**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of policy titled Abuse Prevention Program, the facility failed to maintain an environment free from physical abuse for two residents (R) (R#1 and R#3), and sexual abuse for three residents (R#1, R#4, and R#8), from a total sample of 27 residents. On 4/25/23 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. The facility Administrator and the Minimum Data Set (MDS) Director were informed of the Immediate Jeopardy (IJ) on 4/25/23 at 1:25 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/6/22. At the time of exit on 5/1/23, an acceptable Immediate Jeopardy Removal Plan had not been received, therefore, the Immediate Jeopardy remained ongoing. Findings include: The facility had an Abuse Prevention Program policy, with a revision date of December 2016. The policy statement included that the residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. That included, but was not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse. However, the facility failed to implement this policy regarding abuse effectively, resulting in the physical abuse of one resident (R#1) by a facility staff member and the sexual abuse of three residents (R#1, R#4, and R#8) by other residents. 1. Review of the clinical record for R#8 revealed that he was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, Chronic Obstructive Pulmonary Disease (COPD), metabolic encephalopathy, Parkinson's Disease, dementia, hypertension, major depressive disorder, ataxia and dysphagia. Review of the 10/13/22 Quarterly MDS assessment revealed that R#8 was assessed as having severe cognitive impairment with a Brief Interview of Mental Status (BIMS) score of 00 out of 15. He was also assessed on the MDS assessment as being provided with limited assistance for Activities of Daily Living (ADL's) including ambulation. He was also assessed as using a wheelchair. He resided on Unit 6 in the facility. Review of the clinical record for R#9 revealed that he resided at the facility from 7/20/20 through 12/8/22 and had diagnoses that included, but were not limited to, prostate cancer, open angle glaucoma, anemia, right knee contracture, vitamin D deficiency, and vitamin B12 deficiency. Review of the 9/21/22 Quarterly MDS assessment revealed that R#9 was assessed as being cognitively intact (BIMS score of 15 out of 15) and being independent and/or being provided with supervision for ADL's, including ambulation. He was also assessed as using a wheelchair. He resided on Unit 6 in the facility. R#9 is a registered sex offender. A review of facility reported incidents revealed a Facility Incident Report Form, dated 11/6/22, that documented an allegation of resident-to-resident abuse had occurred on 11/6/22 at 8:00 p.m. The form included that LPN TT reported an inappropriate act between R#8 and R#9, with R#9 being listed as the perpetrator. A further review of the form revealed that the residents were separated, and skin assessments were completed on both residents with no injuries noted. The physician, responsible parties and law enforcement were notified. A review of the accompanying investigation that included employee and resident interviews, police reports, and the facility's follow-up summary conclusion revealed evidence that the allegation had occurred. The investigation revealed that when LPN TT entered R#8's room to administer medication, she observed R#9 at R#8's bedside sexually abusing R#8. R#8 and R#9 were not roommates. A review of the 11/6/23 police department Incident Report revealed that an officer responded to the facility at 9:14 p.m. in reference to a sexual assault. LPN TT alleged in the police report that she entered R#8's room to administer his medication and observed R#9 at R#8's bedside in his wheelchair. LPN TT observed R#9 leaned over R#8, performing a sexual act on him. The report included that LPN TT and R#9 left R#8's room and that the residents had remained separated. Further review of the police report revealed that LPN TT stated that she initially thought the act was consensual, but due to R#8's cognitive state, it was not. During an interview on 4/13/23 at 2:20 p.m., when the Administrator was questioned if R#8 had the capacity to consent, she responded that she did not think so, because of his BIMS score. Following R#8 and R#9's initial separation, review of security guard logs revealed that R#9 was placed on 1:1 supervision with security on 11/6/22 at 8:59 p.m. A review of census information revealed that R#9 was also moved to a different unit of the facility on 11/7/22. He was transferred from Unit 6 to Unit 7. He was subsequently discharged from the facility on 12/8/22. Further review of the facility's follow-up summary revealed that R#9 was considered a parolee with the Department of Correction and had the potential to be returned to the Department of Correction, once determined by the parole board. A review of R#9's clinical record revealed a 12/8/22 Health Status Progress Note that documented R#9 was transferred back to prison; escorted by his parole office. During an interview on 4/12/23 at 4:30 p.m., the Administrator confirmed that R#9 was discharged from the facility to prison on 12/8/22. 2. Review of the clinical record for R#3 revealed that he was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, hemiplegia and hemiparesis, bipolar disorder, major depressive disorder, a history of traumatic brain injury, hypertension, unspecified speech disturbance, hyperlipidemia, arthropathy, and mood disorder. He utilized a communication device due to impaired speech. Review of the 3/14/23 Quarterly MDS assessment revealed that R#3 was assessed as having moderately impaired cognition (BIMS score of 12 out of 15) and using a wheelchair and walker for mobility. R#3 resided on Unit 7 in the facility. A review of facility reported incidents revealed a Facility Incident Report Form, dated 1/31/23, that documented an allegation of staff to resident abuse. The form included that the allegation involved R#3 and LPN AA and had occurred on 1/31/23 at 8:00 p.m. A further review of the form revealed that R#3 had minor scratches to his face and hands and that the police, responsible party, and physician were notified. LPN AA was placed on administrative leave pending the investigation. A review of the accompanying investigation that included staff and resident interviews, police report, and a follow-up summary revealed evidence that the allegation had occurred. LPN AA's agency nurse contract was terminated on 1/31/23. The investigation revealed that R#3 was physically assaulted by LPN AA after a verbal altercation that escalated with R#3 throwing a phone at LPN AA. LPN AA removed R#3 from his wheelchair and began hitting, kicking, and punching him while he lay on the floor, causing injuries to R#3's upper body. A review of the 1/31/23 police department Incident Report revealed that an officer responded to the facility at 8:37 p.m. in reference to an assault that occurred between R#3 and LPN AA. R#3 alleged in the police report that prior to the physical assault, he and LPN AA had cursed at each other earlier in the hallway. R#3 alleged that he thought about what LPN AA said to him, went to the desk to call his social worker, saw LPN AA, and became upset and threw the phone at him. R#3 then alleged that LPN AA came from around the desk, flipped R#3 out of his wheelchair, and stomped on his arm. Another resident, RB, attempted to intervene. The police report documented that the officer observed a bruise on R#3's left shoulder and a laceration on his right hand. Further review of the police report revealed that camera footage was available and viewed by the police officer on 1/31/23 following the incident. The report documented that the footage revealed that the incident at the nurses' station took place at 7:20 p.m. R#3 came around the corner yelling at LPN AA. Once R#3 got to the desk, he picked up the phone and put it back on the receiver. R#3 picked up the phone again and slammed it down in the direction of LPN AA. LPN AA was observed on camera, getting up out of his chair and R#3 pushing himself into the left-hand side of the desk. LPN AA kicked a chair out of his way and flipped R#3 out of his wheelchair by grabbing for R#3's feet and pulling up. The officer observed on the camera footage, R B and other residents gather around LPN AA and R#3 with R B trying to get between the two (LPN AA and R#3). LPN AA was observed striking R#3 with a closed fist. The officer also documented in the report that he observed LPN AA raise one of his legs up as if was going to stomp on R#3. Following the incident, the police report detailed that the police officer contacted LPN AA, and he was subsequently arrested. During an interview on 3/27/23 at 2:45 p.m., RB confirmed he had witnessed the alteration between LPN AA and R#3. He also stated he heard them arguing in the hall prior to it happening. RB said that he heard R#3 and LPN AA exchange words in the hall. R#3 was trying to apologize to LPN AA for something he previously said, but the nurse wasn't having it and they exchanged words. RB stated that after the argument in the hall, LPN AA was at the nursing station and R#3 came up to the nursing station and was hollering. R#3 picked up the phone and banged the phone on the counter and it flew up at LPN AA. LPN AA went ballistic and went at R#3 and got him out of the wheelchair onto the floor. RB stated that LPN AA hit, kicked, punched R#3. RB said he got in between LPN AA and R#3 and tried to keep R#3 from getting hurt and get the nurse to stop. When RB was questioned if he got hit by the nurse also when he was in between LPN AA and R#3, RB responded yes, but he did not get hurt. During an interview on 3/30/23 at 3:02 p.m. LPN PP confirmed she witnessed the altercation between LPN AA and R#3. LPN PP stated she was going off shift and LPN AA was coming on-shift. LPN AA was seated at the nursing station, and she was standing by him and showing him something on the computer screen and was giving report. R#3 rolled up yelling and yelling. R#3 then picked up the phone and threw it at LPN AA and it struck him. LPN PP stated that LPN AA tried to ignore R#3 at first and that she had never seen LPN AA act that way before. LPN PP stated she got on the phone to notify security. A review of R#3's clinical record revealed documentation of the assault. A 1/31/23 Nurse's Note documented that R#3 was assaulted by a nurse and sustained bruises on the right wrist, back of right hand, left thumb, and redness on the left upper arm. R#3 refused treatment. During an interview on 3/30/23 at 1:07 p.m. LPN DD stated that she did not witness the incident between LPN AA and R#3, but she responded afterwards and assessed R#3. LPN DD stated that R#3 had a big bruise on his left shoulder and redness on his chest and shoulders area. She stated that R#3 was angry and upset. Although R#3 initially refused medical treatment and evaluation on 1/31/23, a review of the facility's investigation summary revealed that the following day, on 2/1/23, he was observed to be in a manic state. A 1013 emergency transfer order was initiated. R#3 was sent to the emergency room on 2/1/23 for evaluation and medical clearance and admitted to a behavioral health unit from 2/2/23 through 2/16/23. During an interview on 3/30/23 at 3:52 p.m., the Administrator confirmed that R#3 had refused assessment attempts and a hospital transfer on 1/31/23, but he became manic over the next day and was sent out to the hospital, as ordered by the psychiatrist. A review of hospital emergency room documentation from 2/1/23 documented that R#3 was sent to the emergency room on a 1013 for aggression with medical clearance requested. R#3 presented with back pain. The physical exam documented ecchymosis with linear demarcation at the upper border of the left arm. The emergency room assessment included clinical impressions of 1) aggression 2) bipolar disorder, current episode mixed, severe, without psychotic features 3) history of traumatic brain injury. R#3's psychiatrist was consulted, and the resident was accepted for transfer to a behavioral health unit. R#3 completed a stay at behavioral health unit and returned to the facility on 2/16/23. 3. Review of the clinical record for R#1 revealed that he was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, cerebral infarction, occlusion and stenosis of left carotid artery, seizures, atrial fibrillation, aphasia, diabetes, Parkinson's, schizophrenia, mood disorder, anemia, and major depressive disorder. Review of the 1/17/23 Quarterly MDS assessment revealed that R#1 was assessed as having moderately impaired cognition (BIMS score of 12 out of 15). He was also assessed on the MDS assessment as being ambulatory with a rolling walker. Further review of the clinical record revealed that R#1 wore a soft helmet for protection from falls and/or seizures. R#1 resided on Unit 4. His roommate was R#2. Review of the clinical record for R#2 revealed that he resided at the facility from 11/13/19 to 4/26/23 and had diagnoses that included, but were not limited to, congested heart failure, peripheral vascular disease, cystic disease of liver, atrial fibrillation, hypertension, dementia, dyspnea, polyneuropathy, intellectual disabilities, and diabetes. Review of the 12/22/22 Quarterly MDS assessment revealed that R#2 was cognitively intact (BIMS score of 15 out of 15) and ambulatory with a rolling walker. R#2 resided on Unit 4 of the facility and was R#1's roommate. R#2 is a registered sex offender. A review of facility reported incidents revealed a Facility Incident Report Form, dated 3/9/23, that documented an allegation of resident-to-resident abuse. The form included that the allegation involved R#1 and R#2 and had occurred on 3/9/23 at 10:50 a.m. R#1 reported that R#2 had inappropriately touched his private area. Further review of the form revealed that the residents were separated, a skin assessment was completed on R#1, and he was sent to the emergency room for a forensic physical exam. R#2 was placed on 1:1 supervision. The physician, responsible parties and law enforcement were also documented as being notified. A review of the accompanying investigation that included employee and resident interviews, police reports, and the facility's follow-up summary conclusion revealed evidence that abuse had occurred. The investigation revealed that on 3/9/23, Certified Nursing Assistant (CNA) BB responded to screams from R#1 in his room. She observed R#1 and R#2 coming from around the privacy curtain from R#2's side of the room. Both were clothed, but R#1 was holding his groin area. R#1 alleged that he had been touched inappropriately by R#2. He also alleged that he had previously been sexually abused by R#2 on other occasions. A skin assessment on 3/9/23 revealed bruising to R#1's sacrum, hips, and buttocks that was not there on the previous skin assessment dated [DATE]. A review of the 3/9/23 police department Incident Report revealed that an officer responded to the facility at 11:30 a.m. in reference to sexual misconduct between two residents, one of which had bruises on his bottom. The report documented that CNA BB responded to loud screaming coming from R#1 and R#2's room and entered the room to find both residents on the window side of the room. R#1 was visually upset and had placed his hands over his private parts. Both residents were clothed. R#2 alleged he was trying to prevent R#1 from falling. Further review of the police report revealed that the Administrator reported that R#1 alleged that R#2 had also sexually abused him previously, but that today was the first time R#1 had reported the allegations. During an interview on 3/22/23 at 1:48 p.m. Detective NN stated he had taken out two warrants on R#1, one for false imprisonment and one for battery. The results of the sexual assault examination, completed on 3/9/23, were pending. During an interview on 3/23/23 at 2:21 p.m., CNA BB stated that on 3/9/23, she was in a room next door to R#1 and R#2's room and heard R#1 scream. She went to his room and knocked on the door then entered. She stated she was making sure he had not fallen because he was a fall risk. She observed R#1 and R#2 coming from behind the privacy curtain together from R#2's side of the room, with R#1 coming out first like he was scurrying away from R#2. Both had their clothes on. Review of the 3/9/23 Skin Observation Tool revealed that R#1 refused an assessment by LPN treatment nurse OO and was guarded and uncooperative. However, he allowed an assessment to be completed by LPN DD. The 3/9/23 skin observation tool documented bruising to the coccyx and left and right hips. During an interview on 3/30/23 at 1:07 p.m. LPN DD stated that after the incident between R#1 and R#2, she brought R#1 to the conference room. She was the only one he would let talk to him and see him. She stated he was upset and crying and scared to return to his room. She reassured him that R#2 had been moved and encouraged him to go back to his room with her, to complete a skin assessment. However, she said he stood up and began taking his clothes off on his own in the conference room, so she assessed him there. LPN DD stated that R#1 had a dark black bruise right at his sacral area and bruising to his left and right buttocks and hips. LPN DD stated that the bruising on his right was in the shape of a cupped hand; the bruises were dark black and not yellow or green to indicate they were old. LPN DD stated that she had not seen bruising like that on him before. She stated that they looked at his skin a lot because he had seizures and falls. Record review revealed R#1's last fall was on 2/9/23 during a seizure, at which time he was hospitalized and returned to the facility on 2/23/23. Further record review of skin assessments completed (prior to 3/9/23) for R#1 on 2/23/23, and 3/7/23 revealed no documentation of bruising. Following the alleged assault by R#2, R#1 was sent to the emergency room on 3/9/23. Review of hospital emergency department documentation revealed that R#1 complained that his roommate had been raping him for the past 3 months. He was noted with bruising of the left hip and sacrum as well as anal pain. R#1 was also noted as very tearful. The clinical impression section documented sexual assault of adult, initial encounter and traumatic hematoma of lower back, initial encounter. Following the exam, R#1 returned to the facility on 3/9/23. Following R#1 and R#2's initial separation on 3/9/23, review of security guard logs revealed that R#2 was placed on 1:1 supervision with security on 3/9/23 at 12:15 p.m. A review of census information revealed that R#2 was also moved to a different unit of the facility on 3/9/23. He was transferred from Unit 4 to Unit 7 and remained on routine security checks every two hours. Review of an Appearance Bond form, dated 4/4/23, revealed that R#2 had been charged with misdemeanor battery and felony false imprisonment. During an interview on 4/11/23 at 10:52 a.m. the Administrator stated that R#2 had been arrested and was holding at the facility until his court date, which was undetermined at that time. On 4/26/23, R#2 was discharged from the facility. Review of R#2's clinical record revealed a 4/26/23 Nurse's Note that documented R#2 was escorted by three police officers out from the unit. During an interview on 4/27/23 at 4:10p interview, the Administrator stated that R#2 went to prison until his court date. She confirmed he was discharged from the facility. 4. Review of the clinical record for R#4 revealed that he was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, seizures, schizophrenia, aphasia following nontraumatic intracranial hemorrhage, and major depressive disorder. Review of the 3/14/23 Quarterly MDS assessment revealed that R#4 was assessed as having severe cognitive impairment (BIMS score of 3 out of 15). Further review of the clinical record revealed that R#4 was ambulatory with impaired balance at times. He wore a soft helmet for seizure and fall protection. R#4 resided on Unit 2 in the facility. Review of the clinical record for R#5 revealed that he was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, deafness, vitamin D deficiency, glaucoma, hypertension, hyperlipidemia, and major depressive disorder. Review of the 1/27/23 Quarterly MDS assessment revealed that R#5 was assessed as being cognitively intact (BIMS of 15 out of 15) and being provided with supervision and set up assistance with ADL's. Further review of the clinical record revealed that R#5 communicated via written word and hand gestures. R#5 resided on Unit 2 in the facility. R#5 is a registered sex offender. A review of facility reported incidents revealed a Facility Incident Report Form, dated 3/16/23 that documented an allegation of resident-to-resident abuse had occurred on 3/16/23. The form included that R#5 made contact with R#4's private area, and this was witnessed by CNA CC. Further review of the form revealed that the residents were separated, and R#5 was moved to another unit in the facility (unit 6) and placed on 1:1 supervision. A skin assessment was completed on R#4 with no injuries noted. The physician, responsible parties and law enforcement were notified. A review of the accompanying investigation that included employee and resident interviews, police report, and the facility's follow-up summary conclusion revealed evidence that the allegation of sexual abuse had occurred. The investigation revealed that when CNA CC entered R#4's room to pick up his meal tray, she observed R#5 at R#4's bedside sexually abusing him, while R#4 was asleep. R#4 and R#5 were not roommates. A review of the 3/16/23 police department Incident Report revealed that an officer responded to the facility at 5:38 p.m. in reference to a sexual assault. The report documented that CNA CC entered R#4's room on 3/16/23 and observed R#5 touching R#4's genital area, head, shoulders, and buttocks. She got R#5's attention and she and R#5 exited R#4's room. The report includes that CNA CC reported the incident to LPN QQ, who then notified the Administrator. Further review of the police report revealed that both residents, R#4 and R#5, declined medical attention. During an interview on 3/30/23 at 11:45 a.m., Detective NN confirmed they were moving forward with charges against R#5. Investigator QQ stated R#5 was charged with sexual battery, which was a misdemeanor. During an interview on 3/30/23 at 1:54 p.m., CNA CC stated that on 3/9/23, she went into R#4's room to pick up his supper tray. She stated R#4 was asleep, and she knew he must be asleep because he did not eat his supper. The privacy curtain near his bed was open just a little bit at the sink area and she looked and saw R#5 at R#4's bedside. CNA CC observed R#5 put his hand under the bed covers at R#4's groin area and then take his hand out. CNA CC stated she was not even sure what she was seeing at first, so she looked further and saw R#5 rub R#4's head, shoulder, and squeeze his buttocks. CNA CC stated that R#5 smiled when he squeezed R#4's buttocks. CNA CC stated she yelled out and it scared R#5 and he threw his hands up. R#5 followed CNA CC out of R#4's room and CNA CC reported the incident to the charge nurse. They kept the residents separated and R#5 was moved to a different unit. CNA CC stated that R#4 was asleep when R#5 touched him, and R#5 was standing up from his wheelchair over R#4 when he touched him. Review of R#4's clinical record revealed a 3/16/23 Nurse's Note entry from LPN QQ that documented the LPN was notified by the CNA that R#5 was observed touching and rubbing R#4's genital region while he was in the bed resting. A head-to-toe assessment was completed with no injuries noted. Further review of the clinical record revealed that a Skin Observation Tool was also completed the following day, on 3/17/23, with no skin abnormalities noted. Following R#4 and R#5's initial separation on 3/16/23, review of security guard logs revealed an entry on 3/16/23 at 5:20 p.m. that documented R#5 was placed on 1:1 supervision. During an interview on 4/18/23 at 3:50 p.m., the Administrator confirmed R#5 was placed on 1:1 supervision, then transferred to another unit and remained on 1:1 supervision for 72 hours. Review of census information revealed that R#5 was moved to a different unit of the facility on 3/16/23. He was transferred from Unit 2 to Unit 6. Review of a Policy: Involuntary Transfer and Discharge letter, dated 3/23/23, revealed that the facility had also issued a discharge notice to R#5 with an effective date of 4/3/23. However, R#5 remained in the facility. Review of an Appearance Bond form, dated 4/3/23, revealed that R#5 had been charged with misdemeanor sexual battery. Review of a Stay Away Order Addendum to Appearance Bond, dated 4/3/23, revealed R#5 was ordered to have no further contact of any nature with R#4. During an interview on 4/11/23 at 10:52 a.m., the Administrator stated that R#5 had been arrested and was being held at the facility until his court date. Further review of the Appearance Bond form revealed that his court date was 5/18/23. During an interview on 4/12/23 at 10:55 a.m. the facility's Head of Security stated that R#5 remained on routine (every 2 hour) security rounds.

Based on interviews and record reviews, the facility failed to develop care plans for four residents (R) (R#2, R#5, R#8, and R#9) with a known inappropriate sexual behavior background to address the behavior and the potential risk to reoffend. The sample size was 27. On 4/25/23 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. The facility Administrator and the Minimum Data Set (MDS) Director were informed of the Immediate Jeopardy (IJ) on 4/25/23 at 1:25 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/6/22. At the time of exit on 5/1/23, an acceptable Immediate Jeopardy Removal Plan had not been received, therefore, the Immediate Jeopardy remained ongoing. Findings include: Review of the Georgia Bureau of Investigation's (GBI) Georgia Sex Offender Registry online revealed that R#2, R#5, R#8, and R#9 were registered sex offenders. During an interview on 4/18/23 at 12:33 p.m. the Minimum Data Set (MDS) Director, when questioned if a resident's registered sex offender status would be included in their care plan, she responded that they used to include the sex offender status and other crimes residents committed in the care plan, but they had to do some cleaning up of those care plans because it did not pertain to their care at the facility. The MDS Director stated that they could include the registered sex offender status in the care plan because those residents would continue to have to report to an external entity. When the MDS Director was questioned if a history of sexually inappropriate behavior be care planned, she responded that they would include that information if the resident had a diagnosis related to it or if they were receiving medication related to the behavior issue. They would also care plan a behavior if it was displayed at the facility. However, the facility failed to develop care plans to address the current sex offender registry status and thus a history of sexually inappropriate behavior, to ensure interventions were in place to prevent reoccurrence for R#2, R#5, R#8 and R#9. 1. R#2 was registered as a sex offender with the GBI since 3/13/2000. However, a review of the clinical record revealed that a care plan had not been developed to address his current sex offender status and history of inappropriate sexual behavior. R#2 physically and sexually abused R#1 on 3/9/23. R#1 and R#2 were roommates. Based on staff interviews, record review and review of the police report and investigation, on 3/9/23, Certified Nursing Assistant (CNA) BB responded to screams from R#1 in his room. She observed R#1 and R#2 coming from around the privacy curtain from R#2's side of the room. The CNA stated that R#1 appeared to be scurrying away from R#2. Both were clothed, but R#1 alleged that R#2 touched him inappropriately on his groin area. R#1 also alleged that he had previously been sexually abused by R#2 on other occasions. A skin assessment on 3/9/23 revealed bruising to R#1's sacrum, hips, and buttocks that was not there on the previous skin assessment. R#1 was also emotionally upset following the incident. Following the incident, R#1 was sent to the emergency room for evaluation on 3/9/23. R#2 was arrested on 4/4/23 and charged with misdemeanor battery and felony false imprisonment. He was discharged from the facility on 4/26/23. Cross reference to F600 2. R#5 was registered as a sex offender with the GBI since 8/9/22. However, a review of the clinical record revealed that a care plan had not been developed to address his current sex offender status and history of inappropriate sexual behavior. R#5 sexually abused R#4 on 3/16/23. Based on staff interviews, record review, and review of the police report and facility investigation information, on 3/16/23, CNA CC entered R#4's room to pick up his meal tray. She witnessed R#5 (who was not R#4's roommate) in the room, touching R#4's groin, head, shoulders, and buttocks. R#4 was asleep in his bed at the time and R#5 was standing up from his wheelchair over R#4. R#5 was arrested and charged with misdemeanor sexual battery on 4/3/23 and remained in the facility until the pending court date. Cross reference to F600 3. R#8 was registered as a sex offender with the GBI since 8/14/19. Review of the clinical record revealed that a care plan was developed on 2/28/20 for a history of the potential to be physically and sexually aggressive towards females/staff. A 4/13/23 revision to a trauma care plan problem included that R#8 was at risk for recurring thoughts and behaviors related to past events. However, the care plan did not include that R#8 was currently a registered sex offender. Cross reference to F600 4. R#9 was a registered as a sex offender with the GBI since 7/20/20. Review of the clinical record revealed that a care plan had not been developed to address his current sex offender status and history of inappropriate sexual behavior. R#9 sexually abused R#8 on 11/6/22. R#9 was assessed as being cognitively intact on the 9/21/22 Quarterly MDS assessment with a Brief Interview for Mental Status (BIMS) score of 15. R#8 was assessed as having severe cognitive impairment on the 10/13/22 Quarterly MDS assessment with a BIMS score of 00. On 11/6/22, LPN TT entered R#8's room to administer mediation and observed R#9 at R#8's bedside sexually abusing R#8. R#8 and R#9 were not roommates. Based on staff interview and record review, R#8 did not have the capacity to consent. R#9 was discharged from the facility on 12/8/22 and returned to prison. Cross reference to F600

Based on interviews and record reviews the facility failed to ensure care plans were revised to include occurrences of abuse with the interventions implemented for six residents (R#1, R#2, R#4, R#5, R#8 and R#9). The sample size was 27. On 4/25/23 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. The facility Administrator and the Minimum Data Set (MDS) Director were informed of the Immediate Jeopardy (IJ) on 4/25/23 at 1:25 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/6/22. At the time of exit on 5/1/23, an acceptable Immediate Jeopardy Removal Plan had not been received, therefore, the Immediate Jeopardy remained ongoing. Findings include: During an interview on 4/18/23 at 12:33 p.m. the MDS Director, when questioned if a history of sexually inappropriate behavior would be care planned, she responded that they would include that information if the resident had a diagnosis related to it or if they were receiving medication related to the behavior issue. They would also care plan a behavior if was displayed at the facility. When questioned about whose responsibility it was for updating a care plan after abuse occurrences, the MDS Director stated that it would be the person who witnessed the incident or the person completing the incident report, such as the charge nurse. The MDS Director stated that they (the MDS staff) reviewed the care plans every three months and if they were aware of an incident, they would review to see if the care plan had been updated correctly. However, there was no evidence that the care plans were thoroughly and timely revised after occurrences of abuse for resident (R)#1, R#2, R#4, R#5, R#8, and R#9. 1. Review of the clinical record for R#1 revealed a care plan problem, dated 2/8/22, for having a history of Post Traumatic Stress Disorder (PTSD) but not experiencing any symptoms currently. R#1 was sexually and physically abused by R#2 on 3/9/23. Based on staff interviews, record review and review of the police report and investigation, on 3/9/23, Certified Nursing Assistant (CNA) BB responded to screams from R#1 in his room. She observed R#1 and R#2 coming from around the privacy curtain from R#2's side of the room. The CNA stated that R#1 appeared to be scurrying away from R#2. Both were clothed, but R#1 alleged that R#2 touched him inappropriately on his groin area. R#1 also alleged that he had previously been sexually abused by R#2 on other occasions. A skin assessment on 3/9/23 revealed bruising to R#1's sacrum, hips, and buttocks that was not there on the previous skin assessment. R#1 was also emotionally upset following the incident. Following the incident, R#1 was sent to the emergency room for evaluation on 3/9/23. R#2 was arrested on 4/4/23 and charged with misdemeanor battery and felony false imprisonment. He was discharged from the facility on 4/26/23. Following the sexual and physical abuse of R#1 by R#2 on 3/9/23, R#1's care plan problem was revised on 4/4/23 to include that R#1 had a history of trauma but was not experiencing any symptoms at this time. However, the care plan revision was not thorough to include the 3/9/23 sexual and physical abuse R#1 sustained, with injuries, from R#2. After surveyor inquiry about care plan revisions on 4/18/23, further record review revealed that R#1's care plan was revised to include that he sustained bruising to his buttocks related to an alleged assault by a peer. Cross reference to F600 2. Based on staff interviews, record review and review of the police report and investigation information, R#2 physically and sexually abused R#1 on 3/9/23. Review of the clinical record revealed that his care plan was revised on 3/23/23 to include a care plan problem for the potential to be physically aggressive related to a history of harm to others. However, the care plan revision was not thorough to include the 3/9/23 abuse he inflicted on R#1 until after surveyor inquiry on 4/18/23. Following surveyor inquiry on 4/18/23, further record review revealed that the care plan was revised to include that R#2 was alleged to have physically abused a peer. Cross reference to F600 3. Review of the clinical record revealed that R#4 had a care plan problem, dated 8/29/22, for having a history of PTSD but not experiencing any symptoms. R#4 was sexually abused by R#5 on 3/16/23. Based on staff interviews, record review, and review of the police report and facility investigation information, on 3/16/23, CNA CC entered R#4's room to pick up his meal tray. She witnessed R#5 (who was not R#4's roommate) in the room, touching R#4's groin, head, shoulders, and buttocks. R#4 was asleep in his bed at the time and R#5 was standing up from his wheelchair over R#4. R#5 was arrested and charged with misdemeanor sexual battery. Following the sexual abuse of R#4, the care plan was revised on 4/4/23 and documented that R#4 had a history of trauma but was not experiencing any symptoms at this time. However, the care plan revision was not thorough to include the 3/16/23 sexual abuse R#4 sustained, from R#5, until after surveyor inquiry on 4/18/23. Following surveyor inquiry, R#4's care plan was revised to include that R#4 was groped in his private area by a peer. Cross reference to F600 4. Based on staff interviews, record review, and review of the police report and facility investigation information, R#5 sexually abused R#4 on 3/16/23. Review of the clinical record revealed that his care plan was revised on 3/23/23 to include a care plan problem for the potential to be physically aggressive related to a history of harm to others. However, the care plan revision was not thorough to include the sexual abuse he inflicted on R#4 until after surveyor inquiry on 4/18/23. Following surveyor inquiry on 4/18/23, the care plan was revised to include that R#5 groped a peer's private area. Cross reference to F600 5. Review of the clinical record revealed that R#8 had a care plan problem, dated 7/16/20, for not having a history of PTSD. Based on staff interviews, record review and review of the police report and facility investigation information, R#8 was sexually abused by R#9 on 11/6/22. R#9 was assessed as being cognitively intact on the 9/21/22 Quarterly MDS assessment with a Brief Interview for Mental Status (BIMS) score of 15. R#8 was assessed as having severe cognitive impairment on the 10/13/22 Quarterly MDS assessment with a BIMS score of 00. On 11/6/22, LPN TT entered R#8's room to administer mediation and observed R#9 at R#8's bedside sexually abusing R#8. Based on staff interview and record review, R#8 did not have the capacity to consent. R#9 was discharged from the facility on 12/8/22 and returned to prison. Following the sexual abuse R#8 experienced on 11/6/22, record review revealed that no revisions were made to the care plan until 3/21/23. On 3/21/23 the PTSD care plan was revised to include that the resident did not have any history of trauma. Further record review revealed a 4/13/23 care plan revision that documented R#8 was at risk for recurring thoughts and behaviors related to past events. However, the care plan revisions were not thorough to include the 11/6/22 sexual abuse R#8 sustained from R#9. Cross reference to F600 6. Based on staff interviews, record review and review of the police report and facility investigation information, R#9 sexually abused R#8 on 11/6/22. Review of the clinical record revealed no evidence his care plan was revised to include the sexual abuse he inflicted on R#8 on 11/6/22. R#9 was discharged from the facility on 12/8/22 and returned to prison. During the interview on 4/18/23 at 12:33 p.m. the MDS Director stated she did not have any additional care plan information on R#9. Cross reference to F600

Based on record review and staff interview, the facility failed to conduct and document a facility wide assessment that included and documented all required components of the resident population and facility resources. The facility census was 211. On 4/25/23 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. The facility Administrator and the Minimum Data Set (MDS) Director were informed of the Immediate Jeopardy (IJ) on 4/25/23 at 1:25 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/6/22. At the time of exit on 5/1/23, an acceptable Immediate Jeopardy Removal Plan had not been received, therefore, the Immediate Jeopardy remained ongoing. Findings include: Review of the Facility Assessment Tool revealed a 19-page document with an assessment and assessment review date of 1/28/23. Although the facility listed common diagnoses and conditions to determine the resources necessary to meet the needs of the residents it failed to include that the facility admitted a large percentage of justice involved residents, including 88 registered sex offenders. Further review, the Facility Assessment Tool did not include an evaluation of the care required by that specific resident population. 1. R#2 was registered as a sex offender with the Georgia Bureau of Investigation (GBI) since 3/13/2000. However, a review of the clinical record revealed that a care plan had not been developed to address his current sex offender status and history of inappropriate sexual behavior. R#2 physically and sexually abused R#1 on 3/9/23. 2. R#5 was registered as a sex offender with the GBI since 8/9/22. However, a review of the clinical record revealed that a care plan had not been developed to address his current sex offender status and history of inappropriate sexual behavior. R#5 sexually abused R#4 on 3/16/23. 3. R#8 was registered as a sex offender with the GBI since 8/14/19. Review of the clinical record revealed that a care plan was developed on 2/28/20 for a history of the potential to be physically and sexually aggressive towards females/staff. A 4/13/23 revision to a trauma care plan problem included that R#8 was at risk for recurring thoughts and behaviors related to past events. However, the care plan did not include that R#8 was currently a registered sex offender. 4. R#9 was a registered as a sex offender with the GBI since 7/20/20. Review of the clinical record revealed that a care plan had not been developed to address his current sex offender status and history of inappropriate sexual behavior. R#9 sexually abused R#8 on 11/6/22. During an interview with the Administrator on 5/1/23 at 1:40 p.m., she stated she was the person responsible for completing the Facility Assessment. She confirmed parts of the assessment were incomplete.