**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of the facility policy, the facility failed to ensure residents were free from abuse. Specifically, the facility failed to ensure four residents (R) (residents (R9, R14, R25, and one unknown resident) were free from sexual abuse by R10; and eight residents (R15, R11, R19, R20, R16, R17, and R18) were free from physical abuse in a sample of 35 residents. On 9/13/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator was informed of the Immediate Jeopardy (IJ) on 9/13/2023 at 10:32 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/23/2022. At the time of exit on 9/18/2023, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the IJ remained ongoing. Findings include: Review of the facility policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revised 10/27/2020 revealed: It is the policy of PruittHealth and its affiliated entities (collectively, the Organization) to actively preserve each patient's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation, mistreatment, and misappropriation of patient property, (referred to collectively in this policy as abuse, neglect, mistreatment, and exploitation). The Organization and its partners should assure that best efforts are made to prevent any occurrences of any form of abuse, neglect, and exploitation. Sexual abuse incidents: 1. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed R10 with a Brief Interview of Mental (BIMS) score of seven, indicating severely impaired cognition. Resident was documented as having no behaviors. He required one person supervision with walking in room and corridor, and independent with no setup help needed for locomotion on and off the unit. He had diagnoses including but not limited to Dementia and Psychotic Disorder. a. Review of the Quarterly MDS dated [DATE] revealed R9 with a BIMS score of four, indicating severe cognitive impairment. R9 requires one-person limited assistance with walking in room and locomotion on the unit. Resident required one-person extensive assistance with walking in the corridor and locomotion off the unit. Resident had diagnoses including but not limited to Cerebral Vascular Accident (CVA) and Dementia. No behaviors were documented. Review of Facility Reported Incident (FRI) dated 5/29/2023 revealed R10 walked up to R9 with his penis out and touched R9's head/neck area and pulled her head downwards towards him. Family of R9 called the police and R10 was arrested for this incident. R10 did not return to the facility. Review of the police report dated 5/29/2023 revealed R10 was arrested for an offense of sodomy, aggravated sodomy and charged with criminal intent and public indecency During an interview on 9/18/2023 at 10:24 a.m., Licensed Practical Nurse (LPN) AA stated she was charting at the nurses' station and two certified nursing assistants (CNAs) brought the incident between R9 and R10 to her attention. LPN AA stated she observed R9 seated in a chair and R10 standing to the left of R9 with his penis protruding from his pants. LPN AA stated she removed both residents from the area and reported the incident. During an interview on 9/18/2023 at 11:01 a.m., LPN EE stated she was charting at the nurses' station and CNAs brought the incident between R9 and R10 to her attention. LPN EE stated she saw R10's penis in his hand and was standing near R9, who was seated in a Geri chair. LPN EE stated they reported the incident and called the family. b. Review of the Annual MDS assessment dated [DATE] revealed R14 with a BIMS score of three, indicating severe cognitive impairment. No behaviors were documented. The resident required one-person extensive assistance with walking in the room, and no setup/ independent locomotion on and off the unit. R14 had a diagnosis including but not limited to Alzheimer's Disease. Review of FRI dated 9/12/2022 revealed R14 informed staff she had consensual sex with R10. There was no documented evidence the facility put interventions in place related to the incident. During an interview on 9/12/2023 at 4:00 PM, the Administrator stated she viewed this incident with R14 and R10 as consensual sex. Due to the Administrator's view, no interventions were implemented related to the incident. During an interview on 9/18/2023 at 10:24 a.m., LPN AA further revealed R14 stated she had sex with another resident and was able to identify R10. LPN AA stated she also reported this incident. 2. Review of R10's Progress Note dated 7/29/2022, revealed, Resident asked another female resident for sexual favor. Facility staff was unable to identify the female resident in this incident. Review of R10's Progress Note dated 4/23/2022, revealed, Resident observed going in and out of female resident's room. One female resident reported that Resident asked her to perform a sex act. That female resident was visibly shaken when reporting the problem. Facility staff were able to identify this resident as R25 (BIMS of 11, indicating moderate cognitive impairment and no behaviors documented). During an interview on 9/12/2023 at 4:00 PM, the Administrator stated she was unaware of these incidents occurring on 7/29/2022 and 4/23/2022, therefore no interventions were implemented. During an interview on 9/18/2023 at 11:15 a.m., the Social Services Director (SSD) stated she was aware of the 4/23/2022 incident where R10 asked R25 for a sexual favor. The SSD stated she did not do anything about this incident. The SSD stated that she should have put R10 on a behavioral management program immediately but did not do so until 5/26/2022. Physical Abuse incidents: 3. Review of the Quarterly MDS assessment dated [DATE] revealed R19 with a BIMS of 15, indicating cognitively intact. Resident required one-person supervision with locomotion on and off the unit. The resident uses a wheelchair. No behaviors documented. Review of the Quarterly MDS Assessment also dated 8/10/2023 revealed R20 with a BIMS of 10, indicating moderate cognitive impairment. Resident required one person supervision with locomotion on and off the unit. The resident uses a wheelchair. R20 had a diagnosis of Alzheimer's Disease. Review of FRI dated 8/29/2023, R19 alleged R20 hit her and pulled her hair and R19 threw water in R20's face. R19 stated R20 and Family of R20 dragged R19 to the ground. Staff heard the incident and observed R19 on the floor. There was no documented evidence the facility put interventions in place related to the incident. 4. Review of the Quarterly MDS assessment dated [DATE] revealed R16 with a BIMS score of 12, indicating moderate cognitive impairment. No behaviors documented and resident required one person supervision with locomotion on and off the unit. The resident used a wheelchair. R16 had diagnoses including but not limited to CVA with hemiplegia or hemiparesis and Depression. Review of the admission MDS assessment dated [DATE] revealed R17 with a BIMS of three, indicating severe cognitive impairment, wandering behavior one to three days, used a wheelchair and required one-person limited assistance with locomotion on the unit. Review of FRI dated 8/24/2023 revealed R16 and R17 got into a physical altercation and R17 scratched R16 in his face. Review of R16's Progress Note dated 8/24/2023 revealed, [R17] hit [R16] and he was bleeding from the nose. The writer cleaned resident nose with normal saline and also take care of the nose from bleeding upon assessment. 5. Review of the admission MDS dated [DATE] revealed R15 with a BIMS of 15, no behaviors documented, and required one-person extensive assistance with walking in room and locomotion on and off the unit. The resident used a wheelchair. The resident was discharged on 5/30/2023. Review of the Quarterly MDS assessment dated [DATE] revealed R11 with a BIMS of 15, no behaviors documented and required no setup/ independent with all Activities of Daily Living (ADLs). Review of FRI dated 4/23/2023 revealed R15 and R11 got into a physical altercation. R11 sustained scratches and bruises. 6. Review of the Annual MDs assessment dated [DATE] revealed R18 with a BIMS score of 8, indicating moderate cognitive impairment. No behaviors were documented. The resident required one person supervision with walking and locomotion, used a wheelchair and walker. The resident had diagnoses including but not limited to CVA with hemiparesis or hemiplegia, Dementia, and Depression. Review of FRI dated 12/16/2022 revealed R18 received a scratch on right arm from [R10] after words exchanged. During an interview on 9/12/2023 at 4:00 PM, the Administrator confirmed she was the Abuse Coordinator for the facility. The Administrator stated although she reported the physical altercations above, she did not put interventions in place to prevent the incidents from recurring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of the facility policy, the facility failed to thoroughly report and investigate incidents of abuse. Specifically, the facility failed to report and/or thoroughly investigate incidents of sexual abuse for four residents (R) (residents (R9, R14, R25, and one unknown resident); and of physical abuse for eight residents (R15, R11, R19, R20, R16, R17, R10, R18) in a sample of 35 residents. On 9/13/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator was informed of the Immediate Jeopardy (IJ) on 9/13/2023 at 10:32 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/23/2022. At the time of exit on 9/18/2023, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the IJ remained ongoing. Findings include: Review of the facility policy titled Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revised 10/9/2020 revealed It is the policy of PruittHealth and its affiliated provider entities (collectively, the Organization) to investigate allegations and occurrences of patient abuse, neglect, exploitation, mistreatment, and misappropriation of patient property. Documentation of the investigation should include, but not be limited to, the following: * Date and time of alleged occurrence. * Patient's full name and room number (or address, if at home). * Names of accused and any witnesses. * Names of PruittHealth partners staff who investigated the allegation. * Any physical evidence and description of emotional state of patient(s). * Details of the alleged incident and injury. * Signed statements from pertinent parties; * Cognitive status of victim(s) and patient(s) who are witnesses (e.g., whether they are alert, oriented, and able to answer questions appropriately, which could help in determining whether the witness is credible and able to testify); * Information gathered from the investigation. * Action taken by provider (e.g., safeguarding the patient and preventing a reoccurrence); * The conclusions reached by the investigator; * Name, address, and phone number of the responsible party and relatives of the Victim(s); and * Any other police or ombudsman reports or other documentation related to the investigation. Sexual abuse incidents: 1. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed R10 with a Brief Interview of Mental (BIMS) score of seven, indicating severely impaired cognition. a. Review of the Quarterly MDS dated [DATE] revealed R9 with a BIMS score of four, indicating severe cognitive impairment. Review of Facility Reported Incident (FRI) dated 5/29/2023 revealed R10 walked up to R9 with his penis out and touched R9's head/neck area and pulled her head downwards towards him. Review of the facilities records revealed no evidence that the facility thoroughly investigated the incident and did not report the incident to the police. Family of R9 called the police and R10 was arrested for this incident. During an interview on 9/18/2023 at 10:24 a.m., Licensed Practical Nurse (LPN) AA stated she observed R9 seated in a chair and R10 standing to the left of R9 with his penis protruding from his pants. LPN AA stated she removed both residents from the area and reported the incident. During an interview on 9/18/2023 at 11:01 a.m., LPN EE stated she saw R10's penis in his hand and was standing near R9, who was seated in a Geri chair. LPN EE stated they reported the incident and called the family. b. Review of the Annual MDS dated [DATE] revealed R14 with a BIMS score of 3, indicating severe cognitive impairment. Review of FRI dated 9/12/2022 revealed R14 informed staff she had consensual sex with R10. There is no documented evidence that this incident was thoroughly investigated. During an interview on 9/12/2023 at 4:00 PM, the Administrator stated she viewed this incident with R14 and R10 as consensual sex. Due to the Administrator's view, this incident was not thoroughly investigated. During an interview on 9/18/2023 at 10:24 a.m., LPN AA further stated R14 stated she had sex with another resident and was able to identify R10. LPN AA stated she also reported this incident. 2. Review of R10's Progress Note dated 7/29/2022, revealed, Resident asked another female resident for sexual favor. Facility staff was unable to identify the female resident in this incident. Review of R10's Progress Note dated 4/23/2022, revealed, Resident observed going in and out of female resident's room. One female resident reported that Resident asked her to perform a sex act. That female resident was visibly shaken when reporting the problem. Facility staff was able to identify this resident as R25. (BIMS of 11, indicating moderate cognitive impairment). There is no documented evidence that the incidents were thoroughly investigated. During an interview on 9/12/2023 at 4:00 PM, the Administrator stated she was unaware of these incidents, and they were never reported or investigated. During an interview on 9/18/2023 at 11:15 a.m., the Social Services Director (SSD) stated she was aware of the 4/23/2022 incident where R10 asked R25 for a sexual favor. The SSD stated she did not do anything about this incident. Physical Abuse incidents: 3. Review of the Quarterly MDS assessment dated [DATE] revealed R19 with a BIMS of 15, indicating cognitively intact. Review of the Quarterly MDS Assessment also dated 8/10/2023 revealed R20 with a BIMS of 10, indicating moderate cognitive impairment. Review of FRI dated 8/29/2023, R19 alleged R20 hit her and pulled her hair and R19 threw water in R20's face. R19 stated R20 and Family of R20 dragged R19 to the ground. Staff heard the incident and observed R19 on the floor. 4. Review of the Quarterly MDS assessment dated [DATE] revealed R16 with a BIMS score of 12, indicating moderate cognitive impairment. Review of the admission MDS assessment dated [DATE] revealed R17 with a BIMS of three, indicating severe cognitive impairment. Review of FRI dated 8/24/2023 revealed R16 and R17 got into a physical altercation and R17 scratched R1 in his face. Review of R16's Progress Note dated 8/24/2023 revealed, [R17] hit [R16] and he was bleeding from the nose. The writer cleaned resident nose with normal saline and also take care of the nose from bleeding upon assessment. 5. Review of the admission MDS dated [DATE] revealed R15 with a BIMS of 15. Review of the Quarterly MDS assessment dated [DATE] revealed R11 with a BIMS of 15. Review of FRI dated 4/23/2023 revealed R15 and R11 got into a physical altercation. R11 sustained scratches and bruises. 6. Review of the Annual MDs assessment dated [DATE] revealed R18 with a BIMS score of 8, indicating moderate cognitive impairment. Review of FRI dated 12/16/2022 revealed R18 received a scratch on right arm from [R10] after words exchanged. There is no documented evidence that the incidents of physical abuse were thoroughly investigated. During an interview on 9/12/2023 at 4:00 PM, the Administrator confirmed she was the Abuse Coordinator for the facility. The Administrator stated although she reported the physical altercations above, she did not thoroughly investigate the incidents. The Administrator stated she did not substantiate the incidents as abuse.

Based on 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 113. On 9/13/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator was informed of the Immediate Jeopardy (IJ) on 9/13/2023 at 10:32 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/23/2022. At the time of exit on 9/18/2023, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the IJ remained ongoing. Findings include: Review of the Administrator's position description signed by the Administrator on 2/6/2022 revealed the job purpose is to direct the day-day functions of the nursing center in accordance with federal, state, and local regulations that govern long-term care centers . Key responsibilities include current knowledge of state and federal laws governing the operation of nursing facilities .Demonstrates knowledge of and respect for the rights, dignity and individuality of each patient/resident in all interactions. Demonstrates competency in the protection and promotion of resident rights. 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. Administration failed to maintain an environment free from sexual abuse for four residents (R9, R14, R25, and one unknown resident) all perpetuated by R10; and failed to maintain an environment free from physical abuse for eight residents (R#15, R#11, R#19, R#20, R#16, R#17, R#10, R#18) Cross refer to F600. 2. Administration failed to ensure that incidents of sexual abuse of four residents (R#9, R#14, R#25, and one unknown resident) and of physical abuse of eight residents (R#15, R#11, R#19, R#20, R#16, R#17, R#10, R#18) were thoroughly investigated, and corrective actions implemented, including protection of the residents, in a timely manner. Cross refer to F610. During an interview on 9/12/2023 at 4:00 PM, the Administrator stated that she was the Abuse Coordinator. She stated that she did not substantiate the above incidents as abuse. The Administrator stated and she considered an incident to be abuse only if the resident states he/she feels abused. During an interview on 9/13/2023 at 11:45 a.m., Regional Nurse Consultant (RNC) NN, stated she was unaware of many of the incidents of physical and sexual abuse that had occurred at the facility. RNC NN stated she had told the Administrator over and over to reach out to me when these types of things happen.