**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to ensure residents were free from abuse. Specifically, the facility failed to ensure two residents (R) (R15 and R13) were free from abuse related to: (1) R15 exposed to sexual abusive behaviors presented by R16, and (2) R13 experiencing physical abuse from R20. On 10/26/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing (DON), Regional Director of Clinical Operations (RDCO), and [NAME] President of Clinical Operations (VPCO) were informed of the Immediate Jeopardy (IJ) on 10/26/2023 at 5:36 pm. The noncompliance related to the IJ was identified to have existed on 8/31/2023. An Acceptable Removal Plan was received on 10/31/2023. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 10/31/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing sexual abuse in the facility. Findings included: 1. A review of the facility policy titled Abuse, Neglect, and Exploitation revised 9/8/2022 revealed: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R15 with a Brief Interview of Mental (BIMS) score of zero, indicating severely impaired cognition. R15 had diagnoses including but not limited to Alzheimer's and depression. A review of the Quarterly MDS dated [DATE] revealed R16 with a BIMS score of 13, indicating resident was cognitively intact. R16 had diagnoses including but not limited to chronic kidney disease and hemiplegia and hemiparesis. Observations throughout the survey revealed that there were two units in the facility, the 100 Unit and the 200 Unit. On 10/25/2023 at 3:30 pm, R16 was observed in his wheelchair independently propelling himself on the 100 Unit towards the lobby area. On 10/26/2023 at 7:15 am, R16 was observed independently propelling himself on the 200 Unit near his bedroom area. On 10/30/2023 at 10:30 am, R16 was observed seated in his wheelchair in the dining room. A review of R16's progress note dated 8/31/2023, documented by the Nurse Practitioner (NP) revealed the following: [R16] was seen today for inappropriate sexual behavior. The nurse called that pt [patient] was trying to kiss other residents and touching them inappropriately, patient was also self-propelling himself around the facility. Unable to redirect the patient on many accounts. His room was also changed but did not help the pt to stop behaving inappropriately .Today was seen today to assess and redirect the patient. Patient unable to express his triggers. A review of R16's progress note dated 8/31/2023, documented by the DON revealed: assessed resident for sexually suggestive behaviors. Resident started on cimetidine. Resident self-propels throughout the facility and was noted to have socially sexually suggestive behaviors that may be offensive to others. A review of R16's progress note dated 9/5/2023, documented by the Physician revealed the following: [R16] seen today for inappropriate sexual behavior. The nurse called that pt was trying to kiss other residents and touching them inappropriately, patient was also self-propelling himself around the facility. Unable to redirect the patient on many accounts. His room was also changed but did not help the pt to stop behaving inappropriately. The patient recently started on cimetidine with no improvement in behavior per nursing staff was seen today to assess and redirect the patient. Patient unable to express his triggers. A review of R16's progress note dated 9/14/2023, documented by the Psychiatric NP (PNP) revealed the following: request by the nursing team for inappropriate sexual behaviors. Patient was noted on multiple occasions attempting to kiss and inappropriately touch other female patients per nursing team. Patient denies any depression or anxiety .He cannot explain his triggers. The patient does not recollect the incident. A review of R16's physician order dated 8/31/2023 revealed an order for Cimetidine 300 milligrams (mg) two times a day for hypersexuality. A review of R16's care plan dated 8/31/2023 revealed R16 had a behavior problem of sexually suggestive displays. During an interview on 10/26/2023 at 7:40 am, the DON stated that it was reported to her in clinicals that R16 masturbates in the common area. The DON stated that was the reason the resident was started on Cimetidine. The DON stated she did not receive a report of R16 attempting to kiss or attempting to touch other residents. The DON stated she was unaware of which female residents were involved. During an interview on 10/26/2023 at 8:22 am, Certified Nursing Assistant (CNA) AA stated she observed R16 to grab R15 by the face, pull her face towards his and attempted to kiss R15. CNA AA stated she intervened and reported to the Administrator. CNA AA stated this incident occurred on the 200 hall a couple of months ago. CNA AA further stated she had not witnessed R16 attempt to kiss any other residents. During an interview on 10/26/2023 at 8:27 am, CNA BB stated she observed R16 kiss R15 on the lips. CNA BB stated she told R16 that behavior was inappropriate, separated the residents, and reported to the nurse on shift. CNA BB stated this incident occurred in the dining room in June 2023 or July 2023. During an interview on 10/26/2023 at 8:51 am, the Administrator stated he was unaware of the allegations of sexual abuse. During an interview on 10/26/2023 at 9:47 am, the NP stated that she was notified by a nurse on 8/31/2023 that R16 attempted to kiss and touch another resident. The NP stated the progress note that she documented was incorrect and should have stated that R16 attempted to kiss and attempted to touch. The NP stated she was unaware the name of the nurse that reported the incident to her and stated she was also unaware of the female resident that R16 was alleged to kiss and/or touch. During an interview on 10/26/2023 at 10:18 am, the PNP stated a floor nurse reported the allegation of sexual abuse to her on 9/13/2023. The PNP stated that she was unaware the name of the nurse that reported the incident to her and stated she was also unaware of the female resident. During an interview on 10/26/2023 at 11:55 am, the Physician stated that it was reported to her by the NP on 9/5/2023 that R16 was having sexually inappropriate behavior towards others. During a follow-up interview on 10/26/2023 at 1:18 pm, the DON stated she had just spoken with CNA BB. The DON stated CNA BB confirmed R16 had kissed R15. The DON stated she did not consider that to be sexual abuse. During an interview on 10/26/2023 at 1:26 pm, the Staff Development Coordinator (SDC) stated that she was responsible for training the staff on abuse. The SDC stated she was unaware of the allegations of sexual abuse and that it had not been discussed in their daily clinical meetings. The SDC stated that kissing another resident is abuse if the resident is unable to consent. The SDC stated the resident should have a BIMS score of 12 or higher to give consent. During an interview on 10/26/2023 at 1:31 pm, the Social Services Director (SSD) stated she was unaware of the allegations of sexual abuse and that it had not been discussed in their daily clinical meetings. The SSD further stated R15 had a lows BIMS score and could not consent to being kissed. 2. A review of the clinical record revealed that R13 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, severe sepsis with septic shock, schizophrenia, and Wernicke's encephalopathy. A review of a quarterly MDS assessment revealed R13 presented with a BIMS score of 10 out of 15, indicating moderate cognitive deficits; R13 had a history of paranoid behaviors associated with his schizophrenia and was care planned for the same; R13 requires stand by assistance with Activities of Daily Living (ADL) care and can manage much of his care with supervision; and R13 can ambulate short distances but has an unsteady gait and uses a wheelchair when out of his room. An observation of R13 on 10/17/2023 at 1:15 pm revealed the resident in his room with four roommates. He is sitting on the side of the bed with his wheelchair next to him. He looks up and shakes/nods head when addressed but doesn't speak. An observation on 10/19/2023 at 10:30 am revealed R13 up in his wheelchair in the dining room during an activity. The game was balloon toss and R13 played from his wheelchair. He was observed standing at times and moving about freely in his wheelchair. He ambulates throughout the facility in his wheelchair with ease. He nods when spoken to but again but doesn't speak. A review of a Progress Note dated 8/17/2023 and found in the electronic medical record (EMR) revealed a nurses note regarding an incident in the dining room with another resident earlier that day and R13 sustained a laceration on the back of his scalp. During an interview with the Administrator on 8/16/2023, it was revealed that R13 was involved in a resident to resident altercation with R20. They were arguing over a pair of reading glasses in the dining room. When both men stood up from their wheelchairs, and R20 shoved R13, who was standing by the ice machine. R13 lost his balance and fell landing on his buttock and striking his head on the ice machine causing a laceration on the back of his head. He was assessed and treated in the facility that day. The NP and facility staff cleaned and dressed R13's head laceration. No other treatment was required. A review of the clinical record revealed that R20 was admitted to the facility on [DATE] from an acute care hospital with diagnoses including Traumatic Brain Injury with subdural hemorrhage. A review of R20's MDS revealed a BIMS score is six, indicating severe cognitive impairments. He required one staff assistant with all ADL care. He is mobile around the facility in a wheelchair. He did exhibit behavior problems and was frequently aggressive with staff by resisting care. In an interview with the DON on 10/19/2023 at 3:30 pm, she stated R20 was only in the facility for a couple of weeks primarily due to his aggressive behaviors and a need for a psychiatric or secure unit with increased supervision. She stated, .we tried to stay on him and watch him until we could get him taken care of .unfortunately this happened with [R13 name], wrong place/wrong time. The DON further stated that staff were in the dining room when it happened but couldn't get between them in time because it happened quickly, but the response time was nominal. In an interview with the Administrator on 10/23/23 at 11:30 am, he confirmed the events as described above. He stated he and the DON conducted the investigation and made all the notifications. There were no additional incidents between these two residents. The facility implemented the following actions to remove the IJ: 1. R16 was seen by NP on 8/31/2023 and recommendations for Cimetidine Tablet 300 mg one tablet two times daily were made and implemented. 2. R16 was referred to and seen by physician on 9/5/2023 and no new recommendations made. 3. R16 was referred to and seen by PNP on 9/14/2023 and a new medication (Zoloft 50mg once a day) recommendation was made and implemented. 4. R16 was placed on behavioral monitoring to assess and monitor for inappropriate touching or kissing behaviors toward others on 10/26/2023. 5. On 10/27/2023, R16 care plan was reviewed by the DON and was updated to assess, monitor, and address inappropriate sexual behaviors toward others. 6. On 10/27/2023, physician order obtained to send R16 out for evaluation and treatment as necessary. 7. On 10/27/2023, R16 was sent to input acute care hospital for behavioral assessment and treatment. On 10/28/2023, the resident returned to the facility with no new orders or recommendations. 8. On 10/29/2023 R15 was assessed by the SSD and NP. Resident presented at baseline and had no recollection of the events of 8/31/2023. 9. On 10/27/2023, the Regional Director of Operations (RDO), RDCO, and Medical Director (MD) reviewed the center policy Abuse and Neglect. No policy changes or recommendations were made as a result of this review. 10. The RDCO and Administrator reviewed the 24-hour reports for the past 30 days to identify residents with documented inappropriate sexual behaviors towards others. Identified documentation with possible allegations of Abuse and Neglect will be reported to the SSA and investigated per state guidelines and facility policy and procedure. Recommendations were reviewed in AD-HOC Performance Improvement meeting 10/26/2023 and 10/27/2023. 11. RDO re-educated the Administrator and DON on the Abuse and Neglect policy and procedure to include screening of potential hires; training of employees; prevention of occurrences; investigation of incidents and allegations; protection of residents during investigations; and reporting of incidents, investigations, and center response to the results of the investigations on 10/26/2023. 12. On 10/26/2023, the SDC interviewed residents with a BIMS of 12 or higher to identify if any other resident has been inappropriately touched or kissed by R16 or any other resident of this facility. Findings of these interviews noted no resident reported any concerns with R16 or any other resident. Interviews were documented on the Resident Interview Tool. 13. On 10/30/2023, the SSD, NP, and Nurse Managers assessed residents with a less than 12 BIMs score for psycho-social well-being and change in mood and behavior. Findings of these assessments noted no resident changes in behavior. Assessments were documented on the Psycho-Social Well-Being Assessment Tool. 14. On 10/26/2023 through 10/27/2023, the DON, SDC, educated all staff on the importance of investigating alleged abuses and neglect. Registered Nurses (RNs) 11 of 11 -100%; Licensed Practical Nurses (LPNs) 15 of 17 -88%; CNAs 26 of 31 - 84%; Administration 13 of 13 - 100%; Dietary nine of 11 - 82%; Housekeeping and Laundry nine of nine - 100%; Therapy 11 of 11 - 100 %; MD one of one - 100% and NPs two of two - 100% OVERALL 92% on the Abuse and Neglect policy and procedure as of October 26, 2023. Employees on leave of absence/ leave - (0), vacation (0) agency staff or new hires will be re-educated by the Staff Development Coordinator prior to returning to duty and will not be given an assignment until they are given additional on-site education. The Administrator, DON, or the SDC will educate all new staff, agency staff or staff not already educated before they are given an assignment. All corrective actions were completed on 10/30/2023. The facility alleges that the IJ is removed on 10/31/2023. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review of the progress/encounter note dated 8/31/2023 revealed that R16 was seen by the NP and new orders were noted at that time. 2. A review of the progress/encounter note dated 9/5/2023 revealed that R16 was seen by the Physician and no new orders were written. 3. A review of the progress/encounter note dated 9/13/2023 revealed that R16 was seen by the PNP and new orders for Zoloft 50mg daily were noted on the Order Summary Report. 4. A review of the order summary report dated 10/26/2023 revealed that the medication and behavior monitoring were ordered and initiated. Nursing will continue monitoring and documenting behaviors per interview with the DON on 11/1/2023 at 12:30 pm. 5. A review was conducted of R16's Care Plan revised 10/27/2023 to include behavior monitoring for inappropriate sexual behaviors. The DON confirmed the updated care plan in an interview on 11/1/2023 at 12:30 pm. 6. A review was conducted of the order for transfer to a behavioral health facility for evaluation and treatment dated 10/27/2023. R16 returned to facility on10/28/2023 with no new orders. The Administrator confirmed these actions in an interview on 11/1/2023 at 12:30 pm and stated the facility will continue to monitor R16. 7. A review of a progress note dated 10/28/2023 revealed the resident returned to facility after psychiatric evaluation with no new orders. This was confirmed with DON on 11/1/2023 at 12:30 pm. 8. A review was conducted of the progress note dated 10/30/2023 for R15's psychosocial assessment. During an interview on 11/1/2023 at 2:00 pm, the DON confirmed R15 remained at baseline. 9. The Abuse Neglect and Exploitation Policy was reviewed, and no revisions were made. This was confirmed by an interview with the Administrator and RDCO on 11/1/2023 at 2:00 pm. 10. A review was conducted of the 24-hour reports and confirmation interviews with the RDCO and Administrator on 11/1/2023 at 12:30 pm. 11. A review was conducted of the Abuse and Neglect Inservice provided to all staff. A review was conducted of the sign in sheets and all staff interviewed from 1:20 pm through 2:30 pm sign in sheets. This included all staff present in the facility on 11/1/2023. The DON will be responsible for training any staff who are not present prior to their next shift. 12. A review was conducted of the list of male and female residents with BIMS score of 12 or higher and the interview questions asked regarding sexual (or other) abuse in the facility. None of the residents reported being abused in any way. 13. A review was conducted of the Psychosocial Well-being Evaluations for all residents with BIMS scores less than 12. No changes identified in the assessments. 14. A review was conducted of abuse training sign in sheets of all employees. Interviews of all staff present at facility on 11/1/2023 beginning at 1:20 pm and ending at 2:30 pm. The interviews verified that all staff were found to be knowledgeable and were able verbalize the information shared during the education. On 11/1/2023, the following staff were interviewed: LPN CC at 1:20 pm; Dietary Aide (DA) DD at 1:22 pm; DA EE at 1:22 pm; DA FF at 1:25 pm; DA GG at 1:27 pm; DA HH at 1:27 pm; Certified Dietary Manager (CDM) at 1:29 pm; Business Office Manager (BOM) at 1:32 pm; CNA II at 1:34 pm; CNA JJ at 1:35 pm; LPN KK at 1:35 pm; LPN LL at 1:36 pm; Housekeeper (HK) MM at 1:37 pm; HK NN at 1:39 pm; Maintenance OO at 1:40 pm; PT PP at 1:42 pm; CNA QQ at 1:43 pm; Certified Occupational Therapy Assistant (COTA) RR at 1:45 pm; HK SS at 1:47 pm; Laundry Aide (LA) TT at 1:48 pm; Registered Nurse (RN) UU at 1:49 pm; Maintenance VV at 1:51 pm; LPN WW at 1:53 pm; Activity Assistant XX at 1:55 pm; Account Manager for Housekeeping and Laundry at 1:57 pm; Physician YY at 1:58 pm; NP at 1:59 pm; Physical Therapy Assistant (PTA) ZZ at 2:02 pm; CNA AAA at 2:03 pm; Receptionist BBB at 2:04 pm; Activity Director (AD) at 2:07 pm; Admissions Coordinator (AC) at 2:08 pm; Director of Therapy (DOT) at 2:09 pm; LPN CCC at 2:11 pm; CNA AA at 2:14 pm; CNA DDD at 2:14 pm; Staffing Coordinator at 2:16 pm; SDC at 2:17 pm; MDS Coordinator at 2:18 pm; CNA EEE at 2:24 pm; and Assistant ADON at 2:30 pm. All corrective actions were completed on 10/30/2023. The IJ is removed on 10/31/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to report an incident of alleged abuse. Specifically, the facility failed to report an incident of sexual abuse for one of 27 residents (R) (R15). On 10/26/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing (DON), Regional Director of Clinical Operations (RDCO), and [NAME] President of Clinical Operations (VPCO) were informed of the Immediate Jeopardy (IJ) on 10/26/2023 at 5:36 pm. The noncompliance related to the IJ was identified to have existed on 8/31/2023. An Acceptable Removal Plan was received on 10/31/2023. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 10/31/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing sexual abuse in the facility. Findings included: A review of the facility policy titled Abuse, Neglect, and Exploitation revised 9/8/2022 revealed: The facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R15 with a Brief Interview of Mental (BIMS) score of zero, indicating severely impaired cognition. A review of the Quarterly MDS dated [DATE] revealed R16 with a BIMS score of 13, indicating resident was cognitively intact. A review of R16's encounter note dated 8/31/2023 documented by the Nurse Practitioner (NP), an encounter noted dated 9/5/2023 documented by the Physician, and encounter note dated 9/14/2023 documented by the Psychiatric Nurse Practitioner (PNP) revealed R16 was on their caseload for attempting to kiss and inappropriately touching female residents. Observations throughout the survey revealed that there are two units in the facility, the 100 Unit and the 200 Unit. On 10/25/2023 at 3:30 pm, R16 was observed in his wheelchair independently propelling himself on the 100 Unit towards the lobby area. On 10/26/2023 at 7:15 am, R16 was observed independently propelling himself on the 200 Unit near his bedroom area. On 10/30/2023 at 10:30 am, R16 was observed seated in his wheelchair in the dining room. A review of facility reported incidents showed no evidence that the allegation of sexual abuse was reported as required. During an interview on 10/26/2023 at 8:22 am, Certified Nursing Assistant (CNA) AA stated she observed R16 to grab R15 by the face, pull her face towards his and attempted to kiss R15. CNA AA stated she intervened and reported to the Administrator. CNA AA stated this incident occurred on the 200 hall a couple of months ago. CNA AA further stated she had not witnessed R16 attempt to kiss any other residents. During an interview on 10/26/2023 at 8:27 am, CNA BB stated she observed R16 kiss R15 on the lips. CNA BB stated she told R16 that behavior was inappropriate, separated the residents, and reported to the nurse on shift. CNA BB stated this incident occurred in the dining room in June 2023 or July 2023. During an interview on 10/26/2023 at 8:51 am, the Administrator confirmed he was the Abuse Coordinator and stated he was unaware of the allegations of sexual abuse. The Administrator stated if he had known of the abuse, he would have reported it immediately. During an interview on 10/26/2023 at 9:47 am, the NP stated that she was notified by a nurse on 8/31/2023 that R16 attempted to kiss and touch another resident. The NP stated that she did not report the allegation to anyone and stated that she did not know if she was a mandatory reporter. The facility implemented the following actions to remove the IJ: 1. On 10/26/2023, the Administrator reported allegations of abuse and neglect related to the 8/31/2023 incident with R16 once alerted by the surveyor. 2. On 10/26/2023, the administrator was re-educated by the Director of Operations (DOO) on timely reporting, investigating and resolution of abuse and neglect allegations. 3. On 10/26/2023, the Regional Director of Operations (RDO) and the Administrator conducted an audit of all reported alleged violations and grievances in the last 30 days to validate that reporting occurred in a timely manner. All reported alleged violations and grievances in the last 30 days were made in a timely manner. 4. Between 10/26/2023 through 10/30/2023, the Social Services Director (SSD), NP, Staff Development Coordinator (SDC), and nurse managers interviewed and assessed residents using the Psycho-Social Well-Being Assessment. Any resident(s) with a noted change in baseline or who reported any change in psychosocial well-being was referred to Mental Health Provider for continuous treatment and support. 5. On 10/26/2023, the RDO and the VPCO reviewed the Abuse and Neglect Policy which includes timely reporting and follow up resolution. No revisions or amendments of the policy were recommended. 6. Beginning 10/26/2023, The DON, SDC, educated all staff on the importance of investigating alleged abuses and neglect to include proper notification of the reporting of alleged violations and grievances. Registered Nurses (RNs) 11 of 11 -100%; Licensed Practical Nurses (LPNs) 15 of 17 -88%; CNAs 26 of 31 - 84%; Administration 13 of 13 - 100%; Dietary nine of 11 - 82%; Housekeeping and Laundry nine of nine - 100%; Therapy 11 of 11 - 100 %; MD one of one - 100% and NPs two of two - 100% OVERALL 92% on the Abuse and Neglect policy and procedure as of October 26, 2023. Employees on leave of absence/ leave - (0), vacation (0) agency staff or new hires will be re-educated by the Staff Development Coordinator prior to returning to duty and will not be given an assignment until they are given additional on-site education. The Administrator, DON, or the SDC will educate all new staff, agency staff or staff not already educated before they are given an assignment. All corrective actions were completed on 10/30/2023. The facility alleges that the IJ is removed on 10/31/2023. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review was conducted of facility reported incident dated 10/26/2023 revealed the facility Administrator reported the 8/31/2023. This was confirmed by an interview with the Administrator on 11/1/2023 at 12:30 pm. 2. A review was conducted of the Abuse, Neglect, and Exploitation policy signed by the Administrator on 10/26/2023. Interview with Administrator and RDCO 11/1/2023 at 2:00 pm confirmed the Administrator had been re-educated. 3. A review was conducted of a statement dated 10/26/2023 by the Administrator related to the audit of allegations and grievances. The audits were confirmed in an interview with the RDCO and Administrator on 11/1/2023 at 4:30 pm. 4. A review was conducted of Psycho-Social Well-Being Assessment Tool for all residents completed on 10/30/2023 with no new concerns. The DON confirmed in an interview on 11/1/2023 at 12:30 pm that she would continue to audit for inappropriate behaviors and any necessary follow-up. 5. A review was conducted of the Abuse, Neglect, and Exploitation policy signed by the Administrator and RDCO on 10/26/2023. Interview with Administrator and RDCO 11/1/2023 at 2:00 pm confirmed their review and will update as needed. 6. A review was conducted of abuse training sign in sheets of all employees. Interviews of all staff present at facility on 11/1/2023 beginning at 1:20 pm and ending at 2:30 pm. The interviews verified that all staff were found to be knowledgeable and were able verbalize the information shared during the education. On 11/1/2023, the following staff were interviewed: LPN CC at 1:20 pm; Dietary Aide (DA) DD at 1:22 pm; DA EE at 1:22 pm; DA FF at 1:25 pm; DA GG at 1:27 pm; DA HH at 1:27 pm; Certified Dietary Manager (CDM) at 1:29 pm; Business Office Manager (BOM) at 1:32 pm; CNA II at 1:34 pm; CNA JJ at 1:35 pm; LPN KK at 1:35 pm; LPN LL at 1:36 pm; Housekeeper (HK) MM at 1:37 pm; HK NN at 1:39 pm; Maintenance OO at 1:40 pm; PT PP at 1:42 pm; CNA QQ at 1:43 pm; Certified Occupational Therapy Assistant (COTA) RR at 1:45 pm; HK SS at 1:47 pm; Laundry Aide (LA) TT at 1:48 pm; Registered Nurse (RN) UU at 1:49 pm; Maintenance VV at 1:51 pm; LPN WW at 1:53 pm; Activity Assistant XX at 1:55 pm; Account Manager for Housekeeping and Laundry at 1:57 pm; Physician YY at 1:58 pm; NP at 1:59 pm; Physical Therapy Assistant (PTA) ZZ at 2:02 pm; CNA AAA at 2:03 pm; Receptionist BBB at 2:04 pm; Activity Director (AD) at 2:07 pm; Admissions Coordinator (AC) at 2:08 pm; Director of Therapy (DOT) at 2:09 pm; LPN CCC at 2:11 pm; CNA AA at 2:14 pm; CNA DDD at 2:14 pm; Staffing Coordinator at 2:16 pm; SDC at 2:17 pm; MDS Coordinator at 2:18 pm; CNA EEE at 2:24 pm; and Assistant ADON at 2:30 pm. All corrective actions were completed on 10/30/2023. The IJ is removed on 10/31/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of the facility policy, the facility failed to investigate incidents of alleged abuse. Specifically, the facility failed to thoroughly investigate an incident of sexual abuse for one of 27 residents (R) (R15). On 10/26/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing (DON), Regional Director of Clinical Operations (RDCO), and [NAME] President of Clinical Operations (VPCO) were informed of the Immediate Jeopardy (IJ) on 10/26/2023 at 5:36 pm. The noncompliance related to the IJ was identified to have existed on 8/31/2023. An Acceptable Removal Plan was received on 10/31/2023. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 10/31/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing sexual abuse in the facility. Findings included: A review of the facility policy titled Abuse, Neglect, and Exploitation revised 9/8/2022 revealed: An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R15 with a Brief Interview of Mental (BIMS) score of zero, indicating severely impaired cognition. A review of the Quarterly MDS dated [DATE] revealed R16 with a BIMS score of 13, indicating resident was cognitively intact. A review of R16's encounter note dated 8/31/2023 documented by the Nurse Practitioner (NP), an encounter noted dated 9/5/2023 documented by the Physician, and encounter note dated 9/14/2023 documented by the Psychiatric Nurse Practitioner (PNP) revealed R16 was on their caseload for attempting to kiss and inappropriately touching female residents. Observations throughout the survey revealed that there are two units in the facility, the 100 Unit and the 200 Unit. On 10/25/2023 at 3:30 pm, R16 was observed in his wheelchair independently propelling himself on the 100 Unit towards the lobby area. On 10/26/2023 at 7:15 am, R16 was observed independently propelling himself on the 200 Unit near his bedroom area. On 10/30/2023 at 10:30 am, R16 was observed seated in his wheelchair in the dining room. The facility was unable to provide any additional information on these allegations. The facility was unable to identify the female residents mentioned. There was no evidence (witness statements, interviews, assessments) to indicate that these allegations were investigated. During an interview on 10/26/2023 at 8:22 am, Certified Nursing Assistant (CNA) AA stated she observed R16 to grab R15 by the face, pull her face towards his and attempted to kiss R15. CNA AA stated she intervened and reported to the Administrator. CNA AA stated this incident occurred on the 200 hall a couple of months ago. CNA AA further stated she had not witnessed R16 attempt to kiss any other residents. During an interview on 10/26/2023 at 8:27 am, CNA BB stated she observed R16 kiss R15 on the lips. CNA BB stated she told R16 that behavior was inappropriate, separated the residents, and reported to the nurse on shift. CNA BB stated this incident occurred in the dining room in June 2023 or July 2023. During an interview on 10/26/2023 at 8:51 am, the Administrator confirmed he was the Abuse Coordinator and stated he was unaware of the allegations of sexual abuse. The facility implemented the following actions to remove the IJ: 1. R16 was seen by Nurse Practitioner on 8/31/2023 and recommendations for medication changes (Cimetidine Table 300 milligrams (mg) one tablet twice a day) were made and implemented. 2. R16 was referred to and seen by physician on 9/5/2023 and no new recommendations made. 3. R16 was referred to and seen by PNP on 9/14/2023 and a new medication (Zoloft 50 mg by mouth once a day) recommendation was made and implemented. 4. R16 was placed on behavioral monitoring to assess and monitor for inappropriate touching or kissing behaviors toward others on 10/26/2023. 5. On 10/27/2023, R16 was sent to input acute care hospital for behavioral assessment and treatment. No new orders or recommendations were made. 6. On 10/29/2023, R15 was assessed by the Social Services Director (SSD) and NP. Resident presented at baseline and had no recollection of the events of 8/31/2023. 7. On 10/27/2023, R16 care plan was reviewed by the DON and was updated to assess, monitor, and address inappropriate sexual behaviors toward others. 8. On 10/26/2023, the Administrator reported allegations of abuse and neglect related to R16 inappropriate sexual behavior once alerted by the surveyor. 9. On 10/27/2023, the Administrator interviewed the caregiver (s) and staff related to the allegations made regarding R16. Staff statements were collected and maintained in the investigation file. 10. On 10/26/2023, the administrator was re-educated by the Director of Operations (DOO) to conduct a thorough investigation and resolution of abuse and neglect allegations. 11. On 10/26/2023, the Regional Director of Operations (RDO) and the Administrator conducted an audit of all reported alleged violations and grievances in the last 30 days to validate that thorough investigations were completed. All reported alleged violations and grievances in the last 30 days were investigated appropriately. 12. On 10/302023, the SSD, NP and Nurse Managers assessed residents with a less than 12 BIMS score for psycho-social well-being and change in mood and behavior. Findings of these assessments noted no resident change in behavior. Assessments were documented on the Psycho-Social Well-Being Assessment Tool. 13. On 10/26/2023, the RDO and the Administrator reviewed the Abuse and Neglect Policy which includes timely reporting and follow up resolution. No revisions or amendments of the policy were recommended. 14. On 10/26/2023, the DON and the SDC educated all staff on the importance of reporting allegations of abuse and neglect to ensure proper investigating and correction action are implemented. Registered Nurses (RNs) 11 of 11 -100%; Licensed Practical Nurses (LPNs) 15 of 17 -88%; CNAs 26 of 31 - 84%; Administration 13 of 13 - 100%; Dietary nine of 11 - 82%; Housekeeping and Laundry nine of nine - 100%; Therapy 11 of 11 - 100 %; MD one of one - 100% and NPs two of two - 100% OVERALL 92% on the Abuse and Neglect policy and procedure as of October 26, 2023. Employees on leave of absence/ leave - (0), vacation (0) agency staff or new hires will be re-educated by the Staff Development Coordinator prior to returning to duty and will not be given an assignment until they are given additional on-site education. The Administrator, DON, or the SDC will educate all new staff, agency staff or staff not already educated before they are given an assignment. All corrective actions were completed on 10/30/2023. The facility alleges that the IJ is removed on 10/31/2023. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review was conducted of progress/encounter note dated 8/31/2023 revealed that R16 was seen by the NP and new orders were noted at that time. 2. A review was conducted of progress/encounter note dated 9/5/2023 revealed that R16 was seen by the Physician and no new orders were written. 3. A review was conducted of progress/encounter note dated 9/13/2023 revealed that R16 was seen by the PNP and new orders for Zoloft 50 mg daily were noted on the Order Summary Report. 4. A review was conducted of an order summary report dated 10/26/2023 revealed that the medication and behavior monitoring were ordered and initiated. Nursing will continue monitoring and documenting behaviors per interview with the DON on 11/1/2023 at 12:30 pm. 5. A review was conducted of the progress note dated 10/27/2023 detailing resident evaluation at [NAME] Behavioral Health. A review of emergency service patient care report was reviewed with the Director of Nursing on 11/1/2023 at 12:30 pm. 6. A review was conducted of progress notes dated 10/30/2023 and 10/31/2023 regarding assessment of R15 was reviewed with the Director of Nursing on 11/1/2023 at 12:30 pm. 7. Review of care plan updated on 10/26/2023 revealed R16 has a behavior problem of sexually suggestive displays and potential for sexually inappropriate behaviors toward others. This was reviewed with the DON on 11/1/2023 at 12:30 pm. 8. A review was conducted of facility reported incident dated 10/26/2023 reviewed with the Administrator on 11/1/2023 at 2:00 pm. 9. A review was conducted of witness statements by staff dated 10/27/2023. This was reviewed with the Administrator on 11/1/2023 at 2:00 pm. 10. A review was conducted of the Abuse, Neglect, and Exploitation policy signed by the Administrator on 10/26/2023. This was reviewed with the RDCO 11/1/2023 at 12:30 pm. 11. A review was conducted of statement dated 10/26/2023 by the administrator related to the audit of allegations and grievances. This was reviewed with the Administrator on 11/1/2023 at 2:00 pm. 12. A review was conducted of Psycho-Social Well-Being Assessment Tool for all residents completed on 10/30/2023. This was reviewed with the DON on 11/1/2023 at 12:30 pm. 13. A review was conducted of the Abuse, Neglect, and Exploitation policy signed by the Administrator and by the RDCO on 10/26/2023. This was reviewed with the Administrator on 11/1/2023 at 2:00 pm. 14. A review was conducted of abuse training sign in sheets of all employees. Interviews of all staff present at facility on 11/1/2023 beginning at 1:20 pm and ending at 2:30 pm. The interviews verified that all staff were found to be knowledgeable and were able verbalize the information shared during the education. On 11/1/2023, the following staff were interviewed: LPN CC at 1:20 pm; Dietary Aide (DA) DD at 1:22 pm; DA EE at 1:22 pm; DA FF at 1:25 pm; DA GG at 1:27 pm; DA HH at 1:27 pm; Certified Dietary Manager (CDM) at 1:29 pm; Business Office Manager (BOM) at 1:32 pm; CNA II at 1:34 pm; CNA JJ at 1:35 pm; LPN KK at 1:35 pm; LPN LL at 1:36 pm; Housekeeper (HK) MM at 1:37 pm; HK NN at 1:39 pm; Maintenance OO at 1:40 pm; PT PP at 1:42 pm; CNA QQ at 1:43 pm; Certified Occupational Therapy Assistant (COTA) RR at 1:45 pm; HK SS at 1:47 pm; Laundry Aide (LA) TT at 1:48 pm; Registered Nurse (RN) UU at 1:49 pm; Maintenance VV at 1:51 pm; LPN WW at 1:53 pm; Activity Assistant XX at 1:55 pm; Account Manager for Housekeeping and Laundry at 1:57 pm; Physician YY at 1:58 pm; NP at 1:59 pm; Physical Therapy Assistant (PTA) ZZ at 2:02 pm; CNA AAA at 2:03 pm; Receptionist BBB at 2:04 pm; Activity Director (AD) at 2:07 pm; Admissions Coordinator (AC) at 2:08 pm; Director of Therapy (DOT) at 2:09 pm; LPN CCC at 2:11 pm; CNA AA at 2:14 pm; CNA DDD at 2:14 pm; Staffing Coordinator at 2:16 pm; SDC at 2:17 pm; MDS Coordinator at 2:18 pm; CNA EEE at 2:24 pm; and Assistant ADON at 2:30 pm. All corrective actions were completed on 10/30/2023. The IJ is removed on 10/31/2023.

Based on observations, interviews, record review, and review of the Administrator position description, facility Administration failed to effectively oversee an abuse prevention program to promote, foster and maintain an abuse free environment. The facility census was 95. On 10/26/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing (DON), Regional Director of Clinical Operations (RDCO), and [NAME] President of Clinical Operations (VPCO) were informed of the Immediate Jeopardy (IJ) on 10/26/2023 at 5:36 pm. The noncompliance related to the IJ was identified to have existed on 8/31/2023. An Acceptable Removal Plan was received on 10/31/2023. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 10/31/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing sexual abuse in the facility. Findings included: A review of the Administrator's position description revealed Ensures resident incidents and concerns that rise to a reportable event such as alleged abuse, neglect, mistreatment, misappropriation, etc. are reported to the correct entity within the stated regulatory requirement . Treats all residents with dignity and respect. Promotes and protects all residents' rights . Report any allegations of abuse, neglect, misappropriation of property, exploitation, or mistreatment of residents to appropriate regulatory entities. Protects residents from abuse, and cooperates with all investigations. The Administration failed to demonstrate competency consistently and effectively in the protection and promotion of residents' rights to be free from abuse that were included in the Administrator's job description. 1. The Administration failed to maintain an environment free from sexual abuse for one R15 perpetuated by R16. Cross reference to F600. 2. The Administration failed to ensure that incidents of sexual abuse for one R15 perpetuated by R16 was reported in a timely manner to required agencies. Cross reference to F609. 3. The Administration that incidents of sexual abuse for one R15 perpetuated by R16 was thoroughly investigated, and corrective actions implemented, including protection of the resident, in a timely manner. Cross reference to F610. Observations throughout the survey revealed that there are two units in the facility, the 100 Unit and the 200 Unit. On 10/25/2023 at 3:30 pm, R16 was observed in his wheelchair independently propelling himself on the 100 Unit towards the lobby area. On 10/26/2023 at 7:15 am, R16 was observed independently propelling himself on the 200 Unit near his bedroom area. On 10/30/2023 at 10:30 am, R16 was observed seated in his wheelchair in the dining room. On 10/31/2023 at 9:45 am, R16 was observed independently propelling himself down the main hallway towards the dining room. On 11/1/2023 at 11:15 am, R16 was observed seated in his wheelchair in the dining room in a group activity. During an interview on 10/26/2023 at 8:22 am, Certified Nursing Assistant (CNA) AA stated she observed R16 to grab R15 by the face, pull her face towards his and attempted to kiss R15. CNA AA stated she intervened and reported to the Administrator. CNA AA stated this incident occurred on the 200 hall a couple of months ago. CNA AA further stated she had not witnessed R16 attempt to kiss any other residents. During an interview on 10/26/2023 at 8:27 am, CNA BB stated she observed R16 kiss R15 on the lips. CNA BB stated she told R16 that behavior was inappropriate, separated the residents, and reported to the nurse on shift. CNA BB stated this incident occurred in the dining room in June 2023 or July 2023. During an interview on 10/26/2023 at 8:51 am, the Administrator confirmed he was the Abuse Coordinator and stated he was unaware of the allegations of sexual abuse. The Administrator stated if he had known of the abuse, he would have reported it immediately. The facility implemented the following actions to remove the IJ: 1. On 10/26/2023, a Root Cause Analysis (RCA) on the lack of recognition, reporting and investigation of abuse was completed by Regional Director of Operation (RDO), RDCO, VPCO, Administrator, and DON. Documentation of analysis was put on the RCA Tool and will be included in the next Quality Assurance Performance Improvement (QAPI) meeting. 2. On 10/26/2023, RDO re-educated the Administrator on adequately ensuring staff are properly trained to recognize and identify situations of inappropriate sexual behaviors that may lead to abuse and neglect; the importance of timely reporting and investigating all instances of abuse and neglect to prevent future recurrence that may affect the physical, mental, and psychosocial well-being for residents. 3. On 10/27/2023, the RDO issued a Performance Improvement Plan (PIP) to the Administrator. 4. Administrator hosted an AD HOC QAPI meeting on 10/26/2023 and 10/27/2023, with the MD, DON, RDCO, Administrator, VPCO, and RDO to review the center's residents at risk for being touched or kissed inappropriately. 5. On 10/26/2023, the RDO and the Administrator identified Improvement Activities based on the findings of the RCA. PIP plans and RCA documents will be maintained as part of the QAPI process. 6. Beginning 10/26/2023, the DON and Staff Development Coordinator (SDC) educated all staff on the importance of reporting, investigating, and implementing correction actions related to alleged abuse and neglect. Registered Nurses (RNs) 11 of 11 -100%; Licensed Practical Nurse (LPNs) 15 of 17 -88%; CNAs 26 of 31 - 84%; Administration 13 of 13 - 100%; Dietary nine of 11 - 82%; Housekeeping and Laundry nine of nine - 100%; Therapy 11 of 11 - 100%; Medical Director (MD) one of one - 100% and Nurse Practitioners (NPs) two of two - l 00% OVERALL 92% on the Abuse and Neglect policy and procedure as of 10/26/2023. on the Abuse and Neglect policy and procedure as of 10/26/2023. Employees on leave of absence Family Medical Leave (FMLA)- (0), vacation (0) agency staff or new hires will be re-educated by the Staff Development Coordinator prior to returning to duty and will not be given an assignment until they are given additional on-site education. The Administrator, DON, or the SDC will educate all new staff, agency staff or staff not already educated before they are given an assignment. 7. On 10/30/2023, the Administrator held additional AD HOC meeting with (Interdisciplinary Team (IDT), RDO, RDCO, and MD to discuss investigation and completion of IJ removal plan. All corrective actions were completed on 10/30/2023. The facility alleged that the IJ was removed on 10/31/2023. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review of RCA PIP dated 10/26/2023 with description of event, root cause and contributing factors, corrective action plans. This was confirmed in an interview with the RDCO, and Administrator on 11/1/2023 at 4:30 pm. 2. A review was conducted of the Abuse, Neglect, and Exploitation policy signed by the Administrator on 10/26/2023. This was reviewed with the RDCO on 11/1/2023 at 12:30 pm. 3. A review was conducted of the PIP dated 10/27/2023 for the Administrator placed on 30-day PIP with the following areas of concern - failure to identify, timely report, and investigate an allegation of abuse and/or neglect. This was confirmed in an interview with the Regional Director of Clinical Operations and Administrator on 11/1/2023 at 4:30 pm. 4. A review was conducted of the QAPI Meeting Minutes - QAPI AD HOC - investigation and completion of IJ Removal Plan. Also reviewed list of attendees: Administrator, Physician, DON, Assistant DON, RDCO, SSD, Activity Coordinator, Minimum Data Set (MDS) Coordinator, Unit Manager, SDC, Wound care nurse, Dietary Manager, and Business Office Manager. This was confirmed in an interview with the Administrator on 11/1/2023 at 4:30 pm. 5. A review was conducted of the RCA PIP dated 10/26/2023 with description of event, root cause and contributing factors, corrective action plans. This was confirmed in an interview with the RDCO and Administrator on 11/1/2023 at 4:30 pm. 6. Review of abuse training sign in sheets of all employees. Interviews of all staff present at facility on 11/1/2023 beginning at 1:20 pm and ending at 2:30 pm. The interviews verified that all staff were found to be knowledgeable and were able verbalize the information shared during the education. On 11/1/2023, the following staff were interviewed: LPN CC at 1:20 pm; Dietary Aide (DA) DD at 1:22 pm; DA EE at 1:22 pm; DA FF at 1:25 pm; DA GG at 1:27 pm; DA HH at 1:27 pm; Certified Dietary Manager (CDM) at 1:29 pm; Business Office Manager (BOM) at 1:32 pm; CNA II at 1:34 pm; CNA JJ at 1:35 pm; LPN KK at 1:35 pm; LPN LL at 1:36 pm; Housekeeper (HK) MM at 1:37 pm; HK NN at 1:39 pm; Maintenance OO at 1:40 pm; PT PP at 1:42 pm; CNA QQ at 1:43 pm; Certified Occupational Therapy Assistant (COTA) RR at 1:45 pm; HK SS at 1:47 pm; Laundry Aide (LA) TT at 1:48 pm; Registered Nurse (RN) UU at 1:49 pm; Maintenance VV at 1:51 pm; LPN WW at 1:53 pm; Activity Assistant XX at 1:55 pm; Account Manager for Housekeeping and Laundry at 1:57 pm; Physician YY at 1:58 pm; NP at 1:59 p.m.; Physical Therapy Assistant (PTA) ZZ at 2:02 pm; CNA AAA at 2:03 pm; Receptionist BBB at 2:04 pm; Activity Director (AD) at 2:07 pm; Admissions Coordinator (AC) at 2:08 pm; Director of Therapy (DOT) at 2:09 p.m.; LPN CCC at 2:11 pm; CNA AA at 2:14 pm; CNA DDD at 2:14 pm; Staffing Coordinator at 2:16 pm; SDC at 2:17 pm; MDS Coordinator at 2:18 pm; CNA EEE at 2:24 pm; and Assistant DON at 2:30 pm. 7. A review of QAPI Meeting Minutes - QAPI AD HOC - investigation and completion of IJ Removal Plan. Also reviewed list of attendees: Administrator, Physician, DON, ADON, RDCO, SSD, Activity Coordinator, MDS Coordinator, Unit Manager, SDC, Wound care nurse, Dietary Manager, and Business Office Manager. This was confirmed in an interview with the Administrator on 11/1/2023 at 4:30 pm. All corrective actions were completed on 10/30/2023. The IJ was removed on 10/31/2023.