) supervision, but I heard he got caught with someone else and was put on 1:1 again. During an interview on 01/10/24 at 3:15 p.m., Staff I, CNA reported she remembered Resident #32 reporting the allegation of sexual abuse. She said she reported the incident but was not sure who she had reported it to. Staff I was aware law enforcement was called but was not present at the facility when law enforcement came. Staff I said Resident #90 was placed on 1:1 supervision immediately after she reported it. Resident #90 was taken off of the 1:1 supervision (date unknown) but was placed back on 1:1, maybe less than two weeks later. A follow-up interview was conducted with Staff I, CNA on 01/11/24 at 1:17 p.m. She recalled reporting the event with Residents #32 and #90 on a Saturday (11/18/21) to the weekend nurse supervisor, Staff N, Registered Nurse (RN). Staff I, CNA did not know if Staff N, RN called the Director of Nursing (DON) or the Nursing Home Administrator (NHA) to report the event but remembered they wanted a statement. They had Resident #32 write the statement and Staff I, CNA signed under Resident #32's statement. The weekend supervisor (Staff N, RN) was sick the next day and I made a copy of the statement, but I can't find the copy. I slid the statement under the NHA's door on Sunday before I left the facility. On Monday, the NHA said the housekeeper must have swept up the statement because she did not see it. I came in that Tuesday, 11/21/2023 and went to the NHA's office. I attempted to give the NHA a copy of the statement, and the NHA didn't take it from me. The NHA said that she had it handled. An interview was conducted with the NHA on 01/11/2024 at 5:58 p.m. to discuss the incident between Resident #32 and #90 and the investigation of the incident. The NHA said she first learned of the incident when Resident #32 called law enforcement on 11/21/2023 and the evening unit manager, Staff L, LPN called her. The NHA said she came to the building and talked to both residents and staff but did not document any of the interviews. She said no staff witnessed the incident and neither resident involved remembered what date the event took place. Resident #32 did not report telling any other staff, so no other staff were interviewed. The NHA said she did not receive a written statement from Staff I, CNA. The NHA expressed that Resident #32 and Resident #90 stated this incident was consensual. The NHA said the 1:1 supervision was for a short period of time. When asked if Resident #32's call to 911 to report the event as a crime on 11/21/2023 indicated a consensual event took place for Resident #32, the NHA did not respond. On 01/11/24 at 1:15 p.m. a telephone call was made to Staff L, LPN who documented the report of abuse on 11/21/2023. Staff L, LPN did not answer and a message stating the phone number was not accepting messages received. Due to this, no voicemail could be left for a return call. On 01/11/24 at 1:36 p.m. a telephone call was placed to the weekend nurse supervisor/Staff N, RN related to Staff I, CNA's report to her of a sexual abuse allegation by Resident #32 on 11/18/23. A voicemail message was left but no return call was received prior to exiting the facility on 1/12/24. Review of Resident #90's progress note, dated 11/21/2023 at 8:38 p.m. and signed by Staff L, LPN revealed, this resident was reported by another resident of inappropriately touching her. Resident #90 stated that he accidentally brushed his hand against a female resident's breast. He explained that he jokingly asked the resident if she would like to be harassed, and she answered yes. He then reached to touch her shoulder and he accidentally touched her breast. The incident was reported as per facility policy. skin check completed. patient placed on 1:1 for safety. Review of Resident #90's most recent Quarterly MDS, dated [DATE], revealed a BIMS score of 15, indicating cognitively intact. The MDS did not reveal any behaviors. Resident #90's clinical record was void of any documentation of 1:1 supervision in November 2023 or December 2023 and no orders for 1:1 supervision for this time frame could be found. Continued review of the abuse log revealed Resident #90 had another resident to resident incident on 12/26/23 involving Resident #100. Review of Resident #90's progress note, dated 12/26/2023 at 3:13 p.m., indicated resident observed in a confused resident's room this afternoon touching the resident. Resident voiced understanding but stated, even if she asked for it. The resident was placed on a 1:1 and police were notified. Resident will be moved to a different hallway. Medical Doctor, Responsible Party (RP), and NHA notified. Review of Resident # 90's Social Service note, dated 12/29/2023 at 1:28 p.m., revealed the Social Services Director and the Licensed Clinical Social Worker (LCSW) met with the resident to facilitate a BIMS. The resident scored a 15 of the BIMS. Impulsive behavior discussed during the meeting, Resident verbalized understanding regarding consequences of continued, inappropriate behavior. Resident verbalized agreement to cease the aforementioned behavior. DON consulted on this meeting. Social services will follow up as needed. Review of Resident #90's care plan following the 12/26/23 incident revealed a care plan for behavior was initiated on 12/29/23 for inappropriately touching female residents and staff. Interventions did not include any 1:1 supervision. The interventions documented were: Control\Minimize Outburst; Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care; Document episodes of behavior & review to determine the effectiveness of intervention; Psychiatry Services as needed; and Psychological Services as needed. Review of Resident #100's admission Record revealed an admission date of 11/3/2023 with diagnoses to include cerebral infarction, hemiparesis and hemiplegia to left non-dominant side, diabetes mellitus type 2, chronic obstructive pulmonary disease (COPD), psychoactive substance abuse, anxiety disorder, major depressive disorder recurrent, congestive heart failure, gastro-esophageal reflux disease, and history of malignant neoplasm of the esophagus. Review of the admission MDS, dated [DATE] revealed a BIMS score of 3, indicating severe cognitive impairment. A review of the resident's care plan revealed a care plan for communication difficulty was initiated on 11/10/23. Review of Resident #100's progress note, dated 12/26/23 at 3:10 p.m. and written by the DON revealed, following an event with another resident a skin check was performed. Resident's skin is clean, dry, and intact. No open areas and no redness noted. Resident was questioned if another resident touched her inappropriately anywhere, resident declined and stated they were just talking to each other. RP and NHA notified. Review of Resident #100's progress note, dated 12/27/23 at 11:24 a.m. and written by the DON revealed, a phone call was made to resident's RP to inform him of the events that occurred 12/26/23. RP did not have any questions or concerns at this time. On 01/12/24 at 2:21 p.m. an attempt was made to contact Resident #100's RP but the voicemail was not set up to receive messages. During an interview on 1/9/24 at 5:58 p.m. the Law Enforcement Officer (LEO), who responded to the facility following the event on 12/26/2023, reported he interviewed Resident #100 about the incident and she stated that she consented, but for most of the interview her responses were inappropriate other than stating her name. He also reported that other staff at the facility told him the alleged perpetrator, Resident #90 had a previous history of this behavior but due to Resident #100's responses he was not able to take further action. During an interview with Resident #90 on 01/10/24 at 8:16 a.m. he was observed in bed with a staff member providing 1:1 supervision. Resident #90 said the incident from about a month ago was blown out of proportion and his side of the story was very different from the other person. He also said that he had someone with him 1:1 for a few days after that. When asked about the 1:1 today, he said that was permanent now, even though he doesn't agree with it, but he has no choice. He denied that any other interventions had been discussed with him or were attempted. He denied any involvement of his doctor, or discussion about or changes in medications or other treatments. Based on observation, interviews with residents, facility staff, resident representatives, the Clinical Manager of a dialysis facility, and the Medical Director, and review of policy and procedures, clinical records, training records and incident logs, it was determined the facility failed to identify, investigate, prevent, and take corrective action for the neglect of two (#308 and #106) of 12 residents reviewed for abuse and neglect. The facility failed to ensure wound care orders were implemented for Resident #308 and #106 resulting in the worsening of the wounds, and failed to investigate the cause of a fracture of unknown origin for one (#12) of 12 residents. The facility failed to ensure six (#6, #32, #36, #90, #100, and #164) residents with allegations of physical, verbal, psychological, psychosocial and sexual abuse out of 12 residents reviewed for abuse and neglect had investigations initiated, thorough investigations conducted, documentation of a thorough investigation maintained, protective measures implemented, and corrective actions taken to prevent further abuse. These systemic failures resulted in Immediate Jeopardy which began on 09/19/23 and was ongoing at the time of survey exit on 01/12/2024. Findings included: Cross reference: F600, F726, F835, and F867. A review of the facility's Abuse Prevention Program with an effective date of 2012 and a most recent change date of August 2022 revealed: POLICY: The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment and misappropriation of resident's property. These policies guide the identification, management and reporting of suspected, or alleged, abuse, neglect, mistreatment and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burnout, or resident behavior which may increase the likelihood of such events. PROCEDURE The facility has implemented the following processes in an effort to provide residents, visitors and staff with a safe and comfortable environment. o The Administrator is responsible for designating an Abuse Coordinator. o The designated shift supervisor is identified as responsible for immediate initiation of the reporting process. o The Administrator, DON and/or designated individual are responsible for the investigation and reporting of suspected, or alleged, abuse, neglect, and exploitation and misappropriation. o The Administrator, DON and/or designated individual are also ultimately responsible for the following: o Implementation o Ongoing monitoring o Investigation o Reporting o Tracking and Trending IMPLEMENTATION and ONGOING MONITORING: o TRAINING Facility orientation program & ongoing training programs will include, but may not be limited to: o 483.95(c): Freedom from abuse, neglect, & exploitation requirements in 483.13. o 483.95(c): Activities that constitute abuse, neglect, exploitation, & misappropriation of resident property as set forth in 483.12. o 483.95(c): Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property. o 483.95(c): Dementia management & resident abuse prevention. o Elder Justice Act, (See Elder Justice Act Policy & Procedure). o Identification of abuse, neglect, mistreatment, exploitation and misappropriation. o Utilization of appropriate interventions to manage resident behaviors that might result in harm to the resident or staff, aggressive &/or catastrophic reactions of residents. Refer to Behavior Management Program and Code CAT process for further information. o How staff should report their knowledge related to allegations without fear of reprisal. o How to provide protection for residents. o Components of a complete and thorough investigation. o Methods to reduce the risk of abuse, neglect, mistreatment, misappropriation, and exploitation that may include, but may not be limited to, recognizing signs of burnout, f[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, medical record reviews personnel record reviews and training records, the facility failed to have competent staff to identify abuse, protect residents during abuse investigations and investigate abuse allegations to prevent reoccurring abuse; the facility failed to have competent staff to accurately assess residents' medical conditions and to provide care and treatment to prevent worsening of conditions, for pressure ulcers, and significant change in condition after a fall. The facility failed to provide ongoing staff training and monitoring to ensure nursing skills and competencies to provide safe and adequate care for the residents to achieve their highest practicable level of well-being for 10 residents (#164, #207 #90, #100, #32, #12, #308, #6, #36, and #106) of 112 residents in the facility census. These failures created situations that resulted in worsened conditions and the likelihood for serious injury and or death to residents (#164, #207 #90, #100, #32, #12, #308, #6, #36 and #106) and resulted in the determination of Immediate Jeopardy determined to be ongoing at the time of facility exit on 01/12/2024. Findings included: Cross reference F600, F610, F686, and F835 During a survey conducted 01/08/24 to 01/12/24 non-compliance was found for 9 of 12 residents reviewed for abuse and neglect. Review of records, interview with facility staff, families and medical director revealed concerns with facility's reporting, investigation, and implementation of safety processes to prevent abuse and neglect. Resident #164 reported that Staff R, Certified Nursing Assistant (CNA) poisoned his coffee on 09/19/23. This resident was admitted to the facility on [DATE] and discharged on 9/30/23. Diagnoses included muscle wasting and atrophy, not elsewhere classified, multiple sites, epilepsy, unspecified, not intractable, without status epilepticus and unspecified dementia, unspecified severity, with agitation. A Quarterly Minimum Data Set (MDS), dated [DATE], showed a BIMS (Brief Interview of Mental Status) score of 07 indicating severe cognitive impairment. Resident #32 reported allegations of sexual abuse by another resident on 11/18/23. This resident was admitted on [DATE] with diagnoses to include post-traumatic stress disorder, chronic, schizoaffective disorder, unspecified anxiety disorder and major depressive disorder. An MDS, dated [DATE], showed a BIMS score of 15 indicating intact cognition. Resident #90 was identified on 11/21/23 to be involved in a resident-to-resident abuse incident. This resident was admitted on [DATE] with diagnoses to include hemiplegia and hemiparesis following cerebral infarction, occlusion and stenosis of right carotid artery, personal history of transient ischemic accident (TIA), history of falling, and muscle wasting. An MDS, dated [DATE], revealed a BIMS score of 15 indicating intact mental cognition. Resident #6 reported allegations of physical abuse by Staff W, Certified Nursing Assistant (CNA) on 12/15/23. This resident was admitted to the facility on [DATE] with diagnoses to include other sequelae or other cerebrovascular disease and aphasia. A Quarterly MDS, dated [DATE], showed a BIMS score of 15 indicating intact cognition. Resident #100 was involved in a resident-to-resident sexual abuse incident on 12/26/23. This resident was admitted to the facility on [DATE] with diagnoses to include cerebral infarction, hemiparesis and hemiplegia to left non-dominant side, diabetes mellitus type 2, chronic obstructive pulmonary disease (COPD), anxiety disorder, major depressive disorder recurrent, congestive heart failure, gastro-esophageal reflux disease, and history of malignant neoplasm of the esophagus. An admission MDS, dated [DATE], showed a BIMS score of 03 indicating severe cognitive impairment. Resident #36 was involved in a verbal abuse incident by a staff member on 12/23/23. This resident was admitted to the facility on [DATE] with diagnoses to include muscle wasting, COPD, other abnormalities of gait, seizures, bipolar disorder, major depressive disorder. A Quarterly MDS, dated [DATE], showed a BIMS score of 13 indicating intact cognition. Resident #308 failed to receive goods and services resulting in worsening of wounds identified on 11/29/23. This resident was readmitted to the facility on [DATE] with diagnoses to include encephalopathy unspecified, pneumonia unspecified, sepsis, cellulitis, local infection of the skin and subcutaneous tissue, acute respiratory failure, cerebral infarction unspecified and muscle wasting among others. A Quarterly MDS, dated [DATE], showed the resident had a BIMS score of 99 indicating the resident was unable to complete cognition interview. Resident #106 was involved in an allegation of neglect related to wound care on 10/24/23. This resident was admitted to the facility on [DATE] with diagnoses to include partial amputation of right foot, other specified local infections of the skin and subcutaneous tissue, type 2 diabetes, cellulitis, osteomyelitis, sepsis, other kidney failure, and muscle wasting, Resident #12 was involved in an allegation of possible neglect related to a failure to complete a full investigation following a possible fall with a fracture on 12/4/23. This resident was originally admitted to the facility on [DATE] and readmitted on [DATE] following a 10-day hospitalization. The resident was re-admitted with a primary diagnosis of unspecified fracture of upper end or right tibia, sequela and prior diagnoses to include legal blindness, end stage renal disease, contracture of right hand, contracture of right wrist, hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, unspecified convulsions, and psychotic disorder with delusions due to unknown physiological condition. Review of the admission Record for Resident #207 revealed an original admission date of 12/4/23 and a readmission date on 12/26/23 with diagnoses to include repeated falls, pain in right arm, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unspecified lack of coordination, difficulty in walking, and unsteadiness on feet. Review of The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities (https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html#:~:text=1.-,Evaluate%20and%20Monitor%20Resident%20for%2072%20Hours%20After%20the%20Fall,provide%20immediate%20treatment%20if%20necessary) showed: Chapter 2. Fall Response 1. Evaluate and Monitor Resident for 72 Hours After the Fall Immediate evaluation by the nurse after a resident fall should include a review of the resident systems and description of injuries. Upon evaluation, the nurse should stabilize the resident and provide immediate treatment if necessary. Evaluation of the resident's condition before, during or immediately after the fall provides clues to possible causes. 6. Complete Falls Assessment In addition to the clues discovered during immediate resident evaluation and increased monitoring, the FMP (Falls Management Program) Falls Assessment is used for a more in-depth look at fall risk. Five areas of risk accepted in the literature as being associated with falls are included. Because the Falls Assessment will include referrals for further workup by the primary care provider or other health care professionals, contact with the appropriate persons should be made quickly. A review of Resident #207's SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers, dated 1/1/2024 at 3:15 a.m., revealed: Situation: The Change In Condition (CIC)/s reported on this CIC Evaluation are/were: Falls, Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: No changes observed - Functional Status Evaluation: Fall - Neurological Status Evaluation: Nursing observations, evaluation, and recommendations are: resident found sitting on floor next to bed in room. Stated the gas is on nonskid socks on, bed was in lowest position. No injuries noted. Neuro checks initiated. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: NNO (No New Orders). Review of a Post Event Note, dated 1/1/2024 at 3:15 a.m. documented, Note Text: This is an Initial Event Note for: (Resident #207) The following event has occurred: Unwitnessed Fall The noted date and time of the event are as follows: 01/01/2024 3:15 AM The event took place in the following location: resident's room Mental status was evaluated and the resident is noted to be oriented to the following: Oriented to person The following are noted to be the most recent Vital Signs: T (temperature) 97.8 - 1/1/2024 03:15 Route: Forehead (non-contact) P (pulse) 78 - 1/1/2024 03:15 Pulse Type: Regular R (respirations) 16.0 - 1/1/2024 03:15 BP (blood pressure) 104/64 - 1/1/2024 03:15 Position: Lying l/arm O2 (oxygen saturation) 96.0 % - 1/1/2024 03:15 Method: Room Air The resident displayed Active ROM (range of motion). The body parts ROM was completed on include the following: extremities Regarding LOC (level of consciousness), the resident is noted to be alert. Regarding mobility, the resident is noted to be wheelchair dependent. The resident's left pupil was evaluated and can be described as: Brisk. The resident's right pupil was evaluated and can be described as: Brisk. The left hand grasp is greater than the right. The following are the extremities that the resident can move: The resident can move the left arm. The resident can move the left leg. The resident is cognitively impaired, and evaluation of facial expression indicates there is no pain. The resident's response to pain is described as: Appropriate. The findings of the Skin Check that was completed include the following: intact. The description of the event as provided by licensed staff is as follows: resident found sitting on floor next to bed in room The resident has provided the following description of the event: the gas on The resident was assisted from the floor. The resident was noted to be able to transfer from the floor with the assistance of a mechanical lift. The last time the resident was toileted: 01/01/2024 1:00 AM The name of the practitioner notified is: (Physician's name) The date and time of practitioner notification: 01/01/2024 3:25 AM The name of the Resident Representative notified: (name of family member). The date and time the Resident's Representative was notified: 01/01/2024 4:00 AM. Review of a Neuro Check Note, dated 1/1/2024 at 3:15 a.m., documented: The left hand grasp is noted to be greater than the right. The following are the extremities that the resident can move: The resident can move the left arm. The resident can move the left leg. Movement of the noted extremities is described as left greater than right. The resident's response to pain is noted to be appropriate. Review of a Neuro Check Note, dated 1/1/2024 at 3:30 a.m., documented: The left hand grasp is noted to be greater than the right. The following are the extremities that the resident can move: The resident can move the left arm. The resident can move the left leg. Movement of the noted extremities is described as left greater than right. The resident's response to pain is noted to be appropriate. Review of a Post Event Note, dated 1/3/2024 at 1:12 a.m., documented: A fall event occurred .Neuro Checks were completed and there is no change in orientation, cognition, or consciousness noted A Skin Check was completed and no redness, swelling, bruising, or other concern is noted There is noted to be no change in ROM (Range of Motion). No pain is noted when performing ROM, The intervention initiated related to this fall has been reviewed and remains in place. Review of a Post Event Note, dated 1/4/2024 at 4:59 a.m., documented: A fall event occurred .Neuro Checks were completed and there is no change in orientation, cognition, or consciousness noted A Skin Check was completed and no redness, swelling, bruising, or other concern is noted There is noted to be no change in ROM. No pain is noted when performing ROM The intervention initiated related to this fall has been reviewed and remains in place. Review of a Post Event Note, dated 1/5/2024 at 2:53 a.m., documented: A fall event occurred to [Resident #207] The most recent Vital Signs are as follows: Neuro Checks were completed and there is no change in orientation, cognition, or consciousness noted A Skin Check was completed and no redness, swelling, bruising, or other concern is noted There is noted to be no change in ROM. No pain is noted when performing ROM The intervention initiated related to this fall has been reviewed and remains in place. Review of nursing progress notes for assessment completed from 1/1/2024 to 01/10/2024 did not indicate a swollen condition to either shoulder. During an observation on 01/10/2024 at 2:17 p.m. Resident #207 was in his room in bed sleeping, with a sheet over him. During an interview on 01/10/2024 at 12:23 p.m. Staff Z, Licensed Practical Nurse (LPN) was asked if Resident #207's shoulders were swollen and when Staff Z, LPN checked she confirmed his right shoulder was swollen. Review of the electronic medical record showed on 01/10/2024 at 4:43 p.m., the record was silent of documentation related to Resident 207's swollen right shoulder. During a record review on 01/10/2024 at 5:18 p.m. Staff B, Director of Nursing (DON) was interviewed related to Resident #207's right swollen shoulder and she said there was no notification to her that Resident #207's shoulder was swollen. There was no progress note documented about Staff Z, LPN's finding or a right swollen shoulder. During an interview on 01/12/2024 at 8:06 a.m. Staff Z, LPN was asked why she did not document on 01/10/2024 the confirmation of Resident #207's right swollen shoulder. She said she was waiting to get guidance, but she did tell Staff G, Registered Nurse (RN)/Unit Manager (UM) about the swollen shoulder. During an interview on 01/12/2024 at 8:10 a.m. Staff G, RN/UM said Staff Z, LPN did inform her of the swollen shoulder, and she submitted an order for an X-ray. She was requested to provide a copy of when she submitted the X-ray request. On 01/12/24 at 11:52 a.m. Staff C, RN/Regional Nurse Consultant provided a copy of the submitted request to [name of company] for X-Ray, dated 01/10/2024 at 5:37 p.m. (after interview with Staff B, DON at 5:18 p.m.). During an interview on 01/11/2024, Staff B, DON (Director of Nursing) said the facility does not have competency for completing a head-to-toe assessment. Staff B, DON said Staff Z and Staff AA are LPNs (Licensed Practical Nurse) and based on their LPN license they should have come to the facility with skills to do a head-to-toe assessment. When asked if the facility completes any follow-up monitoring of nursing skills, she indicated just the annual skills fair completed in September, but it did not include head to toe assessment. Staff Z/LPN's Hire Date is 08/07/2022. Staff AA/LPN's Hire Date is 08/15/2012. Review of personnel files revealed Staff Z, LPN had a new employee orientation checklist that did not include nursing skill assessment/evaluations or change in condition evaluation. Staff Z, LPN had no competency training in her personnel file. Review of Staff AA, LPN's personnel file revealed no competency training in her personnel file. During an interview on 01/11/2024 at 12:41 p.m., Staff H, LPN/Unit Manager East (110 and 200 Halls) and Staff G, RN(Registered Nurse)/Unit Manager [NAME] (300 and 400 Halls) said the Staffing Coordinator drafts the schedule and assigns the RNs and LPNs; the CNAs(Certified Nursing Assistant) select their assignment based on history and choice and familiarity with the resident on the hall. The Unit Managers will make staff assignment adjustments of staff on duty based on the needs of the residents. The facility uses Per Patient Day (PPD) to determine the number of staff assigned to work on each day and shift. The Nursing Home Administrator (NHA) and Staffing Coordinator/Central Supply determine how many staff need to be assigned per day to the facility. During an interview on 01/11/2024 at 2:19 p.m., Staff B, DON said Staff Z, LPN and Staff AA, LPN do not have orientation packets in their personnel files. Nursing annual training was completed in September 2023 for competencies. The training competencies provided in September were reviewed during the interview and none addressed the head-to-toe assessment/evaluation of residents. Staff B, DON said based on discussions during the survey the facility identified the need to develop and implement a competency for head-to-toe assessment/evaluation of residents. During an interview on 01/11/2024 at 4:31 p.m., the NHA and Staffing Coordinator/Central Supply said the facility has a staffing meeting every day at 11:00 a.m. to ensure the schedule is covered if we have any call offs. The Staffing Coordinator/Central Supply had her draft paper filled out based on the master and has scheduled day and she completed the day based on the master. When there are open shifts, we have a group chat she sends out to nursing and CNAs to make sure there is never a hole on the schedule and if there is a hole the NHA and nursing team, Unit Mangers, and Staff B, DON and the 3-11 Supervisor will make sure it is covered. We look at the resident acuity to determine staffing. To provide 1 one on one staff you have 2 additional staff. When they have one on one, they have regularly assigned staff cover if one on one staff needs to take a break. The acuity level for identified residents are discussed every time at the 11:00 a.m. meeting. When asked if the facility has a tool to assist them to identify what level of acuity is required for a resident, they indicated there is no tool used, it is based on nursing management staff knowledge of the residents. When asked if there was any training they had to identify a specific resident acuity level the NHA and Staffing Coordinator/Central Supply were not sure if there was a guide for accurate identification of a specific resident's acuity level/need. The NHA confirmed there was no current formal training or guide to identify a specific resident's acuity level. On 01/11/24 at 10:44 a.m. the DON entered the conference room with a laptop computer and showed a copy of the Lippincott Manual 9th Edition, which was described to be the nursing procedure manual. When asked how often this is updated she said she thinks corporate loads the most recent version. The DON said she had not used this manual before and uses the competencies. When asked how staff are trained to access the material, she said she thinks the NHA tells them and is supposed to have a hard copy. The DON described that she had worked in the facility since January 2023 and was in the position of ADON (assistant director of nursing) from May 2023 until December 2023 when she was promoted to DON. When asked if she does the training, she said no, that is typically the ADON. She said competencies are on the company electronic portal and gave the example of showing new staff in orientation how to access the dress code. She said she had not shown nurses specifically how to access the portal. She was not sure if the nurses knew how to access the competencies on the portal. She described there was a schedule provided by corporate that she follows for new employee orientation. After the 3-day orientation they are sent on the floor to a nurse preceptor for 3 days. The DON did not know who the nurse preceptors were or if they are given training to be considered preceptors. When asked who the nurses can go to if they need clinical assistance, she said the manager and if she doesn't know an answer she will go to the regional consultant. The DON did not refer to the nursing procedure manual as a resource for clinical guidance. When asked how often nurses are required to demonstrate competency, the DON responded, Typically annually, but sometimes we do it more often. We had a skills fair in September. The DON confirmed the nurse and CNA annual competencies should be in the employee file. During the interview, a review of the employee file for Staff K, LPN revealed no annual competency and the orientation competency dated 08/2022 was signed by the employee, but the signature block for the training supervisor was blank. The DON confirmed there was no annual competency in the file. During the interview a review of the employee file of Staff L, LPN revealed no annual competency. Staff L's file contained a New Employee Orientation checklist signed by the employee on 7/19/2022. There was no signature for the employee services coordinator or the staff development person. A nursing administration orientation checklist dated 7/27/2022 was signed by the employee but no signature in the blank for the nursing administrator. The DON said, During the time that I was the ADON, I never was part of an annual competency. I don't remember being told that, but it might be in my job description. If I was told I needed to do an annual competency for everyone in the building, I would have done it, but I don't know. I'll ask if that was kept somewhere else. A review of the facility assessment included a date of completion as 09/27/2023. The facility assessment described the resident population as consisting of capacity of 120 residents, ages 25 - 85+ years old, including bariatric residents. Resident conditions included but was not limited to post-surgical neuro, colostomy, infections, dementia, psychiatric disorders, tracheostomy, IV (intravenous) antibiotics, PICC (peripherally inserted central catheter) lines, urinary catheters, PEG/J-tube (percutaneous endoscopic gastrostomy and jejunostomy), wounds (surgical/pressure), hospice, and outpatient hemodialysis. Equipment needed for residents listed was standing scale, wheelchair scale, O2 (oxygen) concentrators, tanks, PD (peritoneal dialysis) equipment, hoyer lifts, sit to stand lifts, walkers, wheelchairs, door security, translation services, and communication boards. Under the column describing personnel, the Infection Preventionist and Risk Manager positions were listed as N/A for tenure, education, experience, and meets licensure/certification requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews and review of job descriptions, the facility's administration failed to utilize resources to ensure adequate supervision to effectively implement a systematic process to carry out the facility's abuse policy for seven residents (#32, #90, #100, #6, #36, #12, #164), failed to ensure the facility staff provided care and services to prevent the worsening of wounds for two residents (#308 and #106), failed to ensure hot water temperatures were maintained at a comfortable level for residents on one hallway (Hall 100), and failed to ensure oversight of nurse competency training with the potential to affect a total census of 112 residents. These systemic failures resulted in Immediate Jeopardy which began on 09/19/23 and was ongoing at the time of survey exit on 01/12/2024. Findings included: Cross reference to F584, F600, F610, F686, F726 and F867. During a survey conducted on 01/08/24 to 01/12/24 non-compliance was found for abuse and neglect for incidents/allegations to include resident to resident physical/sexual abuse (#32, #90, #100), staff to resident physical abuse (#6, #164), staff to resident verbal abuse (#36), and neglect resulting in worsening of wounds (#308, #106), and failure to investigate a fracture of unknown origin (#12). 1. Resident #164 reported that Staff R, Certified Nursing Assistant (CNA) poisoned his coffee on 09/19/23. This resident was admitted to the facility on [DATE] and discharged on 9/30/23. Diagnoses included unspecified dementia, unspecified severity, with agitation. A Quarterly Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 07 indicating severe cognitive impairment. During an interview on 01/10/24 at 12:16 p.m. the Nursing Home Administrator (NHA) confirmed an allegation of abuse was made by Resident #164 on 09/19/23 and a federal report was completed. The resident reported his CNA, Staff R poisoned his coffee. The resident stated he witnessed the CNA remove his coffee and put an unknown substance in his coffee. An investigation was initiated. The NHA stated she could not find the statements she obtained from the CNA. She stated she spoke to the nurse who worked that day as well but could not find that statement either. A follow-up interview with the NHA on 01/10/24 at 12:38 p.m., revealed she misplaced the entire file related to Resident #164's abuse investigation to include witness statements. The NHA said Staff R, CNA was suspended for five days and education was conducted for all staff on Abuse and Neglect but no documentation of the training could be provided. 2. Resident #32 reported allegations of sexual abuse by another resident (#90) on 11/18/23. Resident #32 was admitted on [DATE] with diagnoses including post-traumatic stress disorder, chronic, schizoaffective disorder, unspecified anxiety disorder and major depressive disorder. An MDS, dated [DATE], showed a BIMS score of 15 indicating intact cognition. Resident #90 was identified on 11/21/23 to be involved in a resident-to-resident abuse incident. This resident was admitted on [DATE] with diagnoses to include hemiplegia and hemiparesis following cerebral infarction, occlusion and stenosis of right carotid artery, personal history of transient ischemic accident (TIA), history of falling, and muscle wasting. An MDS, dated [DATE], revealed a BIMS score of 15 indicating intact mental cognition. Resident #100 was involved in a resident-to-resident sexual abuse incident involving Resident #90 on 12/26/23. This resident was admitted to the facility on [DATE] with diagnoses to include cerebral infarction, hemiparesis and hemiplegia to left non-dominant side, anxiety disorder, major depressive disorder recurrent. An admission MDS, dated [DATE], showed a BIMS score of 03 indicating severe cognitive impairment. During an interview on 01/10/24 at 3:05 p.m. Resident #32 said Resident #90 came up and asked if I wanted to be sexually harassed. I thought he was joking and then he groped my breast. When asked if she thought the touch on her breast could have been an accident, Resident #32 replied, I never told anyone it was an accident. Resident #32 continued to describe the events and said, Staff I, Certified Nursing Assistant (CNA) overheard me say to Resident #90, there will be no more of that, and asked what I was talking about. Resident #32 reported she told Staff I, CNA about Resident #90 touching her breast. Staff I then came to my room and helped me write a grievance. This was all reported to Staff I, CNA on the day it occurred, but I found out about four days after the incident, on 11/21/2023, that the grievance had been lost. I became hysterical and called the police. The police came and talked to me. This was on 11/21/2023, four days after the incident, and four days after Staff I, CNA helped me write the grievance. When I called the police, I heard Resident #90 was immediately placed on 1:1 (one to one) supervision, but I heard he got caught with someone else and was put on 1:1 again. An interview was conducted with the NHA on 01/11/2024 at 5:58 p.m. to discuss the incident between Resident #32 and #90 and the investigation of the incident. The NHA said she first learned of the incident when Resident #32 called law enforcement on 11/21/2023 and the evening unit manager, Staff L, Licensed Practical Nurse (LPN) called her. The NHA said she came to the building and talked to both residents and staff but did not document any of the interviews. She said no staff witnessed the incident and neither resident involved remembered what date the event took place. Resident #32 did not report telling any other staff, so no other staff were interviewed. The NHA said she did not receive a written statement from Staff I, CNA. The NHA expressed that Resident #32 and Resident #90 stated this incident was consensual. The NHA said the 1:1 supervision was for a short period of time. When asked if Resident #32's call to 911 to report the event as a crime on 11/21/2023 indicated a consensual event took place for Resident #32, the NHA did not respond. 3. Resident #36 was involved in a verbal abuse incident by a staff member on 12/23/23. This resident was admitted to the facility on [DATE] with diagnoses to include muscle wasting, COPD, other abnormalities of gait, seizures, bipolar disorder, major depressive disorder. A quarterly MDS, dated [DATE], showed a BIMS score of 13 indicating intact cognition. On 01/09/24 at 3:43 p.m., an interview was conducted with Resident #36. She reported she was verbally abused by a staff member. Resident #36 stated a staff member yelled at her. She was scared to report the incident, but she told the Social Services Director (SSD) the first time it happened. She stated this happened before Christmas. Resident #36 said, The CNA yelled at me because of a fan. She called me out. Her name is [Staff T, CNA]. She stated she spoke to the DON (Director of Nursing) and SSD about it. Resident #36 stated [Staff T] had gotten into her face about a fan at night. She said, She was just rude and disrespectful. She called me names. I don't want to say much about it. I don't want them to come after me. Then today, it's [Staff R, CNA]. This morning she [Staff R] came up again and said she will not assist me with my shower, and she won't change me. She said if you don't stop that [expletive] you will get into more trouble. On 01/09/24 at 4:15 p.m., an interview was conducted with the DON. She said, When the fan was taken, I questioned [Staff T, CNA] regarding the fan. Staff T said the fan was hers, and she was letting the resident borrow the fan. She stated the resident reported [Staff T] was rude to her when she took the fan back. The DON said, It was the way she took the fan. She [Staff T] told her she was taking it because it was not hers. She apparently told her to shut up. We questioned her [Resident #36] about the incident. It was a couple days after the grievance was documented. I went there with the SSD. Her other roommates were in the room. Resident #36 denied the abuse incident at that time. She did not say [Staff T] used choice words. I don't know why she changed her story. She had first reported the incident to [Staff R] the morning it happened. The DON stated she did not initiate abuse allegation for Resident #36 related to the 12/23/23 grievance because when she went to question the resident, she denied the abuse even though it was already documented. The DON stated she focused on the fan. The DON stated she did not talk to the resident privately. She stated she did not obtain witness statements from other residents or staff regarding the verbal abuse because the resident withdrew her statement. She stated, I don't know why she would have reported abuse and then withdrew it. I did not follow-up. I did not ask other staff about it. On 01/09/24 at 4:55 p.m., an interview was conducted with the NHA and the DON. The NHA stated regarding the fan incident on 12/23/23 with Staff T, the DON resolved the grievance after she spoke to the resident and the resident denied any abuse related to this incident. The NHA stated she did not have any witness statements. The DON stated she did not speak to the nurse who worked that night. She did not interview the roommates. The DON stated she did not document the resident's response related to denying that someone abused her verbally. She stated she did not document any of the interviews. She stated she did not know that she needed to document any of that information. The DON stated she did not know she needed to ask other staff or other residents about the verbal abuse allegations. The DON stated she did not follow-up with Staff R regarding the initial grievance submitted on 12/23/23 on Resident #36's behalf. A follow-up interview was conducted on 01/10/24 at 4:26 p.m. with the DON and the NHA. The DON said, At the time of my investigation they said it did not occur. I did not revisit the issue. I did not think to look further. I did not focus on the verbiage used when the grievance was documented because the residents said it did not happen. I don't know why they changed their story. Now I see how I should have investigated it further. I did not interview other staff or residents. I did not know she still had issues with that incident. 4. Resident #12 was involved in an allegation of possible neglect related to a failure to complete a full investigation following a possible fall with a fracture on 12/4/23. This resident was originally admitted to the facility on [DATE] and readmitted on [DATE] following a 10-day hospitalization. The resident was re-admitted with a primary diagnosis of unspecified fracture of upper end or right tibia, sequela and prior diagnoses to include legal blindness, end stage renal disease (ESRD), contracture of right hand, contracture of right wrist, hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, unspecified convulsions, and psychotic disorder with delusions due to unknown physiological condition. On 01/12/24 at 10:16 a.m., an interview was conducted with the ESRD facility's Clinical Manager where Resident #12 received dialysis. She confirmed Resident #12 was their resident and attended dialysis at their facility every Monday, Wednesday, and Friday. The Clinical Manager stated, She [Resident #12] arrived at the facility on 12/4/23. She had no incidents. Patient comes to our facility under the care of the transport company. She arrives in a stretcher, and then they transfer her into a chair. She never ambulates. The transport puts her in the treatment chair. She never gets out of the treatment chair. The Clinical Manager stated she never received a phone call from the facility. She stated , I was told on 12/6/23 that she was not coming to dialysis because she was hospitalized for a wound infection. The Clinical Manager stated she did not know anything about the patient falling. She said, She probably fell at [name of the nursing home]. She never walks. I received a call from some insurance people while she was at the hospital. They wanted to know the date of the incident. I told them, she did not fall at dialysis. I have not heard from them again. The Clinical Manager confirmed the facility never contacted her to inquire about the resident's fall or an injury she may have sustained at the ESRD facility. On 01/12/24 12:37 p.m. an interview was conducted with the Risk Manager Consultant (RMC), and the Regional Nurse Clinical (RNC). The RMC stated he had reviewed the investigation file. He stated it showed Resident #12 had a BIMS 14 and she reported that she fell at the dialysis center. He stated the paper he was reviewing was undated. He confirmed Resident #12 was transferred out because her X-rays came back positive for a leg fracture. The RMC read a progress note dated 12/4/23 showing, the resident said nobody hurt her and no one abused her. He stated there were two notes from the nurse which read, On 12/4/23 resident alert, she complained of leg pain and pain medication given. Right leg was not swollen but she did complain when I moved it through ROM (range of motion). CNA made me aware she was complaining of pain in her right leg. A CNA report read, I was giving care to [Resident #12] when I moved her leg, she was in pain. I informed the nurse who was on duty. The RMC stated the NHA Investigation summary showed the resident's knee x-ray results showed fracture of right fibula and tibia. It showed the PCP (primary care physician), DON and NHA were notified. The NHA interviewed the patient and she denied anybody was abusing her. She admits to falling at dialysis center. Medical Doctor (MD) ordered transfer to the ED. She left a voice mail with patient's [family member] and was waiting for a call back. The RMC said, I cannot conclude what happened. I agree there is an incomplete investigation. On 01/12/24 12:48 p.m. The RNC stated, The NHA talked to the patient who has a BIMS of 14 there does not seem a reason why we would not trust that patient. I did not know she was blind. I do understand that the patient suffered a significant injury. She reported it happened at dialysis. I agree, there is no evidence that follow-up calls were made to figure out what happened. Further investigation should have been conducted. You are right, dialysis or dialysis company should have been contacted. I don't know if the incident was reported. 01/12/24 at 3:16 p.m. an interview was conducted with the facility's Medical Director (MD), who is also Resident #12's PCP. The MD stated he did not have any recollection of any recent injury reports that resulted in a hospitalization. He could not recollect a fall with injury for Resident #12 and stated I would know. The MD did not remember being notified. The MD stated if there was a significant injury, he would have expected to be notified. The MD said, I would remember if a resident had significant injuries. It should be documented if I had a follow-up visit. Review of physician notes showed Resident #12 was seen by the MD on 04/12/23, 04/26/23 and 09/09/23. There were no physician notes documented on or around the time of Resident #12's injury on 12/04/23 or after she returned from the hospital on [DATE]. 5. Resident #6 reported allegations of physical abuse by Staff W, Certified Nursing Assistant (CNA) on 12/15/23. This resident was admitted to the facility on [DATE] with diagnoses to include other sequelae or other cerebrovascular disease and aphasia. A Quarterly MDS, dated [DATE], showed a BIMS score of 15 indicating intact cognition. During an interview on 1/10/24 at 8:25 a.m., Resident #6 said last month a staff member (Staff W, CNA) hit him in the face. He said he reported this to staff and his [spouse]. He started to tear up during the interview. When asked if it hurt, he said yes. He said the staff member had not worked with him since the incident. During an interview on 1/10/24 at 9:15 a.m. with the NHA and DON, the NHA stated she completed the required State Agency reporting on 12/15/2023 at 11:10 a.m. The local police came to the facility and spoke to Staff V, CNA and Staff W, CNA. The NHA reported the Law Enforcement Officer (LEO) told her Resident #6 said staff had pushed his arm. The NHA said she did tell the LEO Resident #6 reported to facility staff, he was hit by Staff W. The NHA said Staff W, CNA was suspended from 12/15/2023 to 12/22/2023. The NHA informed Resident #6's RP, Staff W, CNA would not work with Resident #6 anymore. The DON provided documentation of Staff W's training, which was done over the phone (OTP) on 12/22/2023. Review of the document titled, INDIVIDUALIZED STAFF EDUCATION, contain Staff W's name, the date of 12/22/23, the Issue was Policy attached . The form included a printed statement: I received one on one education today concerning the issue above. I understand my responsibility, what to do in the future, and how my actions impacted the residents, staff, and the facility in general. I understand that a copy of this training will go in my personal file in case this becomes an issue again. Disciplinary action may be taken in the future if indicated. The line for Employee signature contained a handwritten note Education OTP. The line for Educator signature contained the DON's signature and the signature of Staff H, LPN/UM. The DON confirmed Staff W, CNA did not have a copy of the Abuse Prevention Program policy and procedure (P&P) during the phone training. Review of Staff W's assignment sheets and payroll records revealed she worked the night shift (11 PM to 7AM) on 01/06/2024, 01/07/2024, and 01/08/2024, without being provided in person training for abuse prevention prior to returning to direct contact/care of residents. On 01/10/24 at 10:49 a.m., the NHA provided a copy of facility staff training on the Abuse Prevention Program P&P dated 12/20/2023 with the signature of 24 staff members. The NHA confirmed the facility had not provided any additional training after this 12/20/23 training to 24 staff members. During an interview on 01/10/24 at 4:04 p.m., the DON confirmed Staff W, CNA was not reported to the Florida CNA Registry due to the facility's determination of unsubstantiated abuse. 6. Resident #308 failed to receive goods and services resulting in worsening of wounds identified on 11/29/23. This resident was readmitted to the facility on [DATE] with diagnosis to include encephalopathy unspecified, pneumonia unspecified, sepsis, cellulitis, local infection of the skin and subcutaneous tissue, acute respiratory failure, cerebral infarction unspecified and muscle wasting among others. A Quarterly MDS, dated [DATE], showed the resident had a BIMS score of 99 indicating the resident was unable to complete cognition interview. Review of the Agency for Health Care Administration (AHCA) Form 3008 Patient Transfer Form from the hospital back to the facility signed by the physician on 1/3/24 for readmission of Resident #308 to the facility on 1/4/24 revealed the resident had a stage 4 sacral wound and an x was marked in the box showing a wound vac treatment device was in use. This document was present in Resident #308's current clinical record. A review of the admission/readmission note dated 1/4/24 at 10:27 p.m. showed the sacrum/coccyx wound measurements were 12 cm (centimeters) x 8 cm x 5 cm along with several other wounds. No use of a wound vac was documented. An interview was conducted on 01/09/24, at approximately 8:51 a.m., with the wound care team nurses which consisted of Staff G, Registered Nurse and [NAME] Side Unit Manager (RN/UM) and Staff H, Licensed Practical Nurse and East Side Unit Manager (LPN/UM). When asked about the wound vac for Resident #308, they stated they didn't have any orders on the 3008 Transfer Form when the resident returned from the hospital on [DATE]. Staff G and Staff H reported Resident #308 had a wound vac in place when she originally transferred out to the hospital (prior to 11/29/23), but through the course of the hospitalization, it was removed and no orders related to the wound vac were received upon her return. Staff G and Staff H confirmed the wound vac was returned back to the facility when the resident was readmitted to the facility on [DATE] but not currently in use. Staff G and Staff H said the facility does not have a wound doctor, but they can refer residents out to the wound care clinic when needed. They said this had been the plan for Resident #308 prior to her going to the hospital, but then the resident was sent out with an abdominal wall infection, which was not related to the pressure wound. Review of the general surgeon physician's progress note from the resident's most recent hospitalization dated 12/28/23 at 4:54 p.m., and retrieved from the resident's medical record in the facility revealed the following plan: -general surgery will sign off -please contact General surgery if patient needs debridement in the future otherwise we will continue wound VAC management per wound care team -follow-up with me as an outpatient. -okay to discharge patient standpoint and follow up as an outpatient. Review of a progress note dated 1/8/24 at 1:56 p.m. showed Note Text: abdominal incision noted with 19 staples, area slightly pink, no foul odor, no redness or drainage observed, MD notified, new order to remove every other staple in 1 week, wait an additional 3 days and then remove remainder staples, currently resident receiving wet to dry dressings to sacral wound, left ischium wound and right ischium wound, MD in agreeance with current wound care orders, will re-evaluate on Tuesday 01/09/24 during IDT [interdisciplinary] wound rounds for appropriateness to apply wound vac. [spouse] notified and agrees with current plan of care. On 1/10/24 at approximately 12:05 p.m. an observation of wound care for Resident #308 by Staff G, RN/UM and Staff H, LPN/UM was conducted . Observed at this time were two dressings, one white and clearly dated 1/09/24 located over the sacrum and the other on the left ischium. The left ischium dressing was a light brown color and had a date that was difficult to read but Staff H, verified the date as 1/9/24. The dressing over the left ischium was removed, and the packing material was removed from inside the wound. The wound was the size of a large orange .She then began treatment to the sacrum wound. She removed the old dressing and revealed a large grapefruit size open wound with a dark area noted at the bottom edge of the wound. The wound had a packing material that had a light green color saturating the gauze. No odors were noted at this time . She was able to insert her entire index finger into the area of the wound. The nurse was asked if this was tunneling and she (Staff H, LPN/UM) stated it was undermining not tunneling and proceeded to pack this area with calcium alginate. Staff H used additional calcium alginate to pack the rest of the wound, wiped the edges of the wound with skin prep and covered with a foam dressing. No wound vac was observed to be in use. The nurses were asked about the use of a wound vac, and they reported the resident was sent out to the hospital for about a month because her wound had increased in size but no orders for a wound vac were currently in place. On 1/11/24 at approximately 12:00 p.m. a follow up interview was conducted with Staff G, RN/UM, and Staff H, LPN/UM, in the presence of the Director of Nursing (DON). They reported that Resident #308 was transferred to the hospital for evaluation on 11/29/23 because she had a fever of 104 degrees. Staff H reported she had notified the Medical Director and explained to him that she felt the resident was septic, and that the resident's wounds had deteriorated in that last week. She stated they were not sure why the wound had gotten so bad but thought it was because of the disease process. Staff H, LPN/UM clarified that neither she nor Staff G were wound care nurses, but they were a part of the Interdisciplinary Team in charge of wound measurements and keeping track of wounds. They report to the IDT if there are issues identified during the weekly wound rounds. They stated that neither of them have specialized training in wound care. However Staff H, LPN/UM stated that when she first started in her role, a representative for a wound supply company would offer periodic trainings. They further reported that when Resident #308 came back from the hospital on 1/4/24 there were wet to dry dressings for her wounds and stated that the admitting nurse would have obtained these orders. Staff H stated that admission orders are obtained from the 3008 patient transfer form and there was not an order for the wound vac on the form. At this time, the 3008 signed by the physician on 1/3/24 for discharge to the facility on 1/4/2024 was obtained and presented to Staff G, Staff H, and the DON indicating a wound vac treatment device order was in place. The staff were also shown the note in the hospital discharge record dated 12/28/23 showing the plan was to continue with the wound vac. Staff H, stated the wound vac should have been continued and this had been missed by the admission nurse, herself and the person who conducted the 24 hour chart check following the resident's readmission on [DATE]. A review of the physician progress notes for the Medical Director revealed one progress note dated 9/9/23. The progress note provided no documentation of Resident #308's wounds nor did it make mention of any skin care or any skin conditions. The section for Derm had a circle noted around the words warm and dry. The note revealed [AGE] year old with a past medial history of CVA (Cerebral Vascular Accident), pneumonia, uropathy, DM (diabetes), anemia, seizures and CAD (Coronary Artery Disease). Wounds were not identified. No other progress notes could be located in the resident's clinical record. 7. Resident # 106 was involved in an allegation of neglect related to wound care on 10/24/23. This resident was admitted to the facility on [DATE] with diagnoses to include partial amputation of right foot, other specified local infections of the skin and subcutaneous tissue, type 2 diabetes, cellulitis, osteomyelitis, sepsis, other kidney failure, and muscle wasting, On 01/12/24 at approximately 12:03 p.m. an interview was conducted with Staff G, RN/UM and Staff H, LPN/UM. They reported Resident #106 was admitted status post-surgery in which a specific kind of skin graft was placed, the hospital had requested a wound vac, but their facility did not use wound vacs on that kind of skin graft. They stated the evening shift supervisor had verified the orders but did not address the wound vac noted on the 3008. Staff H stated the wound vac was discussed prior to her leaving the day the resident was admitted but she was not sure where the documentation of this was within the facility's electronic medical record. After reviewing the resident's record in the electronic medical record Staff H verified that any documentation of the wound vac discussion was not in the electronic medical record. At this time Staff G and H were asked if it was appropriate to accept a resident for admission when you could not provide the ordered care and they stated they would not have known the wound vac was for that specific wound until after the resident arrived. They offered the wound vac is used to create negative pressure in a wound, stimulates granulation of tissue and helps with drainage. They then verified that not using the wound vac put the resident as a greater risk for infection, and the resident was transferred to the ER (emergency room) for a possible wound infection but stated they never received confirmation of an infection. During an interview with the Medical Director on 1/12/24 at approximately 3:05 p.m. he stated the Unit Managers (UMs) and the DON were expected to be proactive in caring for the residents as the floor staff were too busy to review clinical status. He verified that Staff H, LPN/UM does all the wound care and would notify him if a wound was getting worse. He clarified that nursing communication needed to be proactive and not reactive. He stated that he sees all short-term rehabilitation residents weekly; however, only sees the long-term residents when the DON advises him there is a concern. He stated he was not involved in the admission process as it goes through nursing and stated that he would assume they would contact him if there was a concern. He referred back to Staff H, LPN/UM as the wound care nurse when asked about wound vacs. He verified that he documented his visits on the form Progress Notes and turns the forms into medical records after each visit. He stated that the facility has all of his progress notes. 8. On 01/08/24 at 10:17 a.m., the residents in Rooms 101, 103, 105 and 106 reported Hall 100 has had water issues for an unknown period of time. They reported the water was cold and this had been going on for a long time. A resident in room [ROOM NUMBER] stated it had been probably three to six months. The residents stated the CNAs (certified nursing assistants) knew of the problem. The resident in room [ROOM NUMBER] stated a grievance was filed during a Resident Council meeting. The resident stated the CNAs complained about cold water when giving residents showers. Review of the Grievance Logs August 2023 to January 8, 2024, revealed no grievances were filed from Resident Council meetings. On 01/09/24 at 1:36 p.m., an interview was conducted with the Director of Maintenance (DOM) and the Regional DOM. They confirmed plumbing issues in Hall 100. The DOM said, Here has been no hot water issues, nothing out of the regular. We had a plumber here today to fix water in one the wings because the water was cold. He stated the problem was the circulating pump. He stated he became aware of the hot water problems the day before. He stated he was notified in the afternoon through a work order submitted in the [maintenance software for documenting work orders]. He stated the problem was in Hall 100. He stated it was the first time he heard about water being cold. He stated the plumber said he would require a new pump. The DOM stated he normally tests hot water once or twice week. He stated he had tested the previous week, and the water temperatures were good. The Regional DOM stated the appropriate water temperature should be 110° to 112°, maximum 115°. On 01/09/24 at 2:11 p.m., a facility tour was conducted with both the DOM and Regional DOM. The facility's DOM conducted water temperatures for a sample of rooms/areas as follows: Hall 300: room [ROOM NUMBER] = 109° Shower room =109°, Hall 200: room [ROOM NUMBER] =106° Shower room [ROOM NUMBER]° and Hall 100: room [ROOM NUMBER] = 86° room [ROOM NUMBER] = 86°. On 01/10/24 at 4:45 p.m. an interview was conducted with the Nursing Home Administrator (NHA) and she stated she did not know the residents had been reporting on-going concerns for six months. She heard about it yesterday. We will fix it ASAP (as soon as possible). She stated the nursing staff should have put in a work order. 9. Review of nurse employee files failed to demonstrate oversight for competency training. On 01/11/24 at 10:44 a.m. the DON confirmed the nurse and CNA annual competencies should be in the employee file. The employee file for Staff K, LPN did not have an annual competency and the orientation competency, dated 08/2022, was signed by the employee, but the signature block for the training supervisor was blank. The DON confirmed there was no annual competency in the file. The employee file for Staff L, LPN was reviewed and was silent of an annual competency. Staff L's file contained a New Employee Orientation checklist signed by the employee on 7/19/2022. There was no signature for the employee services coordinator or the staff development person. A nursing administration orientation checklist, dated 7/27/2022, was signed by the employee but no signature in the blank for the nursing

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to utilize the Quality Assurance and Performance Improvement (QAPI) process to investigate, develop, and implement an effective Performance Improvement Plan (PIP) to ensure the facility was free from abuse and neglect. During a survey conducted on 01/08/24 to 01/12/24 non-compliance was found for 9 of 12 residents reviewed for abuse and neglect. The incidents/allegations included resident to resident physical/sexual abuse (#32, #90, #100), staff to resident physical abuse (#6, #164), staff to resident verbal abuse (#36), and neglect resulting in worsening of wounds (#308, #106), and failure to investigate a fracture of unknown origin (#12). Review of records, interview with facility staff, family members, and the Medical Director revealed concerns with facility's reporting, investigation, protection, and implementation of safety/corrective processes to prevent further and future abuse and neglect from occurring. The facility placed all current residents (census: 112) at risk of serious injury and/or death due to the systemic failure to identify patterns of occurring abuse and neglect incidents/allegations and not initiating a PIP to address the on-going concerns, resulting in the determination of Immediate Jeopardy which began on 09/19/23 and was ongoing at the time of survey exit on 01/12/2024. Findings included: Cross reference F600, F610, F726 and F835. Review of a facility document presented by the Nursing Home Administrator (NHA) revealed 57 reportable incidents of abuse and/or neglect had occurred since the last recertification survey completed on 1/27/2022. Review of the facility's survey history revealed a complaint survey was conducted on 5/23/2022 to 5/26/2022, which identified findings of Immediate Jeopardy at F600 related to resident neglect and F726 related to staff competency for failing to assess, identify resident changes in condition, carry out facility procedures, and administer prescribed treatments. A review of the facility's accepted plan of correction to correct and maintain compliance for F600 and F726 for the survey ending on 5/26/2022 revealed: The DON (Director of Nursing)/Designee educated staff on abuse, neglect, exploitation & misappropriation. The DON/designee educated clinical staff on frequent routine rounding including identification and reporting of concerns with a posttest to confirm understanding. The nurses were educated by the DON/designee on providing prescribed treatments per the provider orders when medications, treatments or interventions are scheduled and the importance of accuracy in documentation. The DON/designee will audit adherence to prescribed treatments by the nurses 3 times weekly in the morning clinical meeting. The audits will be presented to the QA&A (Quality Assurance and Assessment)committee for further recommendations for a period of three months or until substantial compliance is achieved. Adherence to prescribed treatments will be audited for compliance with notifications and adjustments made as prescribed. Results of the Quality of Care (QOC) compliance will be reported to QA&A monthly for recommendations. During a survey conducted on 01/08/24 to 01/12/24 non-compliance was found for 9 of 12 residents reviewed for abuse and neglect. Review of records, interview with facility staff, families and medical director revealed concerns with facility's reporting, investigation, and implementation of safety processes to prevent abuse and neglect. Resident #164 reported that Staff R, Certified Nursing Assistant (CNA) poisoned his coffee on 09/19/23. This resident was admitted to the facility on [DATE] and discharged on 9/30/23. Diagnoses included muscle wasting and atrophy, not elsewhere classified, multiple sites, epilepsy, unspecified, not intractable, without status epilepticus and unspecified dementia, unspecified severity, with agitation. A Quarterly Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 07 indicating severe cognitive impairment. Resident #32 reported allegations of sexual abuse by another resident on 11/18/23. This resident was admitted on [DATE] with diagnoses to include post-traumatic stress disorder, chronic, schizoaffective disorder, unspecified anxiety disorder and major depressive disorder. An MDS, dated [DATE], showed a BIMS score of 15 indicating intact cognition. Resident #90 was identified on 11/21/23 to be involved in a resident-to-resident abuse incident. This resident was admitted on [DATE] with diagnoses to include hemiplegia and hemiparesis following cerebral infarction, occlusion and stenosis of right carotid artery, personal history of transient ischemic accident (TIA), history of falling, and muscle wasting. An MDS, dated [DATE], revealed a BIMS score of 15 indicating intact mental cognition. Resident #6 reported allegations of physical abuse by Staff W, Certified Nursing Assistant (CNA) on 12/15/23. This resident was admitted to the facility on [DATE] with diagnoses to include other sequelae or other cerebrovascular disease and aphasia. A Quarterly MDS, dated [DATE], showed a BIMS score of 15 indicating intact cognition. Resident #100 was involved in a resident-to-resident sexual abuse incident on 12/26/23. This resident was admitted to the facility on [DATE] with diagnoses to include cerebral infarction, hemiparesis and hemiplegia to left non-dominant side, diabetes mellitus type 2, chronic obstructive pulmonary disease (COPD), anxiety disorder, major depressive disorder recurrent, congestive heart failure, gastro-esophageal reflux disease, and history of malignant neoplasm of the esophagus An admission MDS, dated [DATE], showed a BIMS score of 03 indicating severe cognitive impairment. Resident #36 was involved in a verbal abuse incident by a staff member on 12/23/23. This resident was admitted to the facility on [DATE] with diagnoses to include muscle wasting, COPD (chronic obstructive pulmonary disease), other abnormalities of gait, seizures, bipolar disorder, major depressive disorder. A Quarterly MDS, dated [DATE], showed a BIMS score of 13 indicating intact cognition. Resident #308 failed to receive goods and services resulting in worsening of wounds identified on 11/29/23. This resident was readmitted to the facility on [DATE] with diagnoses to include encephalopathy unspecified, pneumonia unspecified, sepsis, cellulitis, local infection of the skin and subcutaneous tissue, acute respiratory failure, cerebral infarction unspecified and muscle wasting among others. A Quarterly MDS, dated [DATE], showed the resident had a BIMS score of 99 indicating the resident was unable to complete cognition interview. Resident #106 was involved in an allegation of neglect related to wound care on 10/24/23. This resident was admitted to the facility on [DATE] with diagnoses to include partial amputation of right foot, other specified local infections of the skin and subcutaneous tissue, type 2 diabetes, cellulitis, osteomyelitis, sepsis, other kidney failure, and muscle wasting, Resident #12 was involved in an allegation of possible neglect related to a failure to complete a full investigation following a possible fall with a fracture on 12/4/23. This resident was originally admitted to the facility on [DATE] and readmitted on [DATE] following a 10-day hospitalization. The resident was re-admitted with a primary diagnosis of unspecified fracture of upper end or right tibia, sequela and prior diagnoses to include legal blindness, end stage renal disease, contracture of right hand, contracture of right wrist, hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, unspecified convulsions, and psychotic disorder with delusions due to unknown physiological condition. On 01/10/24 at 3:40 p.m. an interview was conducted with the Nursing Home Administrator (NHA) and the DON. The NHA stated they meet monthly, the 3rd Tuesday of every month for Quality Assurance. She stated they follow the same agenda each month which included a risk management agenda item which is reviewed monthly. She stated this included event tracking/trending/RCA (root cause analysis), reportable incidents, review or development of PIPs and an audit plan/report of the incidents. On 01/10/24 at 4:22 p.m. an interview was conducted with the NHA. She stated that for allegations of abuse they investigate, make sure the resident is safe, and suspend the employee pending the investigation. She stated if an allegation was verified, they terminate the employee and report them to the board. The NHA stated all staff training was conducted in small groups normally. She said sometimes we would do it via phone if they cannot come in. For general employee training, we conduct monthly training per the training calendar. Typically, the DON, unit managers or department heads conduct these training's. On 01/10/24 at 4:31 p.m. a follow-up interview was conducted with the NHA and the DON regarding what patterns they were addressing and what PIPs (performance improvement plans) were currently in place. The NHA stated they had a PIP on PASRRs (Preadmission Screening and Resident Review), wounds, and they finished one on labs. The NHA said, We do not have a PIP on abuse and neglect. We had not identified a pattern. We did not see it as so and the residents have not voiced any fear. The NHA stated residents sometimes change their stories during an investigation. She said, It has not been a red flag. I did not know staff were afraid to speak up. We have considered team building community with staff and resident. I have not discussed concerns related to resident to resident or staff abuse allegations with Resident Council. I will now. We did not see it as such a large scale. The NHA stated they had competencies on interviewing protocol. She stated they had a checklist. The NHA stated she would provide the surveyors with this checklist. The checklist was not provided. The DON stated she had received training at a sister facility for one day with another DON. She stated she was the ADON (Assistant Director of Nursing) at this facility at the time. She stated she went to a Nursing Summit, a 2-day training. She provided examples of what was covered during the Nursing Summit to include adequately checking files, auditing some things and supporting staff. The NHA stated the facility's SSD (Social Services Director) receives residents' grievances. She stated residents can turn in their grievances anonymously. She said, We have a compliance line. It used to go to an outside company, now the management company is receiving the anonymous calls. She stated she did not know residents' grievances that were discussed in Resident Council were not documented. The NHA stated they would start documenting. She confirmed they should fill out a grievance form for all complaints. On 01/11/24 at 09:00 a.m. an interview was conducted with the facility's Risk Manger Consultant. He stated he had recently been re-assigned to this facility and was filling in. He stated prior to the reassignment, he would review recommendations of falls and events. He stated he had a tool that he used and the facility's policy. He stated he had consulted with the facility on resident-to-resident interactions. He stated he advised the team on how to handle the on-going abuses. He stated he reviewed the trends for QA quarterly. The Risk Manager Consultant provided a blank form stating it was the tool he used. He stated he did not have any documentation of previous visits to the facility or any specific incidents he had consulted on. 01/12/24 at 03:04 p.m. a telephone interview was conducted with the facility's Medical Director (MD). He stated he attend the facility's QAPI meeting monthly. He stated he attended in person. He stated if he overhears there are particular issues related to nursing, education, he gives advice. He stated he would reach out to family members about particular concerns. He stated he did not know if the facility had a PIP to address abuse allegations. Review of a facility policy titled, Quality Assurance Improvement (QAPI) Plan, dated October 2017, showed the facility will develop a QAPI plan to describe how the facility will track and measure performance, establish goals and thresholds for performance measurement, identify and prioritize deviations for performance and other problems in issues, systematically investigate and analyze to determine underlying causes of systemic problems and adverse events, develop and implement corrective actions or performance improvement activities, monitor/evaluate the effects of corrective actions/performance activities. The QAPI plan is reported to QA&A (Quality Assurance & Assessment) compliance committee with regular updates regarding progress with improvement activity, or corrective actions when there is unplanned or unexpected response to such activities It is the responsibility of the QA&A compliance committee to consider all data presented by the improvement team(s) and to direct the team(s) to continue change or conclude the assignment. Procedure: track and measure performance. Clinical areas are tracked through: Weekly reporting of specific clinical indicators to include ulcers, falls, returns to hospital. Quality measures (QM) to include overall staffing and QM's. Incidents e.g. falls. Survey we're finding such as repeat citations, high severity citations, failure to clear at first revisit. Other areas that are tracked may include but are not limited to: Grievances Reportable incident outcomes such as substantiated abuse or neglect . that was within the facilities [sic] control. Concierge around findings such as environmental concerns, staffing concerns such as . any other area identified as a concern requiring investigation and corrective action.