**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and family interviews, and review of the policy titled Abuse Policy, the facility failed to ensure that allegations of verbal, sexual, and physical abuse were reported to the State Survey Agency (SSA). Specifically, residents (R) R30 and R125 were sexually abused by R64; and R60 was verbally and physically abused by Certified Nursing Assistant (CNA AA). The sample size was 57 residents. On 2/5/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 2/5/2025 5:54 pm. The noncompliance related to Immediate Jeopardy (IJ) was identified to have existed on 10/28/2024. A Credible Allegation of Compliance was received on 2/10/2025. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 2/10/2025. The facility remains out of compliance while the facility continues management level oversight as well as continues to develop and implement a Plan of Correction. (POC).This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding preventing, reporting, and investigating abuse. Findings include: Review of the facility policy titled Abuse Policy dated December 2023 documented B. Training Components: Abuse Policy Requirements: It is the policy of this facility that all new and existing employees receive training on all forms of abuse, neglect, exploitation of residents, misappropriation of resident property, corporal punishment, injuries of unknown origin, and involuntary seclusion, including freedom from physical or chemical restraints. Training is to include prohibiting and prevention and identification, recognition, reporting and understanding behavioral symptoms that may increase risk of abuse and neglect. G. Reporting and Response: Allegations of abuse, neglect, exploitation of residents, misappropriation of resident property are reported per federal and state law. The facility will ensure that: b. All alleged violations involving abuse, neglect, exploitation of residents, misappropriation of resident property, corporal punishment, injuries of unknown source, corporal punishment and involuntary seclusion are reported immediately to the administrator. c. All alleged violations involving abuse, neglect, exploitation of residents, misappropriation of resident property, corporal punishment, injuries of unknown source, corporal punishment and involuntary seclusion must also be reported by the facility to officials in accordance with State law, including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities. a. Immediately, but no later than two hours if the alleged violation involves abuse or results in serious bodily injury. b. No later than 24 hours if the alleged violation involves neglect, exploitation, mistreatment or misappropriation of resident property and does not result in serious bodily injury c. Results of all investigations of alleged violations must be reported within five working days of the incident. Review of the employee personnel file for CNA AA revealed a handwritten note written by Licensed Practical Nurse (LPN) CC stating that she had witnessed CNA AA verbally and physically abuse R60 by yelling at her I'm sick of you and then threw a mechanical lift pad at R60, hitting her in the face. Further review of the employee personnel file contained a handwritten statement by CNA AA stating that she did not throw the mechanical lift pad at R60, but instead placed it near her because she always reaches for the mechanical lift pad. Further review of the employee file did not reveal any evidence of reporting of these allegations to the SSA or to law enforcement. The facility staff was asked to provide a copy of the facility reported incident, but none was provided. Interview on 2/4/2025 at 2:51 pm, the DON confirmed that she is the facility's Abuse Coordinator. She revealed the kissing incident between R64 and R30 was reported to her on 12/25/2024 by LPN UM EE. She stated that she reported the incident, but was uncertain if she reported it to the appropriate reporting entity, as she did not get a confirmation about submitting the 5-day follow up report. When asked why she did she not follow up for a confirmation, she revealed she got busy and did not get back around to do the 5-day follow up. During further interview, she stated she could not figure out how to do the 5-day follow up. The DON stated when allegations of abuse are received, it is to be reported within two hours if there is physical harm, and within 24 hours for all other incidents. She stated she asks the resident and/or family if they would like to file a police report. The DON revealed she called the family to inform of the 12/25/2024 incident, but stated the family did not want a police report completed. She was unable to provide the documentation of contacting the families. Furthermore, she revealed she did not follow up with staff regarding a direct order of documenting the occurrence or any other issues. In looking over the behavior notes for R64, the DON stated it is her responsibility to review all of the notes that are put in the system and discuss during the clinical and interdisciplinary team meetings. She revealed that she had not reviewed these notes and they were not discussed with the team. Interview on 2/4/2025 at 3:45 pm with the Administrator revealed he was aware of the incident on 12/25/2024 when it was reported to the DON however, law enforcement was not contacted. There was no evidence that the staff to resident abuse by CNA AA to R60 was reported to the SSA and there was no evidence that the sexual abuse perpetrated by R64 towards R125 was reported to the local law enforcement. The facility implemented the following actions to remove the IJ: 1. On 2/5/2025, the facility failed to notify family and resident representatives of R30, R125, and R60 of alleged incidents of abuse. The facility failed to report incidents of abuse to law enforcement. The facility failed to report the results of the investigations for R30, R60 and R125 to the Administrator and State Survey agency of alleged incidents of abuse. 2. Resident #64 is currently residing at Riverview Health and Rehabilitation Center. On 2/5/2025 resident placed on 1:1 supervision on upon report from State surveyor of other alleged incidents. On 2/5/2025 the resident's primary care physician, representative and the facility Medical Director have been notified of the reported incidents. On 2/5/2025 the facility has reassessed this resident for potential clinical needs per primary care physician. CBC, CMP, UA with C&S, PSA, TSH, RPR, and __ viral load have been ordered. On 2/5/2025 the resident's care plan has been reviewed and revised. On 2/5/2025 the facility contacted psychiatric services requesting an onsite evaluation, however services have been refused by resident. On 2/5/2025 Social Services reviewed current status with IDT for appropriate placement. On 2/5/2025 LTC Ombudsman has been notified. On 2/5/2025 law enforcement was notified of the reported abuse incidents affecting R60, R125, and R30. 3. Resident #R125 is currently residing at the facility. The resident is responsible for self, has a BIMS of 15, and is capable of verbally expressing herself and report to staff. On 2/6/2025 resident #R125 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. On 2/6/2025 the care plan has been reviewed and updated. On 2/5/2025 a psych follow up visit was provided. On 2/5/2025 law enforcement was notified of the reported abuse incident. 4. Resident #60 is currently residing at the facility. Resident's BIM is unable to be determined, but resident can make known nonverbal indicators of discomfort or distress through noises. On 2/6/2025 resident #R60 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incident identified. On 2/6/2025 the care plan has been reviewed and updated. On 2/5/2025 the resident's representative and primary care physician were notified by facility of the reported incidents On 2/5/2025 the facility has referred R60 for psych services for assessment and support. On 2/5/2025 law enforcement was notified of the reported abuse incident. 5. Resident #30 is currently residing at the facility. Resident's BIM is unable to be determined, but resident can make known nonverbal indicators of discomfort or distress through noises. On 2/6/2025 resident #R30 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. On 2/6/2025 the care plan has been reviewed and updated. On 2/5/2025 the resident's representative and primary care physician were notified by facility of the reported incidents On 2/5/2025 the facility has referred R30 for psych services for assessment and support. On 2/5/2025 law enforcement was notified of the reported abuse incident. 6. As of 2/6/2025 the facility met and assessed with R60, R125 and R30's roommates for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified. 7. As of 2/7/2025 the facility met with all residents that were deemed vulnerable for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns identified. 8. On 2/5/2025 upon the report from the State surveyor, CNA AA has been suspended pending further investigation. 9. On 2/5/2025 the facility notified the Medical Director who has been involved in the removal of the Immediate Jeopardy. 10. On 2/5/2025 the facility administrator reviewed and made any necessary changes to the abuse prevention and abuse reporting policies and procedures. 11. On 2/5/2025 the administrator contacted an external consultant(s) to assist with policy review, education development and leadership training on abuse prevention and reporting. 12. As of 2/8/2025, 132 of 150 (88% (percent)) of facility team members (36 CNAs, 25 LPNs, 7 RNs, 15 administrative staff, 3 activities staff, 13 dietary staff, 19 EVS staff, 4 maintenance staff, 3 social workers, 5 unit helpers/clerks, 1 DON and 1 LNHA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining 18 (5 CNAs, 1 LPN, 2 PRN RNs, 6 dietary staff, 3 EVS staff, and 1 unit helper/clerk) team members will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday. 13. As of 2/8/2025, 5 of 5 (100%) agency staff (4 LPNs and 1 CNA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. 14. As of 2/8/2025, 16 of 22 (78%) contracted therapy staff have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining 6 PRN contracted therapy staff will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday. 15. On 2/6/2025 a review and update of the facility orientation program and agency orientation program has been completed with respect to abuse prevention and abuse reporting requirements. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Observation, interviews and record reviews on 2/l l/2025-2/12/2025 revealed the facility environment to free from abuse. 2. R64 is no longer a current resident at the facility; he was discharged [DATE] to a personal care home. A review of the records revealed the facility started paper charting 1:1 hourly monitoring for R64 for the following: 2/5/2025 at 7:05 pm - 5:32 am (Interview with Administrator on 2/11/2025 at 3:00 pm revealed the video recording of where R64 was on 1:1 monitoring with staff.), 2/6/2025 at 7:00 am- 7:00 pm, 2/6/2025 at 7:00 pm- 2/7/2025 at 7:00 am, 2/7/2025 at 7:00 am- 7:20 pm, 2/7/2025 at 7:25 pm - 2/8/2025 at 7:00 am, 2/8/2025 at 7:00 am- 3:00 pm, 2/8/2025 at 3:15 pm- 2/9/2025 at 7:00 am - 3:00 pm. Phone Interview on 2/11/2025 at 2:30 pm with the physician of R30, R60, R64, and R125 and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and ordered the following labs for R64: CBC, CMP, UA with C&S, PSA, TSH, RPR, and __ viral load. Record review on 2/11/2025 revealed that the care plan for R64 has been updated. Record reviews on 2/11/2025 revealed the Social Worker offered mental health services, and he declined the services. Record review on 2/11/2025 revealed documentation that 2/7/2025 R64 was verbally notified of a bed offer at another skilled nursing facility. Residents agreed to transfer on Monday, 2/10/2025. Interview on 2/11/2025 with the Administrator and the DON revealed they were able to contact the Ombudsman. Record review on 2/11/2025 revealed there is a police report with the following reference number CC250205029. Record review revealed that R64 had been discharged to a personal care home from the facility. 3. Interview on 2/11/2025 with R125 revealed she was safe and with no concerns. Record review R125 has been reassessed for safety and potential physical/psychosocial outcomes based on the incidents identified by 2/6/2025. Record reviews on 2/11/2025 revealed that the care plan for R125 has been updated. Evidenced by Progress Note dated 2/6/2025: Resident reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. Vital signs at baseline. No s/s of pain or distress, no facial grimacing or nonverbal moaning currently. The bed is at the safest level, with a floor mat at the bedside. Assessment outcomes were reviewed with the primary care physician. Confirmed care plan revisions have been made for R125 on 2/6/2025. A progress note dated 2/5/2025 revealed R125's family was contacted by Social Services: The resident's family was contacted about an investigation of alleged abuse. Confirmed mental health services were offered, and the resident's family gave verbal consent for the mental health services. Evidence also revealed that law enforcement was notified on 2/5/2025 of the abuse in the facility. 4.Observation on 2/11/2025 at 2:00 pm revealed R60 making moaning sounds to alert staff for assistance. Record review on 2/11/2025 revealed a progress note in the system for R60 dated 2/6/2025 as a Health Status Note Documenting Resident reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. Record reviews on 2/11/2025 revealed that the care plan for R60 has been updated. Phone Interview on 2/11/2025 at 2:30 pm with the physician of R30, R60, R64, and R125 and the Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents. Record review on 2/11/2025 revealed a progress note in the system for R60 dated 2/6/2025 as a Health Status Note documenting R60 reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. Vital signs at baseline. No s/s of pain or distress, no facial grimacing or nonverbal moaning at this time. The bed is at the safest level, with a floor mat at the bedside. Assessment outcomes were reviewed with the primary care physician. Record review on 2/11/2025 revealed a police report was completed on 2/5/2025 with the following reference number CC250205029. 5.Interview on 02/12/2025 at 4:07 pm with the SSD revealed they communicate with the resident by doing observations. She mentioned that sometimes she makes sounds. She mentioned that most of the staff have been with her for a while and know her mannerisms. Confirmed care plan revisions were made on 2/6/2025, Evidenced by a progress note dated 2/5/2025, which revealed the R30's family was contacted by Social Services: The resident's family was contacted about an investigation of the alleged abuse. Confirmed mental health services were offered, and the resident's family gave verbal consent for the mental health services. Confirmed care plan revisions have been made for R30 on 2/6/2025. Phone Interview on 2/11/2025 at 2:30 pm with the physician and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and has participated in clinical meetings daily in the mornings with the facility's clinical team. Review of the progress note dated 2/6/2025 revealed that R30 was reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. Vital signs at baseline. No s/s of pain or distress, no facial grimacing or nonverbal moaning currently. The bed is at the safest level, with a floor mat at the bedside. Assessment outcomes were reviewed with the primary care physician. Confirmed care plan revisions have been made on 2/6/2025. A progress note dated 2/5/2025 revealed that R30's family was contacted by Social Services: The resident's family was contacted about an investigation of alleged abuse. Confirmed mental health services were offered, and the resident's family gave verbal consent for the mental health services. Evidenced by police report case number CC250205029 on 2/5/2025. 6. Record review on 2/11/2025 at 12:45 pm of a document titled Assessment of Vulnerable Population revealed the facility met with and assessed R125's roommate R252. All residents with low BIMs scores received a skin assessment, and residents with high BIMs scores received a written/verbal assessment. It was revealed that the roommate of R252 received a skin assessment due to her low BIMs score of 99. Record review on 2/11/2025 at 12:56 pm of a document titled Assessment of Vulnerable Population revealed the facility met with and assessed R60's roommate R36. All residents with low BIMs scores received a skin assessment, and residents with high BIMs scores received a written/verbal assessment. It was revealed that the roommate of R36 received a skin assessment due to her low BIMS score of 03. Record review on 2/11/2025 at 1:04 pm of a document titled Assessment of Vulnerable Population revealed the facility met with and assessed R30's roommate R19. All residents with low BIMs scores received a skin assessment, and residents with high BIMs scores received a written/verbal assessment. It was revealed that the roommate of R19 received a skin assessment due to her low BIMS score of 2. 7. Record review of assessments conducted by the facility. The vulnerable population is defined by the facility as all women in the facility. Female residents with BIMS greater than or equal to 13 had a written/verbal assessment conducted on 2/5/2025 through 2/7/2025 and signed and dated by social services. Female residents with BIMS less than 13 had a skin assessment conducted on 2/5/2025 through 2/7/2025 and signed and dated by nursing staff. Reviewed all assessments with no safety concerns. An interview with R14 at 12:09 pm in her room revealed that she feels safe in the facility. R14 has a BIMS of 14. An interview with R17 at 12:12 pm in her room revealed that she feels safe in the facility. R17 has a BIMS of 13. 8. An interview with the Administrator and DON on 2/11/2025 at 1:34 pm revealed that CNA AA has been suspended and potentially terminated pending investigation. Record review on 2/11/2025 revealed a time clock in the report, which revealed CNA AA was clocked out on 2/5/2025 with a start time of 7:06 am and work ending at 7:18 pm. 9. Phone Interview on 2/11/2025 at 2:30 pm with the physician and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and has participated in clinical meetings daily in the mornings with the facility's clinical team. 10. During an interview on 2/11/2025 at 2:50 pm with the Administrator, revealed that the policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property was updated on 02/06/2025. 11. Evidence shows the Administrator Spoke with a representative from an external consultant. She stated she discussed the immediate actions needed to remove the IJ citations and began the initial review and revision of the abuse prevention policy and procedures with NHA and DON. Recommendations were also provided. 12. A review of facility in-service record dated 2/8/2025 revealed 36 CNAs, 25 LPNs, 7 RNs, 15 administrative staff, three activities staff, 13 dietary staff, 19 EVS staff, four maintenance staff, three social workers, five-unit helpers/clerks, one DON and one LNHA have been educated on abuse prevention, abuse reporting and comprehensive assessments. Also verified the above education by the following staff interview on 2/11/2025 at 6:15 am with Certified Nursing Assistant (CNA) XX, 2/11/2025 at 6:17 am with Licensed Practical Nurse (LPN) JJ, 2/11/2025 at 6:21 am with LPN YY, 2/11/2025 at 6:26 am with CNA ZZ, 2/11/2025 at 6:31 am with CNA NN, 2/11/2025 at 6:36 am with CNA AAA, 2/11/2025 at 6:46 am with LPN GG, 2/11/2025 at 6:48 am with LPN BBB, 2 /11/2025 at 6:51 am with CNA CCC, 2/11/2025 at 6:54 am with CNA DDD, 2/11/2025 at 7:58 am with Maintenance Director, 2/11/2025 at 8:30 am with Maintenance Assistant, 2/11/2025 at 8:15 am with Housekeeping GGG, 2/11/2025 at 8:46 am with Environmental Services Manager, 2/11/2025 at 8:23 am with Social Services Director, 2/11/2025 at 9:16 am with Social Worker HHH, 2/11/2025 at 8:50 am with Activities Assistant III, 2/11/2025 at 8:35 am with admission Coordinator JJJ, 2/11/2025 at 8:48 am with Medical Records KKK, 2/11/2025 at 10:30 am with Director of Business Development, 2/11/2025 at 6:01 am with CNA MMM, 2/11/2025 at 6:20 am with CNA NNN, 2/11/2025 at 6:31 am with RN Supervisor OOO, 2/11/2025 at 6:31 am with LPN PPP, 2/11/2025 at 6:46 am with Unit Manager (UM) EE, 2/11/2025 at 7:40 am with Assistant Food Service Manager, 2/11/2025 at 7:45 am with Dietary Manager, 2/11/2025 at 8:00 am with Occupational Therapist (OT) WWW, 2/11/2025 at 8:08 am OT XXX, 2/11/2025 at 8:00 am Physical Therapist Assistant (PTA), 2/11/2025 at 6:18 am with Unit Secretary (US) ZZZ, 2/11/2025 at 6:23 am with Staffing Coordinator MM, 2/11/2025 at 6:28 am with LPN AAAA, 2/11/2025 at 6:32 am with LPN QQ, 2/11/2025 at 6:42 am with Floor Tech (FT) BBBB, 2/11/2025 at 6:42 am with CNA CCCC, 2/11/2025 at 6:47 am with CNA CCC, 2/11/2025 at 6:50 am with Housekeeping DDDD, 2/11/2025 at 6:56 am with FT EEEE, 2/11/2025 at 7:52 am with DA FFFF, 2/11/2025 at 8:07 am with Receptionist GGGG, 2/11/2025 at 8:21 am with Admissions Coordinator HHHH, 2/11/2025 at 8:17 am with Housekeeping IIII, 2/11/2025 at 8:20 am with Financial Assistant JJJJ, 2/11/2025 at 8:28 am with Activities Director, 2/11/2025 at 12:53 pm with UM SS, 2/11/2025 at 12:56 pm with Director of Finances, 2/11/2025 at 12:57 pm with US KKKK, 2/11/2025 at 1:07 pm with CNA NNNN, 2/11/2025 at 1:09 pm with Wound Care CNA OOOO, 2/11/2025 at 1:12 pm with CNA PPPP, 2/11/2025 at 1:15 pm with US QQQQ, 2/11/2025 at 1:18 pm with Activities Assistant FF, 2/11/2025 at 1:20 pm with LPN LL, 2/11/2025 at 1:22 pm with Director of Rehabilitation, 2/11/2025 at 1:32 pm with OT RRRR, 2/11/2025 at 1:35 pm with PT SSSS, 2/11/2025 at 1:37 pm with PTA TTTT, 2/11/2025 at 1:40 pm with Speech Therapist (ST) UUUU, 2/11/2025 at with 1:46 pm with Rehab Technician VVVV, 2/11/2025 at 1:56 pm with LPTA WWWW, 2/11/2025 at 1:59 pm with Laundry XXXX, 2/11/2025 at 2:09 pm with ST YYYY, 2/11/2025 at 2:49 pm with EVS Assistant Supervisor, 2/11/2025 at 2:56 pm with CNA DD, 2/11/2025 at 3:00 pm with Housekeeper DDDDD, 2/11/2025 at 3:02 pm with CNA EEEEE, 2/11/2025 at 3:04 pm with Central Supply Clerk FFFFF, 2/11/2025 at 3:07 pm with Registered Dietician, 2/11/2025 at 3:28 pm with LPN TT, 2/11/2025 at 3:30 pm with CNA GGGGG, 2/11/2025 at 3:32 pm with CNA HHHHH, 2/11/2025 at 3:34 pm with DA IIIII, 2/11/2025 at 3:36 pm with [NAME] JJJJJ, 2/11/2025 at 3:43 pm with CNA VV, 2/11/2025 at 3:45 pm with LPN KK, 2/11/2025 at 3:50 pm with DA KKKKK, 2/11/2025 at 3:51 pm with MDS Coordinator LLLLL, 2/11/2025 at 4:02 pm with MDS Coordinator MMMMM, 2/11/2025 at 4:05 pm with DA NNNNN, 2/11/2025 at 4:06 pm with Financial Coordinator OOOOO, 2/11/2025 at 4:08 pm with Payroll Clerk PPPPP, 2/11/2025 at 4:10 pm with Human Resources Director, 2/11/2025 at 4:12 pm with [NAME] RRRRR, 2/11/2025 at 6:54 pm with LPN TTTTT, 2/11/2025 at 5:41 pm with Infection Preventionist, 2/11/2025 at 5:46 pm with Receptionist YYYYY, 2/11/2025 at 5:58 pm with LPN QQQQQ, 2/11/2025 at 5:59 pm with DA A1, 2/11/2025 at 6:11 pm with LPN D1, 2/11/2025 at 6:19 pm with CNA E1, 2/12/2025 at 12:03 pm with Nurse Educator, 2/12/2025 at 12:19 pm with DON, 2/12/2025 at 12:49 pm with Administrator. A review of the facility in-service record dated 2/9/2025 revealed 18 (five CNAs, one LPN, two PRN RNs, six dietary staff, three EVS staff, and one unit helper/clerk) team members were educated on abuse prevention, abuse reporting, and comprehensive assessments. Also verified the above education by the following staff interviews 2/11/2025 at 2:44 pm with Housekeeper ZZZZ, 2/11/2025 at 2:46 pm with Housekeeper AAAAA,2/11/2025 at 2:52 pm with Housekeeper BBBBB, 2/11/2025 at 7:10 with am Dietary Aide (DA) QQQ, 2/11/2025 at 7:15 am with [NAME] RRR, 2/11/2025 at 7:20 am with DA SSS, 2/11/2025 at 7:25 am with DA TTT, 2/11/2025 at 7:30 am with DA UUU, 2/11/2025 at 7:35 am with DA VVV, 2/11/2025 at 6:54 pm with LPN TTTTT, 2/11/2025 at 7:05 pm with RN UUUUU, 2/11/2025 at 7:11 pm with CNA VVVVV, 2/11/2025 at 7:20 pm with CNA WWWWW, 2/11/2025 at 5:37 pm with CNA XXXXX, 2/11/2025, 2/11/2025 at 6:03 pm with CNA B1, 2/11/2025 at 6:08 pm with CNA C, 2/11/2025 at 1:18 pm with Activities Assistant FF, 2/11/2025 at 6:02 am with Wound Care Registered Nurse (RN) LLL. An interview with the Administrator on 2/11/2025 at 1:05 pm revealed that 91% of staff have been educated on abuse. 13. Review of facility in-service record dated 2/8/2025, five of five (100%) agency staff (four LPNs and one CNA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. Also verified the above education by the following staff interviews on 2/11/2025 at 1:01 pm with LPN LLLL, 2/11/2025 at 1:04 pm with LPN MMMM, 2/11/2025 at 5:58 pm with LPN RR, 2/11/2025 at 6:57 pm with LPN SSSSS, 2/11/2025 at 6:42 am with CNA CCCC. 14. By evidence of interview and record review, staff is currently receiving training. An interview with the Administrator on 2/11/2025 at 1:05 pm revealed that 91% of staff have been educated on abuse. An interview with the Administrator on 2/11/2025 at 1:05 pm revealed that 91% of staff have been educated on abuse. 15.Record review of facility documents titled Associate Orientation Checklist and Facility Name Orientation revealed reviews and revisions to the documents made on 2/7/2025, including the addition of comprehensive assessments and abuse reporting. The Administrator confirmed on 2/11/2025 at 1:59 pm that the orientation checklist and agenda are the same for both agency and facility staff. All corrective actions were completed by 2/9/2025. All immediacy of the IJ was removed on 2/10/2025.

Based on record review, staff interview, and review of the facility policy titled, Abuse Policy, the facility failed to ensure allegations of abuse were thoroughly investigated for two of four residents (R) R30 and R60 reviewed for abuse. Specifically, the facility failed to investigate allegations of resident-to-resident sexual abuse for R30 perpetrated by R64 and an allegation of employee to resident abuse for R60, perpetrated by Certified Nursing Assistant (CNA)AA. On 2/5/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 2/5/2025 at 5:54 pm. The noncompliance related to Immediate Jeopardy (IJ) was identified to have existed on 10/28/2024. A Credible Allegation of Compliance was received on 2/10/2025. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 2/10/2025. The facility remains out of compliance while the facility continues management level oversight as well as continues to develop and implement a Plan of Correction. (POC).This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding preventing, reporting, and investigating abuse. Findings include: Review of the facility policy titled Abuse Policy dated December 2023 documented E. Investigation. Abuse Policy Requirements: It is the policy of this facility that reports of abuse, neglect, exploitation of residents, misappropriation of resident property, corporal punishment, injuries of unknown source, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms, are promptly and thoroughly investigated. Procedure: The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration. a. Investigation of abuse: When an incident or suspected incident of abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms, is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. During the investigation, caution will be exercised when handling evidence that could potentially be used in a criminal investigation. The investigation will include statements from all individuals involved to include: i. Statement from individual reporting alleged abuse ii. Resident's statements a. For non-verbal residents, cognitively impaired residents or residents who refuse to be interviewed, attempt to interview resident first. If unable, observe resident, complete an evaluation of resident behavior, affect and response to interaction, and document findings. iii. Resident's roommate statements (if applicable) iv. Visitor statements for anyone who may have witnessed the alleged abuse (if applicable) v. All involved staff who have or may have witnessed the abuse vi. Any non-staff witness statements of events vii. A description of the resident's behavior and environment at the time of the incident viii. An full assessment of the resident to identify any Injuries present ix. Observation of resident and staff behaviors during the investigation x. Environmental considerations *All staff must cooperate during the investigation to assure the resident is fully protected. Additional Investigation Protocols. The results of the investigation will be documented and attached to the report. Review of the facility state reportable incidents failed to document a complete investigation of the incident between R64 and R30 on 12/25/2024. Further review of the documents showed there was only a copied and pasted email statement, an un-dated written statement from the unit manager, two un-dated written statement from a staff who did not witness the incident, and a hand written note regarding the reporting and follow up date, written by the Director of Nursing. There were no resident statements, no evidence the incidents were reported to law enforcement, and no evidence the residents were assessed for physical and/or psychological harm. Review of the employee personnel file for CNA AA revealed a handwritten note written by Licensed Practical Nurse (LPN) CC stating that she had witnessed CNA AA verbally and physically abuse R60 by yelling at her I'm sick of you and then threw a mechanical lift pad at R60, hitting her in the face. Further review of the employee personnel file contained a handwritten statement by CNA AA stating that she did not throw the mechanical lift pad at R60, but instead placed it near her because she always reaches for the mechanical lift pad. Further review of the employee file did not reveal any evidence of reporting of these allegations to the SSA or to law enforcement. The facility staff was asked to provide a copy of the facility reported incident, but none was provided. Interview on 2/4/2025 at 2:51 pm, the DON confirmed that she is the Abuse Coordinator. When questioned why did she not follow up on the confirmation of the reportable, she revealed she got busy and did not get back to complete the 5-day follow up and could not figure out how to do the 5-day follow up but she tried. Interview on 2/12/2025 at 1:21 pm, the Administrator stated that he was aware of both 10/28/2024 and 12/25/2024 incidents which was reported by the DON. The 10/28/2024 incident he thought it was reported by the DON, the team discussed it and the ball got dropped because the follow up was not done for either incident. He stated his expectations are for staff to know how to do their jobs, since they have the tools to do their job. During further interview, he stated that if his expectations are not carried out, he revealed the negative effect if any staff is not able to perform their job duties then harm to others can happen. The facility implemented the following actions to remove the IJ: 1. On 2/5/2025, the facility failed to thoroughly investigate incidents of abuse. 2. Resident #64 is currently residing at the facility. On 2/5/2025 resident placed on 1:1 supervision on upon report from State surveyor of other alleged incidents. On 2/5/2025 the resident's primary care physician, representative and the facility Medical Director have been notified of the reported incidents. On 2/5/2025 the facility has reassessed this resident for potential clinical needs per primary care physician. CBC, CMP, UA with C&S, PSA, TSH, RPR, and __ viral load have been ordered. On 2/5/2025 the resident's care plan has been reviewed and revised. On 2/5/2025 the facility contacted psych services requesting an onsite evaluation, however services have been refused by resident. On 2/5/2025 Social Services reviewed current status with IDT for appropriate placement. On 2/5/2025 LTC Ombudsman has been notified. On 2/5/2025 law enforcement was notified of the reported abuse incident to R30, R60, and R125. As of 2/9/2025 resident R64 has discharged from facility. 3. Resident #R125 is currently residing at the facility. The resident is responsible for self, has a BIMS of 15, and is capable of verbally expressing herself and report to staff. On 2/6/2025 resident #R125 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. On 2/6/2025 the care plan has been reviewed and updated. On 2/5/2025 a psych follow up visit was provided. On 2/5/2025 law enforcement was notified of the reported abuse incident. 4. Resident #60 is currently residing at the facility. Resident's BIM is unable to be determined, but resident can make known nonverbal indicators of discomfort or distress through noises. On 2/6/2025 resident #R60 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incident identified. On 2/6/2025 the care plan has been reviewed and updated. On 2/5/2025 the resident's representative and primary care physician were notified by facility of the reported incidents On 2/5/2025 the facility has referred R60 for psych services for assessment and support. On 2/5/2025 law enforcement was notified of the reported abuse incident. 5. Resident #30 is currently residing at the facility. Resident's BIM is unable to be determined, but resident can make known nonverbal indicators of discomfort or distress through noises. On 2/6/2025 resident #R30 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. On 2/6/2025 the care plan has been reviewed and updated. On 2/5/2025 the resident's representative and primary care physician were notified by facility of the reported incidents. On 2/5/2025 the facility has referred R30 for psych services for assessment and support. 6. As of 2/7/2025 the facility has met and assessed with R60, R125 and R30's roommates as well as residents who are deemed vulnerable for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified. 7. As of 2/7/2025 the facility met with all residents that were deemed vulnerable for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified. 8. On 2/5/2025 upon the report from the State surveyor, CNA AA has been suspended pending further investigation. 9. On 2/5/2025 the facility notified the Medical Director who has been involved in the removal of the Immediate Jeopardy. 10. On 2/5/2025 the facility administrator reviewed and made any necessary changes to the abuse prevention and abuse reporting policies and procedures. 11. On 2/5/2025 the administrator contacted an external consultant(s) to assist with policy review, education development and leadership training on abuse prevention and reporting. 12. As of 2/8/2025, 132 of 150 (88% (percent)) of facility team members (36 CNAs, 25 LPNs, 7 RNs, 15 administrative staff, 3 activities staff, 13 dietary staff, 19 EVS staff, 4 maintenance staff, 3 social workers, 5 unit helpers/clerks, 1 DON and 1 LNHA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining 18 (5 CNAs, 1 LPN, 2 PRN RNs, 6 dietary staff, 3 EVS staff, and 1 unit helper/clerk) team members will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday. 13. As of 2/8/2025, 5 of 5 (100%) agency staff (4 LPNs and 1 CNA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. 14. As of 2/8/2025, 16 of 22 (78%) contracted therapy staff have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining 6 PRN contracted therapy staff will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday. 15.On 2/6/2025 a review and update of the facility orientation program and agency orientation program has been completed with respect to abuse prevention and abuse reporting requirements. All corrective actions were completed by 2/9/2025. All immediacy of the IJ was removed on 2/10/2025. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Interview on 2/11/2025 at 1:10 pm with DON revealed all reported investigation are pending an investigation. 2. R64 is no longer a current resident at the facility, he was discharged on 2/9/2025. A review of the records revealed the facility started paper charting 1: 1 hourly monitoring for R64 for the following: 2/5/2025 at 7:05 pm - 5:32 am, (Interview with Administrator on 2/11/2025 at 3:00 pm revealed the video recording of where R64 was on 1 :1 monitoring with staff.) 2/6/2025 at 7:00 am- 7: 00 pm, 2/6/2025 at 7:00 pm- 2/7/2025 at 7:00 am, 2/7/2025 at 7:00 am- 7: 20 pm, 2/7/2025 at 7:25 pm 2/8/2025 at 7:00 am, 2/8/2025 at 7:00 am- 3: 00 pm, 2/8/2025 at 3: 15 pm, 2/9/2025 at 7: 00 am - 3:00 pm. By evidence of an interview on 2/11/2025 at 2:30 pm with the physician of R30, R60, R64, and R 125 and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and ordered the following labs for R64. By evidence of a phone Interview on 2/11/2025 at 2:30 pm with the physician of R30, R60, R64, and R125 and Medical Director of the facility revealed she was notified and contacted of the incidents with the Record review on 2/11/2025 revealed the care plan for R64 has been updated. Record reviews on 2/11/2025 revealed the Social Worker offered an external contracted mental health services, and he declined the services. Record review on 2/11/2025 revealed documentation that on 2/7/2025 R64 was verbally notified of bed offer at another skilled nursing facility. Residents agreed to transfer on Monday 2/10/2025. Interview on 2/11/2025 with the Administrator and the DON revealed they were able to contact the Ombudsman. Interview ombudsman on 2/10/2025 at 3:00pm confirm she was notified about abuse in the facility. Record review on 2/11/2025 revealed there is a police report with the following reference number CC250205029. Record review revealed R64 has been discharged from the facility on 2/9/2025 to a personal care home. 3. Record review R125 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified by 2/6/2025. Record review R125 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified by 2/6/2025. Record reviews on 2/11/2025 revealed the care plan for R125, R60, R30 and R64 has been updated. Evidenced by Progress Note dated 2/6/2025: Resident reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. Vital signs at baseline. No s/s of pain or distress, no facial grimacing or nonverbal moaning currently. Bed at safest level with floor mat at bedside. Assessment outcomes were reviewed with the primary care physician. Confirmed care plan revisions have been made on 2/6/2025. Progress note dated 2/5/2025 revealed resident's family was contacted by Social Services: The resident's family was contacted about an investigation of alleged abuse. Confirmed mental health services were offered, and the resident's family gave verbal consent for the mental health services. By evidence of record review, it was confirmed that R125 has been reassessed for safety and potential physical/psychosocial harm, care plan has been reviewed and updated, and a psychiatric follow up visit was provided. Evidence also revealed law enforcement was notified of the abuse in the facility. 4.Observation on 2/11/2025 at 2:00 pm revealed R60 making moaning sounds alert staff for assistance. Resident's BIMs is unable to be determined, but resident can make known nonverbal indicators of discomfort or distress through noises. Record review on 2/11/2025 revealed a progress note in the system for R60 dated for 2/6/2025 as a Health Status Note documenting Resident reassessed for safety and potential. physical/psychosocial outcomes based upon the incidents identified. Vital signs at baseline. No signs and symptoms (s/s) of pain or distress, no facial grimacing or nonverbal moaning at this time. Bed at safest level with floor mat at bedside. Assessment outcomes were reviewed with the primary care physician. By evidence of Record review on 2/11/2025 revealed there is a police report with the following reference number CC250205029. Phone Interview on 2/11/2025 at 2:30 pm with the physician and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and have participated in clinical meetings daily in the mornings with the clinical team of the facility. On 2/5/2025 the facility referred to R30 for psychiatric services for assessment and support. Progress Note dated 2/6/2025: Resident reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. Vital signs at baseline. No s/s of pain or distress, no facial grimacing or nonverbal moaning currently. Bed at safest level with floor mat at bedside. Assessment outcomes were reviewed with the primary care physician. Confirmed care plan revisions have been made on 2/6/2025. Progress note dated 2/5/2025 revealed resident's family was contacted by Social Services: The resident's family was contacted about an investigation of alleged abuse. Confirmed mental health services were offered, and the resident's family gave verbal consent for the mental health services. Record review on 2/11/2025 revealed there is a police report with the following reference number CC250205029. 6. Record review on 2/11/2025 at 12:45 pm of document titled Assessment of Vulnerable Population revealed the facility met with and assessed R125's roommate R252. All residents with low BIMs scores received a skin assessment; and residents with high BIMs scores received a written/verbal assessment. It was revealed that the roommate of R252 received a skin assessment due to her low BIMS score of 99. Record review on 2/11/2025 at 12:56 pm of document titled Assessment of Vulnerable Population revealed the facility met with and assessed R60's roommate R36. All residents with low BIMs scores received a skin assessment; and residents with high BIMs scores received a written/verbal assessment. It was revealed that the roommate of R36 received a skin assessment due to her low BIMS score of 03. Record review on 2/11/2025 at 1:04 pm of document titled Assessment of Vulnerable Population revealed the facility met with and assessed R30's roommate R19. All residents with low BIMs scores received a skin assessment; and residents with high BIMs scores received a written/verbal assessment. It was revealed that the roommate of R19 received a skin assessment due to her low BIMs score of 02. 7. Record review of assessments conducted by the facility. The vulnerable population is defined by the facility as all women in the facility. Female residents with BIMs greater than or equal to 13 had a written/verbal assessment conducted on 2/5/2025 through 2/7/2025 and signed and dated by social services. Female residents with BIMs less than 13 had a skin assessment conducted on 2/5/2025 through 2/7/2025 and signed and dated by nursing staff. Reviewed all assessments with no safety concerns. An interview with R14 at 12:09 pm in her room revealed that she feels safe in the facility. R14 has a BIMs of 14. An interview with R17 at 12:12 pm in her room revealed that she feels safe in the facility. R17 has a BIMs of 13. 8. An interview with the Administrator and DON on 2/11/2025 at 1:34 pm revealed CNAAA has been suspended and potentially terminated pending investigation. Record review on 2/11/2025 revealed a time clock in report which revealed CNA AA was clocked out on 2/5/2025 start time 7:06 am and work end at 7: 18 pm. 9. Phone Interview on 2/11/2025 at 2:30 pm with the physician and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and have participated in clinical meetings daily in the mornings with the clinical team of the facility. 10. During an interview on 2/11/2025 at 2:50 pm with Administrator revealed the policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, was updated on 2/06/2025. Evidence shows the Administrator Spoke with a representative from external consultant. She stated she discussed the immediate actions needed to remove the IJ citations and began the initial review and revision of the abuse prevention policy and procedures with NHA and DON. Recommendations were also provided. 11. Evidence revealed the Administrator collaborated with a representative from external consultant. She began her assistance with the NHA as well as the DON on 2/5/2025 and is currently making revisions and recommendations. 12. A review of facility in-service record dated 2/8/2025 revealed 36 CNAs, 25 LPNs, 7 RNs, 15 administrative staff, three activities staff, 13 dietary staff, 19 EVS staff, four maintenance staff, three social workers, five-unit helpers/clerks, one DON and one LNHA have been educated on abuse prevention, abuse reporting and comprehensive assessments. Also verified the above education by the following staff interview on 2/11/2025 at 6:15 am with Certified Nursing Assistant (CNA) XX, 2/11/2025 at 6:17 am with Licensed Practical Nurse (LPN) JJ, 2/11/2025 at 6:21 am with LPN YY, 2/11/2025 at 6:26 am with CNA ZZ, 2/11/2025 at 6:31 am with CNA NN, 2/11/2025 at 6:36 am with CNA AAA, 2/11/2025 at 6:46 am with LPN GG, 2/11/2025 at 6:48 am with LPN BBB, 2 /11/2025 at 6:51 am with CNA CCC, 2/11/2025 at 6:54 am with CNA DDD, 2/11/2025 at 7:58 am with Maintenance Director, 2/11/2025 at 8:30 am with Maintenance Assistant, 2/11/2025 at 8:15 am with Housekeeping GGG, 2/11/2025 at 8:46 am with Environmental Services Manager, 2/11/2025 at 8:23 am with Social Services Director, 2/11/2025 at 9:16 am with Social Worker HHH, 2/11/2025 at 8:50 am with Activities Assistant III, 2/11/2025 at 8:35 am with admission Coordinator JJJ, 2/11/2025 at 8:48 am with Medical Records KKK, 2/11/2025 at 10:30 am with Director of Business Development, 2/11/2025 at 6:01 am with CNA MMM, 2/11/2025 at 6:20 am with CNA NNN, 2/11/2025 at 6:31 am with RN Supervisor OOO, 2/11/2025 at 6:31 am with LPN PPP, 2/11/2025 at 6:46 am with Unit Manager (UM) EE, 2/11/2025 at 7:40 am with Assistant Food Service Manager, 2/11/2025 at 7:45 am with Dietary Manager, 2/11/2025 at 8:00 am with Occupational Therapist (OT) WWW, 2/11/2025 at 8:08 am OT XXX, 2/11/2025 at 8:00 am Physical Therapist Assistant (PTA), 2/11/2025 at 6:18 am with Unit Secretary (US) ZZZ, 2/11/2025 at 6:23 am with Staffing Coordinator MM, 2/11/2025 at 6:28 am with LPN AAAA, 2/11/2025 at 6:32 am with LPN QQ, 2/11/2025 at 6:42 am with Floor Tech (FT) BBBB, 2/11/2025 at 6:42 am with CNA CCCC, 2/11/2025 at 6:47 am with CNA CCC, 2/11/2025 at 6:50 am with Housekeeping DDDD, 2/11/2025 at 6:56 am with FT EEEE, 2/11/2025 at 7:52 am with DA FFFF, 2/11/2025 at 8:07 am with Receptionist GGGG, 2/11/2025 at 8:21 am with Admissions Coordinator HHHH, 2/11/2025 at 8:17 am with Housekeeping IIII, 2/11/2025 at 8:20 am with Financial Assistant JJJJ, 2/11/2025 at 8:28 am with Activities Director, 2/11/2025 at 12:53 pm with UM SS, 2/11/2025 at 12:56 pm with Director of Finances, 2/11/2025 at 12:57 pm with US KKKK, 2/11/2025 at 1:07 pm with CNA NNNN, 2/11/2025 at 1:09 pm with Wound Care CNA OOOO, 2/11/2025 at 1:12 pm with CNA PPPP, 2/11/2025 at 1:15 pm with US QQQQ, 2/11/2025 at 1:18 pm with Activities Assistant FF, 2/11/2025 at 1:20 pm with LPN LL, 2/11/2025 at 1:22 pm with Director of Rehabilitation, 2/11/2025 at 1:32 pm with OT RRRR, 2/11/2025 at 1:35 pm with PT SSSS, 2/11/2025 at 1:37 pm with PTA TTTT, 2/11/2025 at 1:40 pm with Speech Therapist (ST) UUUU, 2/11/2025 at with 1:46 pm with Rehab Technician VVVV, 2/11/2025 at 1:56 pm with LPTA WWWW, 2/11/2025 at 1:59 pm with Laundry XXXX, 2/11/2025 at 2:09 pm with ST YYYY, 2/11/2025 at 2:49 pm with EVS Assistant Supervisor, 2/11/2025 at 2:56 pm with CNA DD, 2/11/2025 at 3:00 pm with Housekeeper DDDDD, 2/11/2025 at 3:02 pm with CNA EEEEE, 2/11/2025 at 3:04 pm with Central Supply Clerk FFFFF, 2/11/2025 at 3:07 pm with Registered Dietician, 2/11/2025 at 3:28 pm with LPN TT, 2/11/2025 at 3:30 pm with CNA GGGGG, 2/11/2025 at 3:32 pm with CNA HHHHH, 2/11/2025 at 3:34 pm with DA IIIII, 2/11/2025 at 3:36 pm with [NAME] JJJJJ, 2/11/2025 at 3:43 pm with CNA VV, 2/11/2025 at 3:45 pm with LPN KK, 2/11/2025 at 3:50 pm with DA KKKKK, 2/11/2025 at 3:51 pm with MDS Coordinator LLLLL, 2/11/2025 at 4:02 pm with MDS Coordinator MMMMM, 2/11/2025 at 4:05 pm with DA NNNNN, 2/11/2025 at 4:06 pm with Financial Coordinator OOOOO, 2/11/2025 at 4:08 pm with Payroll Clerk PPPPP, 2/11/2025 at 4:10 pm with Human Resources Director, 2/11/2025 at 4:12 pm with [NAME] RRRRR, 2/11/2025 at 6:54 pm with LPN TTTTT, 2/11/2025 at 5:41 pm with Infection Preventionist, 2/11/2025 at 5:46 pm with Receptionist YYYYY, 2/11/2025 at 5:58 pm with LPN QQQQQ, 2/11/2025 at 5:59 pm with DA A1, 2/11/2025 at 6:11 pm with LPN D1, 2/11/2025 at 6:19 pm with CNA E1, 2/12/2025 at 12:03 pm with Nurse Educator, 2/12/2025 at 12:19 pm with DON, 2/12/2025 at 12:49 pm with Administrator. A review of the facility in-service record dated 2/9/2025 revealed 18 (five CNAs, one LPN, two PRN RNs, six dietary staff, three EVS staff, and one unit helper/clerk) team members were educated on abuse prevention, abuse reporting, and comprehensive assessments. Also verified the above education by the following staff interviews 2/11/2025 at 2:44 pm with Housekeeper ZZZZ, 2/11/2025 at 2:46 pm with Housekeeper AAAAA,2/11/2025 at 2:52 pm with Housekeeper BBBBB, 2/11/2025 at 7:10 with am Dietary Aide (DA) QQQ, 2/11/2025 at 7:15 am with [NAME] RRR, 2/11/2025 at 7:20 am with DA SSS, 2/11/2025 at 7:25 am with DA TTT, 2/11/2025 at 7:30 am with DA UUU, 2/11/2025 at 7:35 am with DA VVV, 2/11/2025 at 6:54 pm with LPN TTTTT, 2/11/2025 at 7:05 pm with RN UUUUU, 2/11/2025 at 7:11 pm with CNA VVVVV, 2/11/2025 at 7:20 pm with CNA WWWWW, 2/11/2025 at 5:37 pm with CNA XXXXX, 2/11/2025, 2/11/2025 at 6:03 pm with CNA B1, 2/11/2025 at 6:08 pm with CNA C, 2/11/2025 at 1:18 pm with Activities Assistant FF, 2/11/2025 at 6:02 am with Wound Care Registered Nurse (RN) LLL. An interview with the Administrator on 2/11/2025 at 1:05 pm revealed that 91% of staff have been educated on abuse. 13. Review of facility in-service record dated 2/8/2025, five of five (100% (percent)) agency staff (four LPNs and one CNA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. Also verified the above education by the following staff interviews on 2/11/2025 at 1:01 pm with LPN LLLL, 2/11/2025 at 1:04 pm with LPN MMMM, 2/11/2025 at 5:58 pm with LPN RR, 2/11/2025 at 6:57 pm with LPN SSSSS, 2/11/2025 at 6:42 am with CNA CCCC. 14. By evidence of interviewed and record review staff is currently receiving training. An interview with the Administrator on 2/11/2025at 1:05 pm revealed 91% of staff have been educated on abuse. 15. Evidenced by: Record review of facility documents titled, Associate Orientation Checklist and The facility Orientation revealed reviews and revisions to the documents made on 2/7/2025 including the addition of comprehensive assessments and abuse reporting. The Administrator confirmed on 2/11/2025 at 1:59 pm that the orientation checklist and agenda are the same for both agency staff and facility staff. All corrective actions were completed by 2/9/2025. All immediacy of the l was removed on 2/10/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, and review of the facility policy titled Specialized Services the facility failed to ensure one resident (R) R64 received necessary behavioral health services to address repeated verbal abuse and hypersexuality behaviors towards other residents in the facility. The sample size was 57. On 2/5/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 2/5/2025 at 5:54 pm. The noncompliance related to Immediate Jeopardy (IJ) was identified to have existed on 10/28/2024. A Credible Allegation of Compliance was received on 2/10/2025. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 2/10/2025. The facility remains out of compliance while the facility continues management level oversight as well as continues to develop and implement a Plan of Correction. (POC).This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding preventing, reporting, and investigating abuse. Findings Include: Review of the facility policy titled Specialized Services revised December 2021, documented routine and emergency specialized services are available to meet the resident's health services (dental, vision, podiatry, psychological, etc.) in accordance with the resident's assessment and plan of care. Policy Interpretation and Implementation: Number 2. Selected specialists must be available to provide follow-up care. Failure of a specialist to provide follow-up services will result in the facility's right to use its consultant specialist to provide the residents specialized needs. Number 4. Social Services representatives will assist residents with appointments, transportation arrangements, and reimbursement of specialized services under the state plan, if eligible. Review of the EMR revealed R64 was admitted to the facility on [DATE] with diagnoses including stroke, hemiplegia affecting left side. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Section C documented a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Section E documented no history of exhibiting physical, verbal, or other behaviors towards others. Review of the Behavior Progress Notes for R64 revealed on 3/16/2023, R64 was yelling and berating two female residents. The DON was notified; 3/16/2023, R64 was noted to be in room [ROOM NUMBER], yelling and cursing at the resident in bed A. He was noted in room [ROOM NUMBER] and grabbed residents arm while she was sleeping; 4/12/2023 the Social Services Director (SSD) documented worker spoke to resident about his going into female rooms uninvited and those who are unable to speak for themselves. Resident stated that he was trying to be helpful, or they have invited him in. Worker informs him that going into these ladies' rooms are against their rights. Interview on 2/3/2025 at 5:30 pm, R64 stated he remembered the incident on Christmas day with R30. He stated that he was in R30's room and he gave her a quick kiss on the lips. He stated he does not have a relationship with R30 and has not had any interactions with any other residents in the facility. R64 stated that the only person that has talked with him about the incident was the DON. He revealed that the DON told him that he could not kiss residents who could not give consent, or only kiss them on the hand. Interview on 2/11/2025 at 1:05 pm with the Administrator and the DON revealed they dropped the ball. They further revealed an attempt to send R64 out for psychiatric services and R64 refused. There was no evidence that Psychiatric Services were sought out by the facility for R64 until after the survey had began. The facility implemented the following actions to remove the IJ: 1. On 2/7/2025, the facility failed to complete a comprehensive assessment in order to provide the necessary behavioral health care and services to R64 based upon incidents identified. 2. Resident #64 is currently residing at Riverview Health and Rehabilitation Center. On 2/5/2025 resident placed on 1:1 supervision on upon report from State surveyor of other alleged incidents. On 2/5/2025 the resident's primary care physician, representative and the facility Medical Director have been notified of the reported incidents. On 2/5/2025 the facility has reassessed this resident for potential clinical needs per primary care physician. CBC, CMP, UA with C&S, PSA, TSH, RPR, ___ viral load, and head CT without contrast have been ordered. On 2/5/2025 the resident's care plan has been reviewed and revised. On 2/5/2025 the facility contacted psych services requesting an onsite evaluation, however services have been refused by resident. On 2/5/2025 the facility administration and social services have reviewed the need for potential alternative placement for R64. This has been reviewed with R64 and the Ombudsman. The facility will continue to seek out options for R64 placement. As of 2/7/2025 Resident R64 has been accepted and agreed to go to another SNF. discharge date pending per other SNF. On 2/5/2025 L TC Ombudsman has been notified. On 2/7/2025 LTC Ombudsman updated. On 2/5/2025 law enforcement was notified of R64's reported abuse incidents and behaviors. As of 2/9/2025 resident R64 has discharged from facility. 3. As of 2/7/2025 the facility met with all residents that were deemed vulnerable for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified. 4. On 2/7/2025 the facility notified the Medical Director who has been involved in the removal of the Immediate Jeopardy. 5. On 2/7/2025 the administrator contacted an external consultant(s) to assist with policy review, education development and leadership training on comprehensive assessment related to behavioral health care and services to attain or maintain the highest practical well-being for residents. 6. On 2/5/2025 the facility administrator reviewed and made any necessary changes to the abuse prevention and abuse reporting and comprehensive assessment related to behavioral health care and services policies and procedures on 2/7/2025. 7. As of 2/8/2025, 132 of 150 (88%) of facility team members (36 CNAs, 25 LPNs, 7 RNs, 15 administrative staff, 3 activities staff, 13 dietary staff, 19 EVS staff, 4 maintenance staff, 3 social workers, 5 unit helpers/clerks, 1 DON and 1 LNHA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining 18 (5 CNAs, 1 LPN, 2 PRN RNs, 6 dietary staff, 3 EVS staff, and 1 unit helper/clerk) team members will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday. 8. As of 2/8/2025, 5 of 5 (100%) agency staff (4 LPNs and 1 CNA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. 9. As of 2/8/2025, 16 of 22 (78%) contracted therapy staff have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining 6 PRN contracted therapy staff will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday. 10. On 2/6/2025 a review and update of the facility orientation program and agency orientation program has been completed with respect to abuse prevention and abuse reporting requirements. 11. On 2/7/2025 a review and update of the facility orientation program and agency orientation program for licensed nursing and therapy staff has been completed with respect to comprehensive assessment processes related to residents behaviors and corresponding interventions for behavioral health care and services requirements. 12. On 2/7/2025 The facility administration reviewed all audits related to residents' vulnerable for potential abuse for identification of safety concerns. No safety concerns were identified. 13. As of 2/8/2025, the facility has reviewed records of residents who display behaviors and corresponding documentation and assessment completion per policy. All corrective actions were completed by 2/9/2025. All immediacy of the IJ was removed on 2/10/2025. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1.Evidence of observations. interviews, and record reviews the facility completed a comprehensive assessment on R64 to address his behavioral health. 2. R64 is no longer a current resident at the facility, he was discharged on 2/9/2025. A review of the records revealed the facility started paper charting 1: 1 hourly monitoring for R64 for the following: 2/5/2025 at 7:05 pm - 5:32 am, (Interview with Administrator on 2/11/2025 at 3:00 pm revealed the video recording of where R64 was on 1 :1 monitoring with staff.) 2/6/2025 at 7:00 am- 7: 00 pm, 2/6/2025 at 7:00 pm- 2/7/2025 at 7:00 am, 2/7/2025 at 7:00 am- 7: 20 pm, 2/7/2025 at 7:25 pm 2/8/2025 at 7:00 am, 2/8/2025 at 7:00 am- 3: 00 pm, 2/8/2025 at 3: 15 pm, 2/9/2025 at 7: 00 am - 3:00 pm. Phone Interview on 2/11/2025 at 2:30 pm with the physician of R30. R60. R64, and Rl25 and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and ordered the following labs for R64. Record review revealed an email was sent on 2/5/2025 to R64's primary care physician to order lab and CT without contrast was ordered and completed on 2/6/2025. Record review on 2/11/2025 revealed the care plan for R64 has been updated. Record review on 2/11/2025 revealed the Social Worker offered mental health services, and he declined the services. Record review on 2/11/2025 revealed documentation that on 2/7/2025 R64 was verbally notified of bed offer at another skilled nursing facility. Resident agreed to transfer on Monday 2/10/25. As of 2/9/2025 resident R64 has discharged from facility to a Personal care home. Interview on 2/11/2025 with the Administrator and the DON revealed they were able to contact the Ombudsman. Record review on 2/11/2025 revealed there is a police report with the following reference number CC250205029. R64 has been discharged from the facility. 3. Record review of assessments conducted by the facility. The vulnerable population is defined by the facility as all women in the facility. Female residents with BIMS greater than or equal to 13 had a written/verbal assessment conducted on 2/5/2025 through 2/7/2025 and signed and dated by social services. Female residents with BIMS less than 13 had a skin assessment conducted on 2/5/2025 through 2/7/2025 and signed and dated by nursing staff. Reviewed all assessments with no safety concerns. 4. Phone Interview on 2/11/2025 at 2:30 pm with the physician and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and have participated in clinical meetings daily in the mornings with the clinical team of the facility. 5. Evidence revealed the Administrator collaborated with a representative from external consultant. She began her assistance with the NHA as well as the DON on 02/05/2025 and is currently making revisions and recommendations. 6. During an interview on 2/11/2025 at 2:50 pm with Administrator revealed the policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, was updated on 2/6/2025. Evidence show the Administrator Spoke with a representative from external consultant. She stated she discussed the immediate actions needed to remove the IJ citations and began the initial review and revision of the abuse prevention policy and procedures with NHA and DON. Recommendations were also provided. 7. A review of facility in-service record dated 2/8/2025 revealed 36 CNAs, 25 LPNs, 7 RNs, 15 administrative staff, three activities staff, 13 dietary staff, 19 EVS staff, four maintenance staff, three social workers, five-unit helpers/clerks, one DON and one LNHA have been educated on abuse prevention, abuse reporting and comprehensive assessments. Also verified the above education by the following staff interview on 2/11/2025 at 6:15 am with Certified Nursing Assistant (CNA) XX, 2/11/2025 at 6:17 am with Licensed Practical Nurse (LPN) JJ, 2/11/2025 at 6:21 am with LPN YY, 2/11/2025 at 6:26 am with CNA ZZ, 2/11/2025 at 6:31 am with CNA NN, 2/11/2025 at 6:36 am with CNA AAA, 2/11/2025 at 6:46 am with LPN GG, 2/11/2025 at 6:48 am with LPN BBB, 2 /11/2025 at 6:51 am with CNA CCC, 2/11/2025 at 6:54 am with CNA DDD, 2/11/2025 at 7:58 am with Maintenance Director, 2/11/2025 at 8:30 am with Maintenance Assistant, 2/11/2025 at 8:15 am with Housekeeping GGG, 2/11/2025 at 8:46 am with Environmental Services Manager, 2/11/2025 at 8:23 am with Social Services Director, 2/11/2025 at 9:16 am with Social Worker HHH, 2/11/2025 at 8:50 am with Activities Assistant III, 2/11/2025 at 8:35 am with admission Coordinator JJJ, 2/11/2025 at 8:48 am with Medical Records KKK, 2/11/2025 at 10:30 am with Director of Business Development, 2/11/2025 at 6:01 am with CNA MMM, 2/11/2025 at 6:20 am with CNA NNN, 2/11/2025 at 6:31 am with RN Supervisor OOO, 2/11/2025 at 6:31 am with LPN PPP, 2/11/2025 at 6:46 am with Unit Manager (UM) EE, 2/11/2025 at 7:40 am with Assistant Food Service Manager, 2/11/2025 at 7:45 am with Dietary Manager, 2/11/2025 at 8:00 am with Occupational Therapist (OT) WWW, 2/11/2025 at 8:08 am OT XXX, 2/11/2025 at 8:00 am Physical Therapist Assistant (PTA), 2/11/2025 at 6:18 am with Unit Secretary (US) ZZZ, 2/11/2025 at 6:23 am with Staffing Coordinator MM, 2/11/2025 at 6:28 am with LPN AAAA, 2/11/2025 at 6:32 am with LPN QQ, 2/11/2025 at 6:42 am with Floor Tech (FT) BBBB, 2/11/2025 at 6:42 am with CNA CCCC, 2/11/2025 at 6:47 am with CNA CCC, 2/11/2025 at 6:50 am with Housekeeping DDDD, 2/11/2025 at 6:56 am with FT EEEE, 2/11/2025 at 7:52 am with DA FFFF, 2/11/2025 at 8:07 am with Receptionist GGGG, 2/11/2025 at 8:21 am with Admissions Coordinator HHHH, 2/11/2025 at 8:17 am with Housekeeping IIII, 2/11/2025 at 8:20 am with Financial Assistant JJJJ, 2/11/2025 at 8:28 am with Activities Director, 2/11/2025 at 12:53 pm with UM SS, 2/11/2025 at 12:56 pm with Director of Finances, 2/11/2025 at 12:57 pm with US KKKK, 2/11/2025 at 1:07 pm with CNA NNNN, 2/11/2025 at 1:09 pm with Wound Care CNA OOOO, 2/11/2025 at 1:12 pm with CNA PPPP, 2/11/2025 at 1:15 pm with US QQQQ, 2/11/2025 at 1:18 pm with Activities Assistant FF, 2/11/2025 at 1:20 pm with LPN LL, 2/11/2025 at 1:22 pm with Director of Rehabilitation, 2/11/2025 at 1:32 pm with OT RRRR, 2/11/2025 at 1:35 pm with PT SSSS, 2/11/2025 at 1:37 pm with PTA TTTT, 2/11/2025 at 1:40 pm with Speech Therapist (ST) UUUU, 2/11/2025 at with 1:46 pm with Rehab Technician VVVV, 2/11/2025 at 1:56 pm with LPTA WWWW, 2/11/2025 at 1:59 pm with Laundry XXXX, 2/11/2025 at 2:09 pm with ST YYYY, 2/11/2025 at 2:49 pm with EVS Assistant Supervisor, 2/11/2025 at 2:56 pm with CNA DD, 2/11/2025 at 3:00 pm with Housekeeper DDDDD, 2/11/2025 at 3:02 pm with CNA EEEEE, 2/11/2025 at 3:04 pm with Central Supply Clerk FFFFF, 2/11/2025 at 3:07 pm with Registered Dietician, 2/11/2025 at 3:28 pm with LPN TT, 2/11/2025 at 3:30 pm with CNA GGGGG, 2/11/2025 at 3:32 pm with CNA HHHHH, 2/11/2025 at 3:34 pm with DA IIIII, 2/11/2025 at 3:36 pm with [NAME] JJJJJ, 2/11/2025 at 3:43 pm with CNA VV, 2/11/2025 at 3:45 pm with LPN KK, 2/11/2025 at 3:50 pm with DA KKKKK, 2/11/2025 at 3:51 pm with MDS Coordinator LLLLL, 2/11/2025 at 4:02 pm with MDS Coordinator MMMMM, 2/11/2025 at 4:05 pm with DA NNNNN, 2/11/2025 at 4:06 pm with Financial Coordinator OOOOO, 2/11/2025 at 4:08 pm with Payroll Clerk PPPPP, 2/11/2025 at 4:10 pm with Human Resources Director, 2/11/2025 at 4:12 pm with [NAME] RRRRR, 2/11/2025 at 6:54 pm with LPN TTTTT, 2/11/2025 at 5:41 pm with Infection Preventionist, 2/11/2025 at 5:46 pm with Receptionist YYYYY, 2/11/2025 at 5:58 pm with LPN QQQQQ, 2/11/2025 at 5:59 pm with DA A1, 2/11/2025 at 6:11 pm with LPN D1, 2/11/2025 at 6:19 pm with CNA E1, 2/12/2025 at 12:03 pm with Nurse Educator, 2/12/2025 at 12:19 pm with DON, 2/12/2025 at 12:49 pm with Administrator. A review of the facility in-service record dated 2/9/2025 revealed 18 (five CNAs, one LPN, two PRN RNs, six dietary staff, three EVS staff, and one unit helper/clerk) team members were educated on abuse prevention, abuse reporting, and comprehensive assessments. Also verified the above education by the following staff interviews 2/11/2025 at 2:44 pm with Housekeeper ZZZZ, 2/11/2025 at 2:46 pm with Housekeeper AAAAA,2/11/2025 at 2:52 pm with Housekeeper BBBBB, 2/11/2025 at 7:10 with am Dietary Aide (DA) QQQ, 2/11/2025 at 7:15 am with [NAME] RRR, 2/11/2025 at 7:20 am with DA SSS, 2/11/2025 at 7:25 am with DA TTT, 2/11/2025 at 7:30 am with DA UUU, 2/11/2025 at 7:35 am with DA VVV, 2/11/2025 at 6:54 pm with LPN TTTTT, 2/11/2025 at 7:05 pm with RN UUUUU, 2/11/2025 at 7:11 pm with CNA VVVVV, 2/11/2025 at 7:20 pm with CNA WWWWW, 2/11/2025 at 5:37 pm with CNA XXXXX, 2/11/2025, 2/11/2025 at 6:03 pm with CNA B1, 2/11/2025 at 6:08 pm with CNA C, 2/11/2025 at 1:18 pm with Activities Assistant FF, 2/11/2025 at 6:02 am with Wound Care Registered Nurse (RN) LLL. An interview with the Administrator on 2/11/2025 at 1:05 pm revealed that 91% of staff have been educated on abuse. 8. Review of facility in-service record dated 2/8/2025, five of five (100% (Percent)) agency staff (four LPNs and one CNA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. Also verified the above education by the following staff interviews on 2/11/2025 at 1:01 pm with LPN LLLL, 2/11/2025 at 1:04 pm with LPN MMMM, 2/11/2025 at 5:58 pm with LPN RR, 2/11/2025 at 6:57 pm with LPN SSSSS, 2/11/2025 at 6:42 am with CNA CCCC. 9. By evidence of interviewed and record review staff is currently receiving training. An interview with the Administrator on 2/1 I /2025 at 1 :05 pm revealed 91 % of staff have been educated on abuse. 10. Record review of facility documents titled, Associate Orientation Checklist and Riverview Health and Rehabilitation Orientation revealed reviews and revisions to the documents made on 2/7/2025 including the addition of comprehensive assessments and abuse reporting. The Administrator confirmed on 2/11/2025 at 1:59 pm that the orientation checklist and agenda are the same for both agency staff and facility staff. 11. Record review of facility documents titled. Associate Orientation Checklist and Riverview Health and Rehabilitation Orientation·· revealed reviews and revisions to the documents made on 2/7/2025 including the addition of comprehensive assessments and abuse reporting. The Administrator confirmed on 2/11/2025 at 1:59 pm that the orientation checklist and agenda are the same for both agency staff and facility staff. 12. An interview with the Administrator on 2/11/2025 at 2:01 pm revealed that these audits include a review of the 24-hour reports. behavioral reports, and the skin and verbal/written assessments for the defined vulnerable population. Review of these records revealed that it has been signed and dated by the Administrator on 2/7/2025. 13. An interview with the Administrator on 2/11/2025 at 2:01 pm revealed that these audits include a review of the 24-hour reports. behavioral reports, and the skin and verbal/written assessments for the defined vulnerable population. Review of these records revealed that it has been signed and dated by the Administrator on 2/7/2025. All corrective actions were completed by 2/9/2025. All immediacy of the IJ was removed on 2/10/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interviews, and review of the facility policy titled Abuse Policy, the facility failed to protect residents from verbal, sexual and physical abuse. Specifically, the facility failed to protect three residents (R) (R30, R60, and R125) of four sampled residents safe from sexual abuse from R64. In addition, the facility to protect R30 from physical and verbal abuse from Certified Nursing Assistant (CNA) AA. The failure of the facility to keep residents safe had the potential to diminish their quality of life and likelihood of resident abuse to continue. On 2/5/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 2/5/2025 at 5:54 pm. The noncompliance related to Immediate Jeopardy (IJ) was identified to have existed on 10/28/2024. A Credible Allegation of Compliance was received on 2/10/2025. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 2/10/2025. The facility remains out of compliance while the facility continues management level oversight as well as continues to develop and implement a Plan of Correction. (POC).This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding preventing, reporting, and investigating abuse. Findings include: A review of the facility policy titled Abuse Policy dated December 2023 documented the policy of [name of facility] that each resident will be free from Abuse. Abuse can include all types of abuse, neglect, exploitation or residents, misappropriation of resident property, corporal punishment, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms and not imposed for purposes of discipline or convenience. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm or any type will be tolerated, and residents and staff will be monitored for protection. The facility will have systems in place to educate employees, residents, resident representatives, contractors, agents, volunteers and other applicable individuals in techniques to protect all parties. Procedure: Letter F. Protection: Immediately upon receiving a report of alleged abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms, the Administrator, and or designee will immediately protect the resident, and coordinate delivery of appropriate medical and/or psychological care and attention. Ensuring safety and well-being for the vulnerable individuals are of utmost priority. Safety, security and support of the resident, their roommate, if applicable and other residents with the potential to be affected will be provided. This should include as appropriate: a. Procedures must be in place to provide the resident with a safe, protected environment during the investigation: i. Staff witnessing abuse or when reported will immediately intervene to stop the abuse and protect the resident. ii. The alleged perpetrator will immediately be removed and resident protected. Employees accused of alleged abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion be immediately removed from the facility and will remain removed pending the results of a thorough investigation. iv. If the alleged perpetrator is a facility resident, the staff member will immediately remove the perpetrator from the situation and another staff member will stay with the alleged perpetrator and wait for further instruction from administration, if possible. If the situation is an emergent danger to the other residents or staff, dial 911 for immediate assistance. vii. If the resident could be at risk in the same environment, evaluate the situation and consider options including a room change or roommate change. x. The facility staff will protect the resident from retaliation. 1. Review of the electronic medical record (EMR) revealed R30 was re-admitted to the facility on [DATE] with diagnoses including cerebral palsy, epilepsy, anxiety, depression (Other Than Bipolar), muscle spasm, and pain. Review if the Quarterly Minimum Data Set (MDS) assessment dated [DATE] Section C documented a Brief Interview for Mental Status (BIMS) score of 99 indicating the assessment was incomplete. Review of an undated statement written by CNA DD documented I didn't observe R64 around R30. I heard about the situation. I have never to attempt {sic} to touch R30 or any other residents. I overheard R64 saying he can't {sic} kissing who can't say yes or no. Interview on 2/2/2025 at 4:27 pm, Licensed Practical Nurse (LPN) CC stated that on 12/25/2024, R64 put his tongue down R30's throat. She stated that the incident was reported to the DON and LPN Unit Manager (UM) EE. During further interview, LPN CC revealed that R64 self-reported to her that the administration staff coached him what to say if anyone asked him about the incident of him putting his tongue down R30's throat, to say that he was giving her a holiday kiss. She stated that LPN BB, who witnessed the incident was an agency nurse, and her contract was cancelled, and the notes she documented were deleted from the EMR. Phone interview on 2/4/2025 at 10:39 am, agency nurse LPN BB stated that on 12/25/2024 she saw R64 kissing R30 deeply in the mouth. She stated staff had reported R64 several times when observed in R30's room doing other sexual acts. During further interview, LPN BB revealed that LPN UM EE stated that the DON was reviewing the video footage. She stated that LPN UM EE informed her that the DON knows about it and she will handle it. She stated that staff members informed her of other incidents involving R64 abusing other residents. Interview on 2/4/2025 at 12:00 pm, LPN UM EE stated she received a phone call on Christmas day that LPN BB saw R64 and R30 in the Evergreen common area, engaged in what looked like a kiss. During further interview, she stated that she reported the incident to the DON via text message, inquiring whether the incident was a state reportable. She stated the DON revealed she would look into it. Furthermore, LPN UM EE stated she never heard back from the DON regarding the incident between R64 and R30. 2. Review of the EMR revealed R60 was admitted to the facility on [DATE] with diagnoses including traumatic brain dysfunction, dementia, anxiety disorder and depression. Review of the Quarterly MDS assessment dated [DATE] revealed Section C documented a BIMS score of 99, indicating the assessment as unable to recall. Review of a handwritten statement written by LPN BB, documented, On 10/28/2024, I was performing patient care with CNA AA on R60's roommate, while R60 was moaning and yelling in her bed. CNA AA said, I'm sick of you and threw the __ lift pad at R60's face. I said, CNA AA! She stated, LPN BB, you didn't see that, I'm sorry. She asked me, are you going to tell on me? I said no. We continued care on R60's roommate, and R60 continued yelling. I notified unit manager upon leaving the room. The statement was signed by LPN BB. Review of the statement written by CNA AA dated 10/28/2024, documented, I put the __ pad on the side of R60 because she was reaching for it I never made the statemat {sic} that I was tired of hearing her moth {sic}. I placed it on the side of her. She always reaches for mechanical lift pad. Interview on 2/4/2025 at 11:40 am, with CNA AA stated that she typically works by herself, unless other staff need her assistance. She stated that she had not witnessed any type of physical abuse nor had she been a part of any type of physical abuse investigations. During further interview, CNA AA stated she had not verbally or physically abused any residents, and stated that she did not drop a mechanical lift pad on a resident. CNA AA confirmed that she had not received any recent Abuse training from the facility staff. Phone interview on 2/5/2025 at 8:54 am, LPN BB stated that on 10/28/2024 she was assisting CNA AA with resident care for R60's roommate in B bed. She stated that CNA AA was standing between A bed and B bed, while she was near the window. R60 was in her bed, with the curtain open and was heard moaning aloud. She stated there was a mechanical lift pad in the B bed's bedside chair. While completing resident care for the resident in B bed, CNA AA turned around to R60 stating, I'm sick of you and grabbed the mechanical lift pad from the chair and threw it aggressively at R60. The pad landed on R60, hitting her upper body and face. LPN BB reported that R60 appeared shocked for a brief moment then continued making noises. During further interview, LPN BB stated she called out CNA AA's name in which CNA AA responded saying, Im sorry, you didn't see that, are you going to tell on me? LPN BB replied, No. LPN BB stated she reported the incident to LPN UM EE and the DON. She stated that the DON told her to write up a statement on what happened. LPN BB stated the DON did not ask her any other questions regarding that incident. She stated LPN UM EE told her that was not CNA AA's first, second, or even fifth time having something like that happen. Interview on 2/5/2025 at 12:00 pm, LPN UM EE stated that LPN BB reported abuse by CNA AA when CNA AA took a mechanical lift pad and threw it on R60. She stated the DON immediately suspended CNA AA following the incident, but stated there were no in-services completed related to Abuse. During further interview, LPN UM EE stated that CNA AA had returned to work, and working on that hall since the incident. 3. Review of the EMR revealed R64 was admitted to the facility on [DATE] with diagnoses including stroke, hemiplegia affecting left side. Review of the annual MDS assessment dated [DATE] revealed Section C documented a BIMS score of 15, indicating no cognitive impairment. Section E documented no history of exhibiting physical, verbal, or other behaviors towards others. Interview on 2/3/2025 at 5:30 pm, R64 stated he remembered the incident on Christmas day with R30. He stated that he was in R30's room and he gave her a quick kiss on the lips. He stated he does not have a relationship with R30 and has not had any interactions with any other residents in the facility. R64 stated that the only person that has talked with him about the incident was the DON. He revealed that the DON told him that he could not kiss residents who could not give consent, or only kiss them on the hand. Interview on 2/4/2025 at 1:00 pm, LPN GG stated there had not been any type of in-service or training since the 12/25/2024 incident between R64 and R30. She also stated that she heard of an incident involving R64 and R125, where he went in her room, kissed her and touched her breast. She stated R125 was unable to consent to the actions of R64. During further interview, she revealed there had not been any in-services or follow up from leadership related to abuse. Interview on 2/4/2025 at 2:51 pm, the DON verified that LPN UM EE reported to her that LPN BB witnessed R64 kissing R30 on 12/25/2024. She stated that she reported the incident, but was uncertain if she reported it to the appropriate reporting entity, as she did not get a confirmation about submitting the 5-day follow up report. When questioned why she did not follow up to confirm the reported incident, she stated that she got busy and never could figure out how to do the 5-day follow up. She confirmed that R64 reported to her he did kiss R30. During further interview, she stated there was a very limited investigation into the incident because R64 admitted that he did it. Interview on 2/4/2025 at 3:45 pm, the Administrator stated that he was aware of the incident on 12/25/2024 when it was reported to the DON. He stated that law enforcement was not contacted regarding the incident. Interview on 2/5/2025 at 4:11 pm, the SSD stated she was informed about R64 going into other resident's room uninvited, and instructed him that he could not do that. She stated the DON is aware of the many situations with R64, dating back to 2023. The facility implemented the following actions to remove the IJ: 1. On 2/5/2025, the facility failed to maintain an environment free from abuse by R64 affecting R60, R125, and R30 and one physical abuse incident affecting R30. 2. Resident #64 is currently residing at the facility. On 2/5/2025 resident placed on 1:1 supervision on upon report from State surveyor of other alleged incidents. On 2/5/2025 the resident's primary care physician, representative and the facility Medical Director have been notified of the reported incidents. On 2/5/2025 the facility has reassessed this resident for potential clinical needs per primary care physician. CBC, CMP, UA with C&S, PSA, TSH, RPR, and __ viral load have been ordered. On 2/5/2025 the resident's care plan has been reviewed and revised. On 2/5/2025 the facility contacted psych services requesting an onsite evaluation, however services have been refused by residents. On 2/5/2025 Social Services reviewed status with IDT for appropriate placement. On 2/5/2025 LTC Ombudsman has been notified. On 2/5/2025 law enforcement was notified of the reported abuse incidents affecting R60, R125, and R30. As of 2/9/2025 resident R64 has discharged from facility. On 2/5/2025 law enforcement was notified of the reported abuse incidents affecting R60, R125, and R30. 3. Resident #R125 is currently residing at the facility. The resident is responsible for self, has a BIMS of 15, and is capable of verbally expressing herself and reporting to staff. On 2/6/2025 resident #R125 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. On 2/6/2025 the care plan has been reviewed and updated. On 2/5/2025 a psych follow- up visit was provided. On 2/5/2025 law enforcement was notified of the reported abuse incident. 4. Resident #60 is currently residing at the facility. Resident's BIM is unable to be determined, but resident can make known nonverbal indicators of discomfort or distress through noises. On 2/6/2025 resident #R60 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incident identified. On 2/6/2025 the care plan has been reviewed and updated. On 2/5/2025 the resident's representative and primary care physician were notified by facility of the reported incidents. On 2/5/2025 the facility has referred R60 for psych services for assessment and support. On 2/5/2025 law enforcement was notified of the reported abuse incident. 5. Resident #30 is currently residing at the facility. Resident's BIM is unable to be determined, but resident can make known nonverbal indicators of discomfort or distress through noises. On 2/6/2025 resident #R30 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. On 2/6/2025 the care plan has been reviewed and updated. On 2/5/2025 the resident's representative and primary care physician were notified by facility of the reported incidents. On 2/5/2025 the facility has referred R30 for psych services for assessment and support. On 2/5/2025 law enforcement was notified of the reported abuse incident. 6. As of 2/6/2025 the facility met and assessed with R60, R125 and R30's roommates for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified. 7. As of 2/7/2025 the facility met with all residents that were deemed vulnerable for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified. 8. On 2/5/2025 upon the report from the State surveyor, CNA AA has been suspended pending further investigation. 9. On 2/5/2025 the facility notified the Medical Director who has been involved in the removal of the Immediate Jeopardy. 10. On 2/5/2025 the administrator contacted an external consultant(s) to assist with policy review, education development and leadership training on abuse prevention and reporting. 11. On 2/5/2025 the facility administrator reviewed and made any necessary changes to the abuse prevention and abuse reporting policies and procedures. 12. As of 2/8/2025, 132 of 150 (88% (percent)) of facility team members (36 CNAs, 25 LPNs, 7 RNs, 15 administrative staff, 3 activities staff, 13 dietary staff, 19 EVS staff, 4 maintenance staff, 3 social workers, 5 unit helpers/clerks, 1 DON and 1 LNHA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining 18 (5 CNAs, 1 LPN, 2 PRN RNs, 6 dietary staff, 3 EVS staff, and 1 unit helper/clerk) team members will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday. 13. As of 2/8/2025, 5 of 5 (100%) agency staff (4 LPNs and 1 CNA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. 14. As of 2/8/2025, 16 of 22 (78%) contracted therapy staff have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining 6 PRN contracted therapy staff will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday. 15. On 2/6/2025 a review and update of the facility orientation program and agency orientation program has been completed with respect to abuse prevention and abuse reporting requirements. 16. On 2/7/2025 The facility administration reviewed all audits related to residents vulnerable for potential abuse for identification of safety concerns. All corrective actions were completed by 2/9/2025. All immediacy of the IJ was removed on 2/10/2025. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Observation and interviews on 2/11/2025-2/12/2025 revealed the facility environment to free from abuse. 2. R64 is no longer a current resident at the facility; he was discharged [DATE] to a personal care home. A review of the records revealed the facility started paper charting 1:1 hourly monitoring for R64 for the following: 2/5/2025 at 7:05 pm - 5:32 am (Interview with Administrator on 2/11/2025 at 3:00 pm revealed the video recording of where R64 was on 1:1 monitoring with staff.), 2/6/2025 at 7:00 am- 7:00 pm, 2/6/2025 at 7:00 pm- 2/7/2025 at 7:00 am, 2/7/2025 at 7:00 am- 7:20 pm, 2/7/2025 at 7:25 pm - 2/8/2025 at 7:00 am, 2/8/2025 at 7:00 am- 3:00 pm, 2/8/2025 at 3:15 pm- 2/9/2025 at 7:00 am - 3:00 pm. Phone Interview on 2/11/2025 at 2:30 pm with the physician of R30, R60, R64, and R125 and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and ordered the following labs for R64. Phone Interview on 2/11/2025 at 2:30 pm with the physician of R30, R60, R64, and R125 and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and ordered the following labs for R64: CBC, CMP, UA with C&S, PSA, TSH, RPR, and HIV viral load. Record review on 2/11/2025 revealed that the care plan for R64 has been updated Record reviews on 2/11/2025 revealed the Social Worker offered mental health services, and he declined the services. Record review on 2/11/2025 revealed documentation that 2/7/2025 R64 was verbally notified of a bed offer at another skilled nursing facility. Residents agreed to transfer on Monday, 2/10/25. Interview on 2/11/2025 with the Administrator and the DON revealed they were able to contact the Ombudsman. Record review on 2/11/2025 revealed there is a police report with the following reference number CC250205029. Record review revealed that R64 had been discharged to a personal care home on 2/9/2025. 3. Interview on 2/11/2025 with R125 revealed she was safe and with no concerns. Record review R125 has been reassessed for safety and potential physical/psychosocial outcomes based on the incidents identified by 2/6/2025. Record reviews on 2/11/2025 revealed that the care plan for R125 has been updated. Evidenced by Progress Note dated 2/6/2025: Resident reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. Vital signs at baseline. No s/s of pain or distress, no facial grimacing or nonverbal moaning currently. The bed is at the safest level, with a floor mat at the bedside. Assessment outcomes were reviewed with the primary care physician. Confirmed care plan revisions have been made on 2/6/2025. A progress note dated 2/5/2025 revealed resident's family was contacted by Social Services: The resident's family was contacted about an investigation of alleged abuse. Confirmed mental health services were offered, and the resident's family gave verbal consent for the mental health services. Evidence also revealed that law enforcement was notified on 2/5/2025 of the abuse in the facility. 4. Observation on 2/11/2025 at 2:00 pm revealed R60 making moaning sounds to alert staff for assistance. Record review on 2/11/2025 revealed a progress note in the system for R60 dated 2/6/2025 as a Health Status Note Documenting Resident reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. Record reviews on 2/11/2025 revealed that the care plan for R60 has been updated. Phone Interview on 2/11/2025 at 2:30 pm with the physician of R30, R60, R64, and R125 and the Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents. Record review on 2/11/2025 revealed a progress note in the system for R60 dated 2/6/2025 as a Health Status Note documenting R60 reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. Vital signs at baseline. No signs and symptoms (s/s) of pain or distress, no facial grimacing or nonverbal moaning at this time. The bed is at the safest level, with a floor mat at the bedside. Assessment outcomes were reviewed with the primary care physician. Record review on 2/11/2025 revealed a police report was completed on 2/5/2025 with the following reference number CC250205029. 5. Interview on 02/12/2025 at 4:07 pm with the SSD revealed they communicate with the resident by doing observations. She mentioned that sometimes she makes sounds. She mentioned that most of the staff have been with her for a while and know her mannerisms. Confirmed care plan revisions were made on 2/6/2025, Evidenced by a progress note dated 2/5/2025, which revealed the R30's family was contacted by Social Services: The resident's family was contacted about an investigation of the alleged abuse. Confirmed mental health services were offered, and the resident's family gave verbal consent for the mental health services. Confirmed care plan revisions have been made for R30 on 2/6/2025. Phone Interview on 2/11/2025 at 2:30 pm with the physician and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and has participated in clinical meetings daily in the mornings with the facility's clinical team. Review of the progress note dated 2/6/2025 revealed that R30 was reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. Vital signs at baseline. No signs and symptoms (s/s) of pain or distress, no facial grimacing or nonverbal moaning currently. The bed is at the safest level, with a floor mat at the bedside. Assessment outcomes were reviewed with the primary care physician. Confirmed care plan revisions have been made on 2/6/2025. A progress note dated 2/5/2025 revealed that R30's family was contacted by Social Services: The resident's family was contacted about an investigation of alleged abuse. Confirmed mental health services were offered, and the resident's family gave verbal consent for the mental health services. Evidenced by police report case number CC250205029 on 2/5/2025. 6. Record review on 2/11/2025 at 12:45 pm of a document titled Assessment of Vulnerable Population revealed the facility met with and assessed R125's roommate R252. All residents with low BIMs scores received a skin assessment, and residents with high BIMs scores received a written/verbal assessment. It was revealed that the roommate of R252 received a skin assessment due to her low BIMS score of 99. Record review on 2/11/2025 at 12:56 pm of a document titled Assessment of Vulnerable Population revealed the facility met with and assessed R60's roommate R36. All residents with low BIMs scores received a skin assessment, and residents with high BIMs scores received a written/verbal assessment. It was revealed that the roommate of R36 received a skin assessment due to her low BIMS score of 3. Record review on 2/11/2025 at 1:04 pm of a document titled Assessment of Vulnerable Population revealed the facility met with and assessed R30's roommate R19. All residents with low BIMs scores received a skin assessment, and residents with high BIMs scores received a written/verbal assessment. It was revealed that the roommate of R19 received a skin assessment due to her low BIMS score of 2. 7. Record review of assessments conducted by the facility. The vulnerable population is defined by the facility as all women in the facility. Female residents with BIMS greater than or equal to 13 had a written/verbal assessment conducted on 2/5/2025 through 2/7/2025 and signed and dated by social services. Female residents with BIMS less than 13 had a skin assessment conducted on 2/5/2025 through 2/7/2025 and signed and dated by nursing staff. Reviewed all assessments with no safety concerns. An interview with R14 at 12:09 pm in her room revealed that she feels safe in the facility. R14 has a BIMS of 14. An interview with R17 at 12:12 pm in her room revealed that she feels safe in the facility. R17 has a BIMS of 13. 8. An interview with the Administrator and DON on 2/11/2025 at 1:34 pm revealed that CNA AA has been suspended and potentially terminated pending investigation. Record review on 2/11/2025 revealed a time clock in the report, which revealed CNA AA was clocked out on 2/5/2025 with a start time of 7:06 am and work ending at 7:18 pm. 9. Phone Interview on 2/11/2025 at 2:30 pm with the physician and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and has participated in clinical meetings daily in the mornings with the facility's clinical team. 10. During an interview on 2/11/2025 at 2:50 pm with the Administrator, revealed that the policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property was updated on 2/6/2025. 11. Evidence shows the Administrator Spoke with a representative from an external consultant. She stated she discussed the immediate actions needed to remove the IJ citations and began the initial review and revision of the abuse prevention policy and procedures with NHA and DON. Recommendations were also provided. 12. A review of facility in-service record dated 2/8/2025 revealed 36 CNAs, 25 LPNs, 7 RNs, 15 administrative staff, three activities staff, 13 dietary staff, 19 EVS staff, four maintenance staff, three social workers, five-unit helpers/clerks, one DON and one LNHA have been educated on abuse prevention, abuse reporting and comprehensive assessments. Also verified the above education by the following staff interview on 2/11/2025 at 6:15 am with Certified Nursing Assistant (CNA) XX, 2/11/2025 at 6:17 am with Licensed Practical Nurse (LPN) JJ, 2/11/2025 at 6:21 am with LPN YY, 2/11/2025 at 6:26 am with CNA ZZ, 2/11/2025 at 6:31 am with CNA NN, 2/11/2025 at 6:36 am with CNA AAA, 2/11/2025 at 6:46 am with LPN GG, 2/11/2025 at 6:48 am with LPN BBB, 2 /11/2025 at 6:51 am with CNA CCC, 2/11/2025 at 6:54 am with CNA DDD, 2/11/2025 at 7:58 am with Maintenance Director, 2/11/2025 at 8:30 am with Maintenance Assistant, 2/11/2025 at 8:15 am with Housekeeping GGG, 2/11/2025 at 8:46 am with Environmental Services Manager, 2/11/2025 at 8:23 am with Social Services Director, 2/11/2025 at 9:16 am with Social Worker HHH, 2/11/2025 at 8:50 am with Activities Assistant III, 2/11/2025 at 8:35 am with admission Coordinator JJJ, 2/11/2025 at 8:48 am with Medical Records KKK, 2/11/2025 at 10:30 am with Director of Business Development, 2/11/2025 at 6:01 am with CNA MMM, 2/11/2025 at 6:20 am with CNA NNN, 2/11/2025 at 6:31 am with RN Supervisor OOO, 2/11/2025 at 6:31 am with LPN PPP, 2/11/2025 at 6:46 am with Unit Manager (UM) EE, 2/11/2025 at 7:40 am with Assistant Food Service Manager, 2/11/2025 at 7:45 am with Dietary Manager, 2/11/2025 at 8:00 am with Occupational Therapist (OT) WWW, 2/11/2025 at 8:08 am OT XXX, 2/11/2025 at 8:00 am Physical Therapist Assistant (PTA), 2/11/2025 at 6:18 am with Unit Secretary (US) ZZZ, 2/11/2025 at 6:23 am with Staffing Coordinator MM, 2/11/2025 at 6:28 am with LPN AAAA, 2/11/2025 at 6:32 am with LPN QQ, 2/11/2025 at 6:42 am with Floor Tech (FT) BBBB, 2/11/2025 at 6:42 am with CNA CCCC, 2/11/2025 at 6:47 am with CNA CCC, 2/11/2025 at 6:50 am with Housekeeping DDDD, 2/11/2025 at 6:56 am with FT EEEE, 2/11/2025 at 7:52 am with DA FFFF, 2/11/2025 at 8:07 am with Receptionist GGGG, 2/11/2025 at 8:21 am with Admissions Coordinator HHHH, 2/11/2025 at 8:17 am with Housekeeping IIII, 2/11/2025 at 8:20 am with Financial Assistant JJJJ, 2/11/2025 at 8:28 am with Activities Director, 2/11/2025 at 12:53 pm with UM SS, 2/11/2025 at 12:56 pm with Director of Finances, 2/11/2025 at 12:57 pm with US KKKK, 2/11/2025 at 1:07 pm with CNA NNNN, 2/11/2025 at 1:09 pm with Wound Care CNA OOOO, 2/11/2025 at 1:12 pm with CNA PPPP, 2/11/2025 at 1:15 pm with US QQQQ, 2/11/2025 at 1:18 pm with Activities Assistant FF, 2/11/2025 at 1:20 pm with LPN LL, 2/11/2025 at 1:22 pm with Director of Rehabilitation, 2/11/2025 at 1:32 pm with OT RRRR, 2/11/2025 at 1:35 pm with PT SSSS, 2/11/2025 at 1:37 pm with PTA TTTT, 2/11/2025 at 1:40 pm with Speech Therapist (ST) UUUU, 2/11/2025 at with 1:46 pm with Rehab Technician VVVV, 2/11/2025 at 1:56 pm with LPTA WWWW, 2/11/2025 at 1:59 pm with Laundry XXXX, 2/11/2025 at 2:09 pm with ST YYYY, 2/11/2025 at 2:49 pm with EVS Assistant Supervisor, 2/11/2025 at 2:56 pm with CNA DD, 2/11/2025 at 3:00 pm with Housekeeper DDDDD, 2/11/2025 at 3:02 pm with CNA EEEEE, 2/11/2025 at 3:04 pm with Central Supply Clerk FFFFF, 2/11/2025 at 3:07 pm with Registered Dietician, 2/11/2025 at 3:28 pm with LPN TT, 2/11/2025 at 3:30 pm with CNA GGGGG, 2/11/2025 at 3:32 pm with CNA HHHHH, 2/11/2025 at 3:34 pm with DA IIIII, 2/11/2025 at 3:36 pm with [NAME] JJJJJ, 2/11/2025 at 3:43 pm with CNA VV, 2/11/2025 at 3:45 pm with LPN KK, 2/11/2025 at 3:50 pm with DA KKKKK, 2/11/2025 at 3:51 pm with MDS Coordinator LLLLL, 2/11/2025 at 4:02 pm with MDS Coordinator MMMMM, 2/11/2025 at 4:05 pm with[TRUNCATED]

Based on record review, staff interviews, review of the Administrator and Director of Nursing job descriptions, and review of the policy titled Abuse Policy, the facility administration failed to provide protective oversight to attain the highest practicable physical and psychosocial wellbeing of the residents. Specifically, Administration failed to take appropriate action on allegations of employee-to-resident physical and verbal abuse for resident (R) R60; and failed to protect R30, R60, and R125 from sexual abuse from R64. The failures of the Administration to take appropriate action has the likelihood to lead to future allegations of abuse, that are not identified, reported, or investigated. The facility census was 161. Specifically: 1. Facility Administrator and Director of Nursing (DON) failed to perform duties of their job descriptions that facilitated providing a safe environment to the residents of the facility. 2. Administration failed to adhere to the facility policies, including the prevention, reporting, and investigating of allegations of abuse. Cross Refer F600, F609, F610 3. Administration failed to provide ongoing abuse and behavioral training to staff related to care for residents with repeated acts of abuse and hypersexual behaviors. Cross Refer F740 On 2/5/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 2/5/2025 at 5:54 pm. The noncompliance related to Immediate Jeopardy (IJ) was identified to have existed on 10/28/2024. A Credible Allegation of Compliance was received on 2/10/2025. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 2/10/2025. The facility remains out of compliance while the facility continues management level oversight as well as continues to develop and implement a Plan of Correction. (POC).This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding preventing, reporting, and investigating abuse. Findings include: Review of the blank document titled, Job Title: Administrator revealed the job description is to direct the day-to-day functions of the Nursing Center in accordance with current federal, state, and local regulations that govern long-term care centers, and as may be directed by the Regional [NAME] President, to provide appropriate care for our patients. Essential Regulatory Functions: Number 7. Operates the Nursing Center in accordance with the established guidelines of the Organization and in compliance with federal state and local regulations. Number 8. Enforce the Nursing Center guidelines. Number 9. Maintains a working knowledge of current licensure standards and survey process.Number 13. Acts as a liaison between the Nursing Center and regulatory agencies, patient advocacy groups and fiscal intermediaries. Number 15. Assists department heads in the planning, conducting, and scheduling in-service training classes and orientation programs. Number 19. Assumes responsibility for procedural guidelines relative to the prevention and reporting of patient abuse. Essential Associate Relations Functions: Number 42. Supervises all department supervisors and administrative staff. Meets with department heads at regular intervals. Review of the blank document titled, Job Title: Nursing Services Director of Nursing Services revealed the job description is to plan, organize, develop and direct the overall operation of our Nursing Services Department in accordance with current federal, state, and local regulations governing our nursing center, and as may be directed by the Administrator and the Medical Director, to provide appropriate care. Essential Skill/Knowledge Function: Number 38. Maintain effective lines of communication with attending physicians. Number 40. Maintain knowledge of documentation procedures including appropriate use of forms, timelines, and Medicare documentation. Number 41. Maintains a working knowledge of current licensure standards and survey process. Essential Clinical Services Functions: Number 42. Direct, evaluate and supervise patient care and initiates corrective action as necessary. Number 49. Report problems of the Administrator, conducts daily patient rounds, and initiates corrective actions as necessary. Number 69. Assume responsibility for procedural guidelines relative to the prevention and reporting of patient abuse. Number 79. Maintain appropriate personnel file documentation including reference checks, screenings, corrective actions, evaluations, skills verification, and others as necessary. Review of the facility policy titled, Abuse Policy dated December 2023 documented B. Training Components: Abuse Policy Requirements: It is the policy of this facility that all new and existing employees receive training on all forms of abuse, neglect, exploitation of residents, misappropriation of resident property, corporal punishment, injuries of unknown origin, and involuntary seclusion, including freedom from physical or chemical restraints. Training is to include prohibiting and prevention and identification, recognition, reporting and understanding behavioral symptoms that may increase risk of abuse and neglect. C. Prevention: The facility is to prevent abuse by establishing a safe environment, identifying, correcting and intervening in situations in which abuse is more likely to occur ensure the health and safety of all residents in regard to visitors and provide residents information on how and to whom to report concerns or grievances without fear of reprisal. D. Identification: All staff to monitor residents and trained on how to identify potential signs and symptoms if abuse, neglect, exploitation of residents, misappropriation of resident property Occurrences, patterns and trends that constitute abuse will be investigated. E. Investigation: Reports of abuse, neglect, exploitation of residents, misappropriation of resident property . are promptly and thoroughly investigated. F. Protection. The resident(s) will be protected from the alleged offender(s). G. Reporting and Response: Allegations of abuse, neglect, exploitation of residents, misappropriation of resident property are reported per federal and state law. The facility failed to ensure that R30 and R125 were free from sexual abuse by R64. Specifically, Administration failed to investigate and report allegations from Licensed Practical Nurse (LPN) CC of witnessed sexual abuse acts which R64 was seen fondling R30's breast with her adult brief undone. Furthermore, the Administration failed to investigate and report allegations from LPN BB who witness R64 tongue kissing R30 in the tv common area without consent. The facility failed to ensure R60 was free from verbal and physical abuse by Certified Nursing Assistant (CNA) AA. Administration failed to thoroughly investigate and report a witnessed and handwritten account of physical abuse by CNA AA towards R60 when CNA AA threw a mechanical lift pad at R60, landing on her face. The facility was not able to provide any documentation to show a thorough investigation, including follow-up interviews with staff, additional resident interviews related to experiences, observations related to potential sexual abuse was conducted, or reporting the incidents to family or local authorities. Interview on 2/4/2025 at 2:51 pm, the DON confirmed that she is the Abuse Coordinator. She stated that all staff are aware to report any allegations of abuse to her. She revealed that she was aware of the incident R64 and R30 that occurred on 12/25/2024. She revealed she did not do a thorough investigation for the incident since R64 admitted that he did it. There was no follow-up interviews with residents or staff done because she had a written statement and R64 admitted to it. Furthermore, the DON stated she did not do any other follow up because she assumed that the girl who reported it would call the family and the police to report the incident on 12/25/2024. When asked about the physical abuse incident 10/28/2024, the DON stated CNA AA was immediately put on suspension following the allegation. Interview on 2/12/2025 at 1:21 pm, the Administrator stated that he was aware of both 10/28/2024 and 12/25/2024 incidents which was reported by the DON. The 10/28/2024 incident he thought it was reported by the DON, the team discussed it and the ball got dropped because the follow up was not done for either incident. He stated his expectations are for staff to know how to do their jobs, since they have the tools to do their job. During further interview, he stated that if his expectations are not carried out, he revealed the negative effect if any staff is not able to perform their job duties then harm to others can happen. The facility implemented the following actions to remove the IJ: 1. On 2/5/2025, the facility failed to provide oversight and supervision to ensure residents R30, R60, and R125 were protected from abuse by R64 and abuse by CNA AA to R30. 2. On 2/5/2025 upon the report from the State surveyor, CNA AA has been suspended pending further investigation. 3. On 2/5/2025 resident R64 placed on 1:1 supervision upon report from State surveyor of other alleged incidents. 4. As of 2/9/2025 resident R64 has discharged from facility. 5. On 2/5/2025 the facility notified the Medical Director who has been involved in the removal of the Immediate Jeopardy. 6. As of 2/7/2025 the facility had completed meeting/assessing with all residents who were deemed vulnerable for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified. 7. On 2/7/2025 The facility administration reviewed all audits related to residents' vulnerable for potential abuse for identification of safety concerns. No safety concerns were identified. 8. On 2/5/2025 the facility administration contacted an external consultant(s) to assist with policy review, education development and leadership training on abuse prevention and reporting. 9. On 2/7/2025 education was provided to Administration from external consultant on job description. 10. On 2/5/2025 the facility administration notified President of Governing Board of Directors. 11. On 2/5/2025 the facility administration reviewed and made any necessary changes to the abuse prevention and abuse reporting policies and procedures. As of 2/8/2025, 132 of 150 of facility team members (36 CNAs, 25 LPNs, 7 RNs, 15 administrative staff, 3 activities (88%) staff, 13 dietary staff, 19 EVS staff, 4 maintenance staff, been educated on 3 abuse social prevention, workers, 5 unit abuse reporting helpers/clerks, and 1 DON comprehensive and 1 LNHA) have assessments. The remaining 18 (5 CNAs, 1 LPN, 2 PRN RNs, 6 dietary staff, 3 prevention, EVS staff, abuse and 1 reporting unit and helper/clerk) comprehensive team assessments members will their be next educated scheduled on abuse workday. 13. As of 2/8/2025, 5 of 5 (100% (percent)) agency staff (4 LPN and 1 CNA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. 14. As of 2/8/2025, 16 of 22 (78%) contracted therapy staff have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining 6 PRN contracted therapy staff will be educated on abuse prevention, abuse reporting and comprehensive assessments of their next scheduled workday. 15. On 2/6/2025 a review and update of the facility orientation program and agency orientation program has been completed with respect to abuse prevention and abuse reporting requirements. 16. On 2/5/2025 a Performance Improvement Plan (PIP) was initiated related to abuse prevention and abuse reporting. ADHOC meeting held on 2/5/2025. All corrective actions were completed by 2/9/2025. All immediacy of the U was removed on 2/10/2025. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Observation on 2/11/2025 revealed R64 was discharged , R25, R30, RG0, and R125 were noted to safe with no concerns. 2. Interview on 2/11/2025 revealed DON suspend CNA AA via phone pending investigation. 3. R64 is no longer a current resident at the facility, he was discharged on 2/9/2025. A review of the records revealed the facility started paper charting 1: 1 hourly monitoring for R64 for the following: 2/5/2025 at 7:05 pm - 5:32 am, (Interview with Administrator on 2/11/2025 at 3:00 pm revealed the video recording of where R64 was on 1 :1 monitoring with staff.) 2/6/2025 at 7:00 am- 7: 00 pm, 2/6/2025 at 7:00 pm- 2/7/2025 at 7:00 am, 2/7/2025 at 7:00 am- 7: 20 pm, 2/7/2025 at 7:25 pm 2/8/2025 at 7:00 am, 2/8/2025 at 7:00 am- 3: 00 pm, 2/8/2025 at 3: 15 pm, 2/9/2025 at 7: 00 am - 3:00 pm. 4. Record review revealed R64 was discharged on 2/9/2025 to a personal care home. 5. Phone Interview on 2/11/2025 at 2:30 pm with the physician and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and have participated in clinical meetings daily in the mornings with the clinical team of the facility. On 2/5/2025 the facility referred to R30 for psych services for assessment and support. Evidenced by Progress Note dated 2/6/2025: Resident reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. Vital signs at baseline. No signs of pain or distress, no facial grimacing or nonverbal moaning currently. Bed at safest level with floor mat at bedside. Assessment outcomes were reviewed with the primary care physician. Evidenced by: Confirmed care plan revisions have been made on 2/6/2025. Evidenced by: Progress note dated 2/5/2025 revealed resident's family was contacted by Social Services: The resident's family was contacted about an investigation of alleged abuse. Confirmed mental health services were offered, and the resident's family gave verbal consent for the mental health services. 6. By evidence of record review, it was confirmed that the facility had completed a meeting assessing with all residents who were deemed vulnerable for potential abuse. 7. Interview with Administrator on 2/7/2025 at 1:30pm revealed steps were made for improvement, weekly audits, review of reportable, education, and discussing change in clinicals meetings. 8. An interview with the Administrator on 2/11/2025 at 1:30 pm revealed contact was made with external consultants and the board to assist with policy review, education development and leadership training on abuse prevention and reporting. 9. By evidence of interview on 2/14/2025 at 12:49 pm with the Administrator and Record review revealed education was provided to Administration from an external consultant on job description. 10. By interview on 2/11/2025 at 1:30pm with Administrator revealed the President of Governing Board of Directors with notified about the abuse allegations. 11. By interview on 2/11/2025 Record review revealed administration reviewed and made any necessary changes to the abuse prevention and abuse reporting policies and procedures. 12. A review of facility in-service record dated 2/8/2025 revealed 36 CNAs, 25 LPNs, 7 RNs, 15 administrative staff, three activities staff, 13 dietary staff, 19 EVS staff, four maintenance staff, three social workers, five-unit helpers/clerks, one DON and one LNHA have been educated on abuse prevention, abuse reporting and comprehensive assessments. Also verified the above education by the following staff interview on 2/11/2025 at 6:15 am with Certified Nursing Assistant (CNA) XX, 2/11/2025 at 6:17 am with Licensed Practical Nurse (LPN) JJ, 2/11/2025 at 6:21 am with LPN YY, 2/11/2025 at 6:26 am with CNA ZZ, 2/11/2025 at 6:31 am with CNA NN, 2/11/2025 at 6:36 am with CNA AAA, 2/11/2025 at 6:46 am with LPN GG, 2/11/2025 at 6:48 am with LPN BBB, 2 /11/2025 at 6:51 am with CNA CCC, 2/11/2025 at 6:54 am with CNA DDD, 2/11/2025 at 7:58 am with Maintenance Director, 2/11/2025 at 8:30 am with Maintenance Assistant, 2/11/2025 at 8:15 am with Housekeeping GGG, 2/11/2025 at 8:46 am with Environmental Services Manager, 2/11/2025 at 8:23 am with Social Services Director, 2/11/2025 at 9:16 am with Social Worker HHH, 2/11/2025 at 8:50 am with Activities Assistant III, 2/11/2025 at 8:35 am with admission Coordinator JJJ, 2/11/2025 at 8:48 am with Medical Records KKK, 2/11/2025 at 10:30 am with Director of Business Development, 2/11/2025 at 6:01 am with CNA MMM, 2/11/2025 at 6:20 am with CNA NNN, 2/11/2025 at 6:31 am with RN Supervisor OOO, 2/11/2025 at 6:31 am with LPN PPP, 2/11/2025 at 6:46 am with Unit Manager (UM) EE, 2/11/2025 at 7:40 am with Assistant Food Service Manager, 2/11/2025 at 7:45 am with Dietary Manager, 2/11/2025 at 8:00 am with Occupational Therapist (OT) WWW, 2/11/2025 at 8:08 am OT XXX, 2/11/2025 at 8:00 am Physical Therapist Assistant (PTA), 2/11/2025 at 6:18 am with Unit Secretary (US) ZZZ, 2/11/2025 at 6:23 am with Staffing Coordinator MM, 2/11/2025 at 6:28 am with LPN AAAA, 2/11/2025 at 6:32 am with LPN QQ, 2/11/2025 at 6:42 am with Floor Tech (FT) BBBB, 2/11/2025 at 6:42 am with CNA CCCC, 2/11/2025 at 6:47 am with CNA CCC, 2/11/2025 at 6:50 am with Housekeeping DDDD, 2/11/2025 at 6:56 am with FT EEEE, 2/11/2025 at 7:52 am with DA FFFF, 2/11/2025 at 8:07 am with Receptionist GGGG, 2/11/2025 at 8:21 am with Admissions Coordinator HHHH, 2/11/2025 at 8:17 am with Housekeeping IIII, 2/11/2025 at 8:20 am with Financial Assistant JJJJ, 2/11/2025 at 8:28 am with Activities Director, 2/11/2025 at 12:53 pm with UM SS, 2/11/2025 at 12:56 pm with Director of Finances, 2/11/2025 at 12:57 pm with US KKKK, 2/11/2025 at 1:07 pm with CNA NNNN, 2/11/2025 at 1:09 pm with Wound Care CNA OOOO, 2/11/2025 at 1:12 pm with CNA PPPP, 2/11/2025 at 1:15 pm with US QQQQ, 2/11/2025 at 1:18 pm with Activities Assistant FF, 2/11/2025 at 1:20 pm with LPN LL, 2/11/2025 at 1:22 pm with Director of Rehabilitation, 2/11/2025 at 1:32 pm with OT RRRR, 2/11/2025 at 1:35 pm with PT SSSS, 2/11/2025 at 1:37 pm with PTA TTTT, 2/11/2025 at 1:40 pm with Speech Therapist (ST) UUUU, 2/11/2025 at with 1:46 pm with Rehab Technician VVVV, 2/11/2025 at 1:56 pm with LPTA WWWW, 2/11/2025 at 1:59 pm with Laundry XXXX, 2/11/2025 at 2:09 pm with ST YYYY, 2/11/2025 at 2:49 pm with EVS Assistant Supervisor, 2/11/2025 at 2:56 pm with CNA DD, 2/11/2025 at 3:00 pm with Housekeeper DDDDD, 2/11/2025 at 3:02 pm with CNA EEEEE, 2/11/2025 at 3:04 pm with Central Supply Clerk FFFFF, 2/11/2025 at 3:07 pm with Registered Dietician, 2/11/2025 at 3:28 pm with LPN TT, 2/11/2025 at 3:30 pm with CNA GGGGG, 2/11/2025 at 3:32 pm with CNA HHHHH, 2/11/2025 at 3:34 pm with DA IIIII, 2/11/2025 at 3:36 pm with [NAME] JJJJJ, 2/11/2025 at 3:43 pm with CNA VV, 2/11/2025 at 3:45 pm with LPN KK, 2/11/2025 at 3:50 pm with DA KKKKK, 2/11/2025 at 3:51 pm with MDS Coordinator LLLLL, 2/11/2025 at 4:02 pm with MDS Coordinator MMMMM, 2/11/2025 at 4:05 pm with DA NNNNN, 2/11/2025 at 4:06 pm with Financial Coordinator OOOOO, 2/11/2025 at 4:08 pm with Payroll Clerk PPPPP, 2/11/2025 at 4:10 pm with Human Resources Director, 2/11/2025 at 4:12 pm with [NAME] RRRRR, 2/11/2025 at 6:54 pm with LPN TTTTT, 2/11/2025 at 5:41 pm with Infection Preventionist, 2/11/2025 at 5:46 pm with Receptionist YYYYY, 2/11/2025 at 5:58 pm with LPN QQQQQ, 2/11/2025 at 5:59 pm with DA A1, 2/11/2025 at 6:11 pm with LPN D1, 2/11/2025 at 6:19 pm with CNA E1, 2/12/2025 at 12:03 pm with Nurse Educator, 2/12/2025 at 12:19 pm with DON, 2/12/2025 at 12:49 pm with Administrator. A review of the facility in-service record dated 2/9/2025 revealed 18 (five CNAs, one LPN, two PRN RNs, six dietary staff, three EVS staff, and one unit helper/clerk) team members were educated on abuse prevention, abuse reporting, and comprehensive assessments. Also verified the above education by the following staff interviews 2/11/2025 at 2:44 pm with Housekeeper ZZZZ, 2/11/2025 at 2:46 pm with Housekeeper AAAAA,2/11/2025 at 2:52 pm with Housekeeper BBBBB, 2/11/2025 at 7:10 with am Dietary Aide (DA) QQQ, 2/11/2025 at 7:15 am with [NAME] RRR, 2/11/2025 at 7:20 am with DA SSS, 2/11/2025 at 7:25 am with DA TTT, 2/11/2025 at 7:30 am with DA UUU, 2/11/2025 at 7:35 am with DA VVV, 2/11/2025 at 6:54 pm with LPN TTTTT, 2/11/2025 at 7:05 pm with RN UUUUU, 2/11/2025 at 7:11 pm with CNA VVVVV, 2/11/2025 at 7:20 pm with CNA WWWWW, 2/11/2025 at 5:37 pm with CNA XXXXX, 2/11/2025, 2/11/2025 at 6:03 pm with CNA B1, 2/11/2025 at 6:08 pm with CNA C, 2/11/2025 at 1:18 pm with Activities Assistant FF, 2/11/2025 at 6:02 am with Wound Care Registered Nurse (RN) LLL. An interview with the Administrator on 2/11/2025 at 1:05 pm revealed that 91% of staff have been educated on abuse. 13. Review of facility in-service record dated 2/8/2025, five of five (100%) agency staff (four LPNs and one CNA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. Also verified the above education by the following staff interviews on 2/11/2025 at 1:01 pm with LPN LLLL, 2/11/2025 at 1:04 pm with LPN MMMM, 2/11/2025 at 5:58 pm with LPN RR, 2/11/2025 at 6:57 pm with LPN SSSSS, 2/11/2025 at 6:42 am with CNA CCCC. 14. Review of facility in-service record dated 2/8/2025, five of five (100%) agency staff (four LPNs and one CNA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. Also verified the above education by the following staff interviews on 2/11/2025 at 1:01 pm with LPN LLLL, 2/11/2025 at 1:04 pm with LPN MMMM, 2/11/2025 at 5:58 pm with LPN RR, 2/11/2025 at 6:57 pm with LPN SSSSS, 2/11/2025 at 6:42 am with CNA CCCC. 15. By evidence of record review revealed 2/6/2025 a review and update of the facility orientation program and agency orientation program has been completed with respect to abuse prevention and abuse reporting requirements 16. By evidence of an interview with the Administrator on 2/11/2025 at 1:30 pm confirmed on 2/5/2025 a Performance Improvement Plan (PIP) was initiated related to abuse prevention and abuse reporting. ADHOC meeting held on 2/5/2025. Record review confirmed ADHOC meeting held on 2/5/2025. All corrective actions were completed by 2/9/2025. All immediacy of the U was removed on 2/10/2025.