**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R24's Face Sheet, located in the resident's EMR under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease unspecified and dementia in other diseases classified elsewhere without behavioral disturbance. Review of R24's quarterly MDS with an (ARD) of 07/09/24 revealed the facility assessed the resident to have a BIMS score of two out of 15 which indicated the resident was severely cognitively impaired. 3. Review of R97's Face Sheet, located in the resident's EMR under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease unspecified, with other behavioral disturbance, and unspecified psychosis not due to a substance or known physiological condition. Review of R97's quarterly MDS with an (ARD) of 02/15/24 revealed the facility assessed the resident's BIMS score was blank, there was no score to assess resident's cognitive status. Record review of R97's Progress Note dated 01/25/24 located in the EMR under the Progress Note tab revealed resident was noted at 4:05 PM by CNA's doing rounds to be in R24's room with the door closed. R24 was lying in her bed on a towel with her pants half-way down and R97 was coming out of R24's bathroom with his shirt up and his pants half-way down. Review of a Witness Statement provided by the facility dated 01/25/24 written by Certified Nurse Aide (CNA) 8 revealed CNA8 went into R24's room to change R24's brief. CNA8 opened R24's bathroom and R97 was in the bathroom barefoot and pulling up his shirt. CNA8's witness statement also stated R24 was sitting on her bed, the covers were pulled back and a towel was spread out on the bed. Review of a Witness Statement dated 01/25/24 written by CNA7 revealed CNA7 entered R24's room, she saw R24's pants down and R97 was in R24's bathroom with his shoes off and his and his shirt up. The statement also revealed there was a large towel laid across R24's bed. Review of a Witness Statement provided by the facility dated 01/25/24 written by Licensed Practical Nurse (LPN) 13 revealed on 01/25/24 approximately 6:00 PM CNA's reported to her that R24's bedroom door was closed and when they entered they witnessed, R24 laying on her bed on a towel with her pants halfway down. The statement also revealed R97 was coming out of R24's bathroom with his shoes off, shirt up and his pants half-way down. The residents could not explain what happened. During an interview on 09/03/24 at 11:15 AM the Administrator stated he was aware of the potential abuse incident between R24 and R97. However, he felt the incident did not need to be investigated or reported to the state, because staff did not witness R24 and R97 doing anything. During an interview on 09/03/24 at 4:04 PM with the DON who read the three witness statements and confirmed the incident between R24 and R97 was potential abuse. She said she did not know if it was an allegation of sexual abuse, because staff did not see R24 and R97 doing anything. During an interview on 09/04/24 at 4:57 PM, CNA7 stated she remembered R97 was in R24's bathroom with his shoes off and his shirt up, while R24's pants were down with a large towel laid on R24's bed. Based on review of facility policy, record review, and interview, the facility failed to ensure three Residents (R) R24, R61 and R97 out of five residents reviewed for abuse/neglect were protected from potential sexual abuse. The facility failed to ensure R61 was protected from potential sexual abuse by a staff member/staff members after she made an allegation of potential sexual assault and failed to ensure R24 and R97 were protected from potential sexual abuse after the two residents, who were not interviewable, were observed together in R24's room with their pants down. The facility's systemic failure to ensure the prevention of abuse created the potential for residents to be, or to continue to be, sexually abused by staff or other residents leading to serious physical and/or psychological harm for each resident. Immediate Jeopardy related to this failure was identified on 09/04/24 at 4:51 PM and was determined to exist since 01/25/24, when the facility failed to ensure R24 and R97 were protected from further potential abuse after an incident of potential resident to resident sexual abuse was observed between the two residents. On 09/04/24 at 4:51 PM, the facility's Administrator was notified of the Immediate Jeopardy at F600, Abuse. The facility Administrator was notified that the Immediate Jeopardy was removed on 09/06/24 at 4:00 PM. The noncompliance remained at a scope and severity level of D (isolated with the with the potential for more than minimal harm) following the removal of the immediate jeopardy. Findings include: Review of the facility's undated Abuse Prohibition, Reporting and Investigation Policy read, in pertinent part, Definitions: 1. Abuse: Means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish; and It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology; and Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; and It is the intent of Magnolia Manor facilities to actively preserve each resident's right to be free from mistreatment, neglect, abuse or misappropriation of resident property. We believe each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. 1. Review of R61's admission Record, dated 09/06/24 and found in the Electronic Medical Record (EMR) under the Admissions Tab, indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included type 2 diabetes, depression, and anxiety. Review of R61's annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 06/07/24 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) assessment was not able to be completed for the resident due to her refusal to participate in the interview. The assessment indicated the resident had both short and long-term memory deficits. The MDS indicated R61 did not display any behaviors during the assessment reference period. Review of R61's comprehensive Care Plan most recently dated 08/16/24 and found in the EMR under the Care Plan tab, indicated the resident exhibited behaviors including refusal of care and sometimes had delusions and/or hallucinations. The Care Plan also indicated the resident exhibited signs and symptoms of depression, including little interest or pleasure in doing things, feeling down, depressed, or hopeless, poor appetite and being short tempered at times. Review of the Complaint Form, dated 08/06/24 provided by the facility and completed by the MDS Coordinator (MDSC) on behalf of R61, read, in pertinent part, I spoke with (R61) asking her if she had any complaints. She said yes. She said the CNAs (Certified Nursing Assistants) let her lay in urine and she is only changed once a shift. She said they are sometimes rough with her when giving care. She said she wondered if the females that work here are Lesies (sic) because they put their fingers up her. She said they put stuff in her drinks and are trying to poison her. Review of R61's EMR indicated nothing related to the resident's report of potential abuse by staff and nothing to indicate the resident was physically assessed and or sent to the local Emergency Department (ED) for evaluation related to the above referenced potential abuse. Nothing could be found in the facility's documentation or in the resident's EMR to indicate any attempt was made to determine what specific staff R61 was referring to related to the allegation of potential abuse or that R61 was protected from further potential abuse by staff after her allegation of potential abuse was made on 08/06/24. During an interview with the MDSC on 09/03/24 at 2:36 PM, she confirmed R61 reported the potential abuse to her on 08/06/24. The MDSC stated R61 alleged female staff put their fingers in her. She stated (R61) looked right at me wide eyed, held my hand, and said she wondered if the females were lezzies (lesbians) because they put their fingers up me. The MDSC stated she reported the allegation to Registered Nurse (RN)1 (the Unit Manager responsible for R61's care), the Administrator, and the Director of Nursing (DON) immediately after the report of potential abuse. The MDSC stated RN1 told her the resident had recently been impacted (with hard stool in her colon) and that R61 had a history of refusing cares. The MDSC indicated she was not aware of how R61's allegation of potential abuse was addressed after it was reported. During an interview with RN1 on 09/03/24 at 3:01 PM, she confirmed the MDSC reported R61's allegation of potential abuse to her on 08/06/24 and confirmed R61's allegations were related to staff poisoning her drinks and her perception that (female) staff in the facility were lesbians and were fingering her (placing their fingers in her vagina). RN1 stated she and the Administrator spoke to R61 related to the allegation of potential abuse two days after the allegation was made and the resident stated she didn't want the CNAs to change her (provide peri-care/incontinence care) because the staff was all lesbians and were going to finger her. RN1 confirmed no physical assessment was completed for R61 nor did staff attempt to send the resident to the local ED for evaluation related to the report of potential abuse. She confirmed nothing was done, after the resident's report of potential abuse, to ensure the resident was protected from further potential abuse by staff as far as she was aware. During an interview with the Social Services Director (SSD) on 09/03/24 at 3:32 PM, she stated she was aware of R61's allegation of potential abuse. She stated the MDSC brought the resident's Complaint Form related to the allegation to her on the day of the report, and that she read the complaint form over and then gave the form to the DON and the Administrator the same day. The SSD stated she and RN1 attempted to interview R61 about the report of potential abuse on the day of the report, but R61 refused to speak with them. The SSD stated she was not involved in/aware of any measures put into place related to the resident's allegation to ensure the resident's protection from further potential abuse. During an interview with the DON on 09/03/24 at 3:42 PM, she confirmed she was the facility's Abuse Coordinator and stated she was aware of R61's allegation of potential abuse, but stated she was not involved in facility follow-up related to the allegation to ensure R61's protection from further potential abuse. The DON stated she had heard a little bit about the resident's allegation from staff, but stated R61 could be a little bit delusional. The DON confirmed R61 had never been physically assessed related to the allegation of potential abuse and stated she did not think any attempt had been made to send the resident to the ED for evaluation. She confirmed nothing had been done related to the resident's allegation of potential abuse to ensure R61 was protected from further potential abuse by staff. She stated her expectation was any resident who reported potential abuse was to be assessed for potential injury and measures were to be taken to ensure the resident was protected from further potential abuse. During an interview with the Administrator and DON on 09/04/24 at 11:16 AM, the Administrator confirmed the DON was the facility's Abuse Coordinator and stated he and the DON were both responsible for ensuring residents were protected from potential abuse. The Administrator stated he was aware of R61's allegation of potential abuse on 08/06/24, but stated he did not interpret the report as potential abuse since the resident often refused care, had a history of kicking a CNA during care, and had a history of urinary tract infections (UTIs) and potential bowel obstruction requiring staff to potentially remove stool digitally from the resident's rectum. The Administrator stated his expectation was that any resident who reported potential abuse should be protected from further potential abuse while an investigation into the alleged abuse was conducted. He confirmed this had not been done related to R61's allegation of potential abuse. During an interview on 09/06/24 at 2:00 PM, R61 confirmed her report of potential abuse to the MDSC on 08/06/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R24's Face Sheet, located in the EMR under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease unspecified and dementia in other diseases classified elsewhere without behavioral disturbance. Review of R24's quarterly MDS with an ARD of 07/09/24 revealed the facility assessed the resident to have a BIMS score of two out of 15 which indicated the resident was severely cognitively impaired. 3. Review of R97's Face Sheet, located in the EMR under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease unspecified, unspecified psychosis not due to a substance or known physiological condition, and dementia. Review of R97's quarterly MDS with an ARD of 02/15/24 revealed the resident's BIMS was blank which indicated there is no score to assess resident's cognitive status. Review of R97's Progress Note dated 01/25/24 located in the EMR under the Progress Note tab revealed Resident was noted at 4:05 PM by CNA's doing rounds to be in R24's room with the door closed. R24 was lying in her bed on a towel with her pants half-way down and R97 was coming out of R24's bathroom with his shirt up and his pants half-way down. There was no evidence in the EMR that the potential sexual abuse was reported to the State Agency. During an interview on 09/03/24 at 11:15 AM the Administrator stated he felt the incident did not need to be investigated or reported to the state, because staff did not witness R24 and R97 doing anything. During an interview on 09/03/24 at 4:04 PM with the DON confirmed the incident witnessed between R24 and R97 should have been reported to the State Agency. Based on review of facility policy, record review, and interviews, the facility failed to ensure allegations of potential abuse related to three (Residents (R) R24, R61 and R97) out of five residents reviewed for abuse/neglect were appropriately reported to the State Agency and other required agencies. The facility failed to report an allegation of sexual abuse by staff members by R61 and failed to report potential sexual abuse between R97 and R24 witnessed by staff members to the State Agency, the local Ombudsman, and local law enforcement. The facility's failure to ensure the alleged potential sexual abuse was reported to appropriate agencies created the potential for residents to continue to be sexually abused by staff or other residents leading to serious physical and/or psychological harm for each resident. Immediate Jeopardy related to this failure was identified on 09/04/24 at 4:51 PM and was determined to exist since 01/25/24, when the facility failed to report potential sexual abuse between R24 and R97 to appropriate outside agencies, including the State Agency. On 09/04/24 at 4:51 PM, the facility's Administrator was notified of the Immediate Jeopardy at F609, Reporting of Potential Abuse. The facility Administrator was notified that the Immediate Jeopardy was removed on 09/06/24 at 4:00 PM. Findings include: Review of the facility's undated Abuse Prohibition, Reporting and Investigation Policy read, in pertinent part, Definitions: 1. Abuse: Means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish; and D. Reporting: 1) Once a complaint or situation is identified involving alleged mistreatment, neglect or abuse including injuries of unknown source/origin and misappropriation of resident property the incident will be immediately reported. a. The Administrator or designee will immediately notify (the State Agency) and resident representative of the incident and pending investigation. The Ombudsman will also be notified as appropriate. The Administrator will direct the investigation. b. If indicated and/or directed notification to the local Police Department should be made Obtain the badge number of the investigation officer. Submit the badge number with the facility report to (the State Agency). 1.Review of R61's admission Record, dated 09/06/24 and found in the Electronic Medical Record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included type 2 diabetes, depression, and anxiety. Review of R61's annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 06/07/24 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) assessment was not able to be completed for the resident due to her refusal to participate in the interview. The assessment indicated the resident had both short and long-term memory deficits. Review of a Complaint Form, provided by the facility dated 08/06/24 and completed by the MDS Coordinator (MDSC) on behalf of R61, read, in pertinent part, I spoke with (R61) asking her if she had any complaints. She said yes. She said the CNAs (Certified Nursing Assistants) let her lay in urine and she is only changed once a shift. She said they are sometimes rough with her when giving care. She said she wondered if the females that work here are Lesies (sic) because they put their fingers up her. She said they put stuff in her drinks and are trying to poison her. Nothing could be found in the facility's documentation or in the resident's EMR to indicate the allegation of potential sexual abuse was reported to the State Agency, the Ombudsman, or the local Police Department. During an interview with the MDSC on 09/03/24 at 2:36 PM, she confirmed R61 reported the potential abuse to her on 08/06/24. The MDSC stated R61 alleged female staff put their fingers in her. She stated (R61) looked right at me wide eyed, held my hand, and said she wondered if the females were lezzies (lesbians) because they put their fingers up me. The MDSC stated she reported the allegation to Registered Nurse (RN)1 (the Unit Manager responsible for R61's care), the Administrator, and the Director of Nursing (DON) immediately after the report of potential abuse. During an interview with RN1 on 09/03/24 at 3:01 PM, she confirmed the MDSC reported R61's allegation of potential abuse to her on 08/06/24 and confirmed the allegation of potential abuse was also reported to the DON and Administrator immediately after the resident's allegation of potential abuse. RN1 stated the DON and Administrator were responsible for reporting allegations of potential abuse to outside agencies. During an interview with the Social Services Director (SSD) on 09/03/24 at 3:32 PM, she stated she was aware of R61's allegation of potential abuse. She stated the MDSC brought the resident's Complaint Form related to the allegation to her on the day of the report, and that she read the complaint form over and then gave the form to the DON and the Administrator the same day. She stated she did not know if the allegation was reported to the State Agency, Ombudsman or Local Law Enforcement. During an interview with the DON on 09/03/24 at 3:42 PM, she confirmed she was the facility's Abuse Coordinator and stated she was aware of R61's allegation of potential abuse, but confirmed the allegation was never reported to the State Agency, Ombudsman or Local Police Department. The DON stated upon reflection of the report, R61's 08/06/24 allegation of potential sexual abuse should have been reported to the appropriate outside agencies, including the State Agency, the Ombudsman, and Local Law Enforcement. During an interview with the Medical Director on 09/04/24 at 11:11 AM, he stated he was not aware of R61's allegation of potential sexual abuse. He stated the allegation should have been reported to himself, the State Agency, the Local Ombudsman and Local Law Enforcement immediately and no later than 24 hours after the allegation was made. During an interview with the Administrator and DON on 09/04/24 at 11:16 AM, the Administrator stated he and the DON were responsible for reporting allegations of potential abuse to local outside agencies and confirmed R61's allegation of potential sexual abuse had never been reported to the appropriate outside agencies, including the State Agency, local Ombudsman, and the Local Police Department. The Administrator stated he was aware of R61's allegation of potential abuse on 08/06/24, but stated he did not interpret the report as potential abuse since the resident often refused care, had a history of kicking a CNA during care, and had a history of urinary tract infections (UTIs) and potential bowel obstruction requiring staff to potentially remove stool digitally from the resident's rectum. The Administrator stated because he did not interpret R61's report as an allegation of potential abuse, the allegation was not reported to relevant outside agencies. During an interview on 09/06/24 at 2:00 PM, R61 confirmed her report of potential abuse to the MDSC on 08/06/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R24's Face Sheet, located in the EMR under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease unspecified, and dementia in other diseases classified elsewhere without behavioral disturbance. Review of R24's quarterly MDS with an ARD of 07/09/24 revealed the facility assessed the resident to have a BIMS score of two out of 15 which indicated the resident was severely cognitively impaired. 3. Review of R97's Face Sheet, located in the EMR under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, unspecified psychosis not due to a substance or known physiological condition, and dementia. Review of R97's quarterly MDS with an ARD of 02/15/24 revealed the resident's BIMS was blank which indicated there is no score to assess resident's cognitive status. Record review of R97's Progress Notes dated 01/25/24 located in the resident's EMR under the Progress Note tab revealed resident was noted at 4:05 PM by CNA's doing rounds to be in R24's room with the door closed. R24 was lying in her bed on a towel with her pants half-way down and R97 was coming out of R24's bathroom with his shirt up and his pants half-way down. There was no evidence in the EMR that the incident between R27 and R97 had been thoroughly investigated. During an interview on 09/03/24 at 11:15 AM the Administrator stated he felt the incident did not need to be investigated, because staff did not witness R24 and R97 doing anything. During an interview on 09/03/24 at 4:04 PM the DON confirmed the incident between R24 and R97 was not thoroughly investigated because staff did not see the residents doing anything. Based on review of facility policy, record review, and interview, the facility failed to ensure allegations of potential abuse related to three Residents (R ) R24, R61 and R97 out of five residents reviewed for abuse/neglect were thoroughly investigated. The facility failed to thoroughly investigate an allegation of sexual abuse by staff members by R61 and potential sexual abuse between R97 and R24 which was witnessed by staff members. The facility's failure to ensure the alleged potential sexual abuse was thoroughly investigated created the potential for residents to continue to be sexually abused by staff or other residents leading to serious physical and/or psychological harm for each resident. Immediate Jeopardy related to this failure was identified on 09/04/24 at 4:51 PM and was determined to exist since 01/25/24, when the facility failed to thoroughly investigate potential sexual abuse between R24 and R97. On 09/04/24 at 4:51 PM, the facility's Administrator was notified of the Immediate Jeopardy at F610, Investigation of Potential Abuse. The facility Administrator was notified that the Immediate Jeopardy was removed on 09/06/24 at 4:00 PM. Findings include: The facility's undated Abuse Prohibition, Reporting and Investigation Policy read, in pertinent part, Definitions: 1. Abuse: Means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish; and E. Investigation: 1) Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source/origin and misappropriation of resident property, the following investigation and reporting procedures will be followed: a. The description of the alleged complaint is written on the investigation form. Any physical evidence and description of emotional state will be documented. b. Information gathering - The following information will be gathered: What allegedly occurred? Who is the alleged victim? Who allegedly did it (Who is the suspect or physical description)? Who did they do it to (Who is the resident)? What happened (Be specific about the event that occurred)? When did it happen (The resident's room, bathroom, dining room, etc.)? Why? Include cognitive status of victims and residents who are witnesses. a. Document the description of the injury. Describe size, color, appearance, and location of any injuries and what treatment was rendered, if any. b. Interview will be conducted of all pertinent parties. Written signed statements from any involved should be obtained if possible. Statements will be gathered from the suspect, person making the accusations, resident involved, reliable residents who may have witnessed the incident, and any other persons who may have some information. Identify any possible conflicts between witnesses. c. Past performance and/or previous incidents of involved parties will be evaluated. Review schedules and assignments showing when and where suspect was working at time of the alleged incident. d. All investigative information will be kept on file in a secured location. All information is confidential in nature. 1. Review of R61's admission Record, dated 09/06/24 and found in the Electronic Medical Record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included type 2 diabetes, depression, and anxiety. Review of R61's annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 06/07/24 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) assessment was not able to be completed for the resident due to her refusal to participate in the interview. The assessment indicated the resident had both short and long-term memory deficits. Review of a Complaint Form, provided by the facility dated 08/06/24 and completed by the MDS Coordinator (MDSC) on behalf of R61, read, in pertinent part, I spoke with (R61) asking her if she had any complaints. She said yes. She said the CNAs (Certified Nursing Assistants) let her lay in urine and she is only changed once a shift. She said they are sometimes rough with her when giving care. She said she wondered if the females that work here are Lesies (sic) because they put their fingers up her. She said they put stuff in her drinks and are trying to poison her. A statement related to R61's allegation of potential abuse and attached to the Complaint Form, dated 08/08/24 (two days after the resident's initial report of potential abuse) and signed by the Administrator and Registered Nurse (RN)1 (the Unit Manager responsible for R61's care) read, Writer and Unit Manager met with resident as an additional follow-up to her recent grievance. Resident voiced that things are going well. She stated that she has not been refusing care and that her mind is good, and she knows when she needs care. Writer recommended that she allow the staff to provide her some nail care. She stated that she would allow (staff) to do it. The writer also encouraged the resident to attend activities, and a TV and radio was offered but she declined. Resident requested more snacks and beverages. Follow-up was conducted with food service. The statement did not address the investigation of resident's allegation of potential sexual abuse. Review of the Findings From Investigation document, attached to R61's 08/06/24 Complaint Form dated 08/08/24, and signed by the Administrator, read, After several attempts to speak with (R61), I met with she and the Social Services Director. We spoke with the resident regarding her concerns, and we spoke with staff members regarding the concern. The staff on both rotations denied her allegations. I also checked the documentation in her records and it indicates that she frequently refuses care. (R61) has a history of having thoughts and making comments that are outside of reality. There was not evidence to support the claims that she made. She accused the staff of placing things in her beverages yet there is no report or finding of poisoning. The document did not specifically address R61's allegation of potential sexual abuse. The facility was not able to provide any additional documentation related to an investigation done in response to R61's 08/06/24 allegation of potential sexual abuse by staff including written and signed statements obtained from residents or staff potentially knowledgeable about the alleged incident, evidence of any attempt to assess R61 physically and psychosocially related to the reported incident, or the facility's attempt to identify potential perpetrators of the alleged abuse, exact circumstances of the alleged abuse, or time/date of the alleged abuse. During an interview with the MDSC on 09/03/24 at 2:36 PM, she confirmed R61 reported the potential abuse to her on 08/06/24. The MDSC stated she was not involved in an investigation related to R61's report of potential abuse nor was she asked to provide a written statement related to R61's allegation of potential abuse. During an interview with the DON on 09/03/24 at 3:42 PM, she confirmed she was the facility's Abuse Coordinator and stated she was aware of R61's allegation of potential abuse, but confirmed a full investigation into the resident's allegation had never been done. The DON stated upon reflection of the report, R61's 08/06/24 allegation of potential sexual abuse should have been thoroughly investigated; however, the allegation was not interpreted as potential abuse at the time of the report due to R61's history of behaviors and delusional thinking. During an interview with the Administrator and DON on 09/04/24 at 11:16 AM, the Administrator stated he and the DON were responsible for investigating allegations of potential abuse. He confirmed R61's allegation of potential sexual abuse had not been thoroughly investigated and that he was unable to locate any additional documentation related to an investigation into the resident's allegation of sexual abuse. The Administrator stated he did not interpret R61's report as potential abuse since the resident often refused care, had a history of kicking a CNA during care, and had a history of urinary tract infections (UTIs) and potential bowel obstruction requiring staff to potentially digitally remove stool from the resident's rectum. The Administrator stated because he did not interpret R61's report as an allegation of potential abuse, the allegation was not investigated as though it was an allegation of potential abuse.

Based on record review, review of job descriptions, interview, and facility policy review, the facility failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently. The facility failed to maintain an abuse free environment, failed to timely report allegations of abuse, failed to thoroughly investigate allegations of abuse for three residents (Residents (R) 24, R61, and R97) of five reviewed for abuse out of a sample of 25. Immediate Jeopardy related to this failure was identified on 09/04/24 at 4:51 PM and was determined to exist since 01/25/24, when the facility's Administration failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently related to potential abuse, reporting abuse, and completing thorough investigations of abuse. On 09/04/24 at 4:51 PM, the facility's Administrator was notified of the Immediate Jeopardy at F835, Administration. The facility Administrator was notified that the Immediate Jeopardy was removed on 09/06/24 at 4:00 PM. Findings include: Review of the Facility Administrator job description undated indicated, .The primary purpose of your job description is to manage operations in accordance with current applicable federal, state, and local standards, guidelines, and regulations.to assure that the organization is operating effectively and efficiently. As the Facility Administrator, you are delegated the administrative authority, responsibility, and accountability for carrying out your assigned duties. Review of the Director of Nursing (DON) job description undated indicated, .The primary purpose of the position is to plan, organize, develop and direct the overall operations of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times. Review of the Social Services Director undated job description indicated, .The primary purpose of the position is to provide interventions that meet the psychosocial needs of residents and families in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Administrator. Review of the RN (Registered Nurse) Supervisor job description indicated, .The primary purpose of the position is to direct and supervise resident care in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility and as may be required by the Director of Nursing to ensure that the highest quality of care is maintained at all times. Review of a facility policy titled Abuse Prohibition/Reporting and Investigation dated 04/17 indicated .It is the intent of [named facility] facilities to actively preserve each resident's right to be free from mistreatment, neglect, abuse.We believe each resident has the right to be free from verbal, sexual, physical, and mental abuse.Any person who hearing a complaint of abuse.must immediately report it to the Administrator or their designee.It will be the responsibility of any department head and/or supervisor receiving the complaint of alleged abuse.must immediately report it to the Administrator and/or their designee.Once a complaint or situation is identified involving alleged.abuse.the incident will be immediately reported.The initial report of the incident will be faxed or emailed within 2 hours abuse.to the Complaint Investigation Intake and Referral Unit.A written report of investigation will be submitted to the .Long Term Care Section Complaint Coordinator, within 5 days of the incident.Details of the incident.Signed statements from pertinent parties.Cognitive status of .resident.Information gathered from the investigation.Action taken by the facility-safeguarding the resident and preventing reoccurrence.Final action/conclusion made by the facility.Through the Quality Assurance Performance Improvement Committee, the facility will analyze the occurrences to determine what changes are needed, if needed, to policies and procedural guidelines to prevent further occurrences. 1. Failure to ensure residents are free from potential Abuse Cross Reference F600: The facility failed to ensure two residents were free from potential sexual abuse. Resident (R61) alleged potential sexual abuse by unknown female staff members on 08/06/24. Staff witnessed R97 potentially sexually assaulting R24 on 01/25/24. 2. Report Alleged Violations of Abuse/Neglect Cross Reference F609: The facility failed to report allegations of potential staff to resident (R61) sexual abuse. Additionally, the facility failed to report allegations of resident (R97) to resident (R24) potential sexual abuse. 3. Investigate Alleged Violations of Abuse/Neglect Cross Reference F610: The facility failed to investigate an allegation of staff to resident (R61) potential sexual abuse. The facility further failed to investigate alleged resident to resident sexual abuse by R97 to R24. During an interview on 09/04/24 at 11:15 AM, the Administrator confirmed his responsibility was to oversee the functions of the facility. The Administrator stated that the DON was the facility's designated abuse coordinator. The Administrator stated that it was his and DON's responsibility to report allegations of abuse to the State Agency and to complete a thorough investigation.