**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility record review, staff and resident interviews, and facility policy reviews the facility failed to ensure 1 of 3 residents (Resident #1) was free from abuse and psychological harm. Resident #1 reported to staff that Staff A CNA had provided peri-cares in a rough manner, had called her names and used curse words in front of her. The facility suspended Staff A while they completed their investigation and allowed her to come back to work as long as she did not provide cares to Resident #1. Staff reported when Staff A would come to work, Resident #1's demeanor would change: she would become guarded, shaky, stay by other staff member's side, tear up, was fearful for her safety. Resident #1 reported it made her mad because this is her home and she should not feel this way about a staff member in her home. The facility reported a census of 26 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 7/30/24 at 5:00 PM. The IJ began on 7/23/24, the day Resident #1 reported her concerns. The facility removed the Immediate Jeopardy on 7/31/24 through the following actions: -Staff A, the Assistant Director of Nursing (ADON) and Director of Nursing (DON) were suspended on 7/30/24. -On 7/30/24 the facility began additional re-education for all employees relating to abuse, neglect, and exploitation. All employees currently working will be educated immediately. All other employees will be educated prior to their next scheduled shift. -When new team members begin employment, they will receive Dependent Adult Abuse Prevention and Reporting training as part of their initial onboarding. All other employees will receive Dependent Adult Abuse Prevention training annually, and with any allegation or investigation regarding abuse. -The facility has interviewed all alert residents related to abuse. -The Administrator will interview five random residents about abuse weekly for the next 12 weeks. -The Administrator will interview five random staff members per week for 12 weeks to verify knowledge related to abuse and reporting policies. -The resident impacted had a head to toe assessment completed, no evidence of any injuries noted. -The facility initiated head to toe skin assessments for all residents. Skin assessments will be completed by the end of the day on 8/2/24. -The resident impacted by the event had a post trauma assessment initiated on 7/31/24. -The resident will be on every shift charting for 72 hours. This documentation will be reviewed by the Administrator during morning clinical review, the day following. The scope lowered from J to G at the time of the survey after ensuring the facility implemented education and their policy and procedure. Findings include: According to the admission Minimum Data Set (MDS) assessment tool with a reference date of 6/24/24, documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairments. Resident #1 had an admission date of 6/19/24. The MDS documented she did not display any physical, verbal, or other behavioral symptoms during the review period. The MDS documented she was frequently incontinent of urine and was always incontinent of bowel. The MDS listed the following diagnoses for Resident #1: acute cystitis with hematuria, anemia, neurogenic bladder, multidrug resistant organism, septicemia, urinary tract infection (UTI), cerebral palsy, anxiety, depression, psychotic disorder (other than schizophrenia), post-traumatic stress disorder (PTSD), borderline personality disorder, and mild intellectual disabilities. The Care Plan focus area with an initiation date of 6/19/24 documented Resident #1 had activities of daily living (ADL) performance deficit related to cerebral palsy and musculoskeletal impairment. The Care Plan focus area with an initiation date of 6/24/24 documented she has the potential to have manipulative behaviors at times. Staff are encouraged to explain all procedures to Resident #1 before starting and allow the resident to adjust to changes. Review of the facility's grievances revealed the following grievance was filed on Resident #1's behalf: a) Resident stated when staff entered room, she got upset stated I've been waiting for two hours to go to bed. Resident #1 stated Staff A said we have 20 something residents, please be considerate. Resident stated she continued to be agitated then stated Staff A said I'm not doing this, then walked out. The form was signed and dated by the SSD on 7/23/24. The following progress note was documented on 7/24/24 at 5:37 PM by Staff C Licensed Practical Nurse (LPN): this nurse spoke with resident and spent much of the afternoon discussing her feelings about an incident that occurred last night. Resident #1 was visibly upset and had asked this nurse to go with her to talk to the Administrator. Staff C and Administrator told resident that she was heard and that the matter will be looked into. Resident #1 told this nurse that she felt safe at this time and that she did not want a certain person to take care of her. Staff C reassured resident that other staff could meet her needs and she would not have to have cares provided by the person who made her feel uncomfortable. She was informed a bit later by Staff C that there is an investigation and it has been turned in. Resident #1 thanked this nurse for giving her support and reassured that she could come to Staff C at any time and she could tell her anything that was bothering her. They all want her to feel safe. Review of Resident #1's clinical record revealed the following Encounter Psych Progress Note, with a visit date of 7/25/24. Current Symptoms/History of Present Illness: The resident is seen today as a follow-up medication assessment. The resident reports that she is doing well. She has been a bit down due to a situation that happened with staff. She tells the provider she wishes she was in her own apartment. She stated there have been situations around her care which turned into an investigation. She is flat and guarded. She was hesitant to talk but later opened up. She reported doing well beside that. Mental Status Exam: the resident's speech was normal, sharing conversation with normal laryngeal efforts. Appropriate mood and affect were seen on exam. Thought processes were logical, relevant, and thoughts were completed normally. Thought content was normal with no psychotic or suicidal thoughts. The resident's judgement was realistic with normal insight into present condition. Mental status included: correct time, place, person orientation, normal recent and remote memory, normal attention span and concentration ability. Language skills included the ability to correctly name objects. Fund of knowledge included normal awareness of current and past events. The facility investigation included the following statements: a) Staff A Certified Nursing Assistant (CNA) wrote: she was working 2:00 PM-10:00 PM on 7/23/24. She had just finished the nurse's orders of passing snacks, ice water, doing rounds, and hourly check-ups on certain residents. She went to assist another resident when a CNA told her that the resident they need to lay down was upset. When Staff A arrived to the resident's room she said: hello, I heard that you were upset and I was wondering if there was anything I could do? Immediately the resident started screaming and yelling, I am not f***ing upset (said that two times), you guys waited forever to come lay me down. Staff A explained the resident, I am sorry, myself and the other CNA just got done with nurse's orders and both of us are getting tired, so we understand. After transporting the resident to bed, Staff A went to assist the CNA with rolling the resident. As soon as Resident #1 saw Staff A was touching her, she started yelling and scream don't f***ing touch me (was said about five times) with the occasional word bitch thrown in. After Staff A ensured the other CNA was at a good stopping point, Staff A told that staff member I can't handle this shit. Staff A then walked over to the other side of the room and grabbed a pillow for the resident's head, then stood around the other CNA, staying there to make sure she did not need any other assistance other than touching the resident. b) Staff B CNA wrote the following statement: on 7/23/24 Staff A and I went to assist Resident #1 to bed. At the time we went in, she was very upset and was yelling at the fact that she did ask two hours prior to be put in bed. Staff B and her were busy doing baths, passing snack cart out and putting other residents to bed. Resident #1 yelled I asked you two f***ing hours ago. Staff A replied with I'm not putting up with your shit tonight. Resident #1 then replied with I am not dealing with your attitude either. Resident #1 was screaming while being put in bed due to her being in pain. After being put in bed, Resident #1 looked at Staff A and said you are not f***ing touching me. Staff B told Resident #1 she had to help roll her to get the sling out from under her. Resident #1 rolled her eyes. Due to the resident screaming while being put in bed, Staff B did ask Resident if she was ok. Resident #1 replied, it didn't matter. Resident #1 was assured she did care if she was ok. Resident #1 did not say anything after that, so Staff B walked out. Staff B told the nurse and she said she would go talk to Resident #1 about it. The ADON (nurse on duty that night) did talk to her and Staff A about the next time letting Resident #1 calm down then reproach her. She signed and dated her statement on 7/25/24. c) The ADON wrote the following statement: on the night of 7/23/24 at 9:30 PM she was passing medications down hall 2 when Staff B came to her and stated Resident #1 was upset, she was screaming at staff when entering her room about how long she had been waiting for staff to put her to bed. Staff A and Staff B apologized for the delay and that they were with other residents and doing the best they could. Resident #1 continued screaming at both CNA's telling them how much bullshit it was and that they were terrible. Staff B then stated Staff A made the comment, I can't deal with this right now. Resident #1 then began screaming at Staff A, don't f***ing touch me, don't f***ing touch me, don't f***ing touch me. Staff B she let Resident #1 know Staff A would not be doing her cares, that Staff B would but still needed Staff A's assistance to roll the resident so Staff B could provide cares. Resident #1 then stated why does that matter, no one cares. Staff B reassured her that they indeed do care. The ADON finished her medications a few minutes later and returned to the nurse's station when the Social Service Director (SSD) informed her that Resident #1 made a grievance that she waited two hours to put to bed and that Staff A was rude to her. The SSD stated she had just talked with Resident #1 and had not had a chance to write it up yet. The ADON questioned Staff A and she stated, Resident #1 was screaming at us for taking so long. She tried to explain why and they couldn't really help it but were trying the best they could. Resident #1 continued to scream at them, saying how awful they were. When they got her into bed, Resident #1 started screaming don't f***ing touch me like five times and Staff A said ok Staff B told Resident #1 that she needed her help rolling her to do cares. The ADON asked why the resident was yelling at Staff A not to touch her. Staff A stated because she was mad and does not like me, never has, she is like that with staff she does not like when she is upset. The ADON asked if she stated that she wasn't or can't going to deal with this right now and she indicated she had not made that statement. After question Staff A, the ADON went to speak with Resident #1. Upon entering the resident's room it was noted that resident was not in distress and was in a calm mood. The ADON stated that she had heard the resident was upset and asked what had happened. Resident #1 stated she was upset because she waited two hours to be laid down and told the staff it was bullshit. She added she should not have to wait that long, then Staff A told her she can't deal with this. Resident #1 indicated she did not like people talking like that to her. The ADON stated she understood and that she would speak with Staff A about the way she spoke to Resident #1 and they apologized. The ADON also took accountability for the staff taking so long to lay her down as she tasked them with passing snacks, fresh ice water, and the baths for the evening to ensure all duties were completed in a timely manner. Resident #1 stated that she understood stuff like that happens sometimes. The ADON then reiterated that this did not excuse Resident #1's comment and that it will be addressed. Resident #1 thanked the ADON, stated no when asked if there was anything else she would like to talk about or needed. Resident #1 still seemed to be in a calm, pleasant mood. After the conversation with Resident #1, the ADON went to the nurse's station and realized a resident needed a neuro check completed and went to find another resident on the floor. This nurse instructed Staff A to complete her charting and take out the trash before leaving as it was already 10:00 PM. Staff A was educated on importance of professionalism and instructed that in situations that are overwhelming, she needs to ensure resident safety then leave the room, go to the charge nurse and allow the charge nurse to intervene. d) The Administrator's statement indicated Staff C entered his office shortly before 3:00 PM on 7/24/24. She stated that she had heard from Staff D CNA had reported a concern to her and that Resident #1 wanted to talk with him. Resident #1 requested Staff C to be with her. Resident #1 came in and said she was very upset with Staff A and the way she's been treatment her. Resident #1 stated Staff A was rude to her but did not want to say what Staff A had said to her. She indicated she reported the incident to the ADON and the SSD. We continued talking but she did not feel comfortable saying anymore. She was assured that is was absolutely fine bringing her concerns to him and that he really wanted to help. The Administrator told her that he wanted her to be happy here because it's her home. Resident #1 asked if Staff A could not be present in her room or provide her care, he agreed. Resident #1 left the room and Staff C returned after and told him that Resident #1 said Staff A said she was not putting up with her shit tonight and that Staff B heard it too. e) On 7/26/24 the Director or Nursing statement indicated herself and Staff E charge nurse entered Resident #1's room and obtained her consent to speak with her about her report of alleged verbal abuse that occurred on 7/23/24 during the evening shift. Resident #1 stated Staff A was mad at her because the ADON made her pass snacks and waters before putting people to bed. She had asked Staff A if she could go to bed and she copped an attitude with her. Resident #1 stated it was really, really bad and she was so vulgar and mean. Resident #1 stated I don't want to tell you want she said. The DON explained the importance of knowing the details. Resident #1 stated Staff A called her a white trash bitch, trailer trash, a f***ing imbecile, told her she never should have been born and she should be dead by now. Resident #1 denied that the statement I am not putting up with your shit tonight was made by any employees to her. Resident #1 was calm and in a pleasant mood prior to the DON and Staff E leaving her room. The DON called Staff B to confirm if any of the above statements were witnessed or heard while her and Staff A were providing cares to Resident #1. Staff B denied hearing any of those and stated the worst thing she heard was Staff A say shit. f) The SSD statement indicated she entered Resident #1's room to do assessments with her. Resident was lying in bed. Once the first assessment was completed, Resident #1 stated she was rude. When asked who was rude, she stated Staff A. When they came in, Resident #1 was upset because she waited two hours to be put to bed. Resident #1 stated Staff A told her there's 20 something other residents and to be considerate. She then stated that Staff A said more but did not state what else was said. Resident #1 stated Staff A said I'm not doing this and walked out of the room. The SSD stated she would write up a grievance and that they would talk to Staff A. Resident #1 thanked her and they finished the assessments. When the SSD left the room, Resident #1 was smiling and appeared content. The facility investigative file included the following summary: a) Resident #1 is a [AGE] year-old cognitively impaired female who was admitted to the facility on [DATE] with a primary diagnosis of acute cystitis without hematuria and spastic diplegic cerebral palsy. b) At 3:00 PM on 7/24/24, Resident #1 reported to the Administer that Staff A had been verbally abusive to her at approximately 9:30 PM on 7/23/24. She could not verbalize the actual statements that Staff A had made to her at that time. When asked if anyone else was present or aware, she stated that Staff B witnessed the incident and that she had reported it to the ADON and SSD the night prior. The DON was immediately notified, and the Administrator initiated an abuse investigation. c) Investigation Findings: 1) On 7/24/24 at approximately 2:00 PM during care, Resident #1 told Staff D that Staff A had yelled at her the night before and that she told her to shut up. She also stated that Resident #1 had reported this to the ADON and the SSD. Staff D immediately reported this to Staff C charge nurse. 2) Staff C followed up with Resident #1 after she finished her talk therapy, at approximately 2:45 PM. Resident #1 told Staff C that Staff A had cursed at her. According to Resident #1's statement to her, Staff A had told her they did not have time for her shit. At that time, she brought Resident #1 to the Administrator, initiating the abuse investigation. Resident #1's initial statement to the Administrator was that Staff A had been verbally abusive to her. When asked what she had said, Resident #1 stated she could not repeat it. She stated it was too terrible for her to report. She also stated that she told Staff A to not touch her after she assisted her to bed. Resident #1 repeated that she no longer felt comfortable with Staff A providing her care. Resident #1 stated she reported her concerns to the ADON and the SSD and Staff B had witnessed all their interactions that night. 3) Staff B stated that Resident #1 was upset and yelling at both staff as they entered her room. They had a hectic night and she had to wait longer than she wanted to be assisted to bed. Staff B confirmed that Staff A told Resident #1 that she wasn't putting up with her shit tonight. She reported this to her charge nurse, ADON that night. 4) The ADON stated that Staff B did inform her of the incident but that Staff A had said she could not deal with this right now to the resident. Staff B stated to her that Resident #1 was upset throughout her cares, but they had tried to reassure her. The ADON followed up with Resident #1 and found her to be calm and not in distress. The ADON let her know that if Staff A had been rude to her that that was not acceptable and that she would follow up with Staff A to address the incident. Resident #1 had no further concerns at that time and stated stuff like that happens sometimes. At no time was Resident #1 upset or voicing concerns about verbal abuse. 5)The SSD stated that the evening of 7/23/24, Resident #1 had brought concerns that Staff A had been rude. When she asked what had happened, Resident #1 told her she had to wait two hours to be put to bed and that Staff A had told her that she needed to be more considerate of the other residents. She also stated that Staff A had said, I am not doing this and walked out of the room. The SSD told her she would fill out a grievance form for her and the team would follow up with Staff A. Resident #1 voiced no other concerns at that time and SSD left her smiling and content. 6)Staff A stated that prior to her entering the room, Staff B had told her the resident was upset. She stated that she entered the room and politely offered to help her. Resident #1 began to yell at them, but she allowed them to assist her to bed. Once in bed, Resident #1 told Staff A that she was not going to f***ing touch her. Staff A only provided support to Staff B as she provided direct care. She left the bedside once Resident #1 was in a safe position and said, I can't handle this shit. Staff A stated she was not directing this at Resident #1 but to her coworker. She denied yelling at Resident #1 and stayed in the room until Staff B completed cares, then left. 7)The Administrator and SSD attempted to follow up with Resident #1 on multiple occasions but were unsuccessful. Resident #1 did not want to speak about the incident or Staff A anymore. 8)On 7/26/24 the DON was able to follow up with Resident #1. At this time she denied that Staff A had told her that she would not put up with her shit or could not put up with this shit. Instead, she now stated Resident #1 called me a white trash bitch, trailer trash, a f***ing imbecile and that she never should have been born and should be dead by now. Resident #1 stated that was what Staff A said on 7/23/24 and Staff B was present. Staff A and Staff B were both asked if any of that was said and they both denied that it was. 9)The Interdisciplinary Team (IDT) reviewed the findings of the investigation. The incident involving Staff A and Resident #1 was the result of frustrations on both party's parts and not intended to be harmful. Review of Staff A's July 2024 timecard, revealed she worked on 7/23/24 from 6:00 PM-10:30 PM. On 7/30/24 at 2:18 PM Resident #1 stated she turned Staff A in because she has been very abusive to a lot of people at the facility, herself included. She works the evening shift, 2:00 PM-10:00 PM, is only 16 and the daughter of the ADON. The ADON will cover Staff A's butt and a lot of her family works here too so they will also cover up for her. She gets special treatment because of that. Resident #1 stated from her stand-point Staff A is very verbally abusive. When asked what has happened, she indicated Staff A has called her a whore, bitch and white trash. She has called her these things to her face. Staff A has also told Resident #1, she is not allowed to have feelings or emotions. Staff A has told her she is not allowed to get her in trouble or say anything. When asked how this made her feel, Resident #1 it pisses her off when Staff A acts like this. This is supposed to be her home, she's not supposed to feel this way about anyone that works here. When Resident #1 does peri-care she does it very hard. She's never been told of any injuries but is sore after Staff A cares for her. She has asked her to please not care for her. Staff A's response to that was I don't f***ing care, I'll f***ing do it anyway's. Last week, while Staff A and Staff B were assisting her to bed, Staff B told the resident I am not dealing with your shit. Resident #1 indicated she has talked with the Administrator, the ADON, DON and SSD about her concerns. All staff tell her when she reports concerns is, they will talk with her. Staff A is back to working at the facility but she is not allowed to care for Resident #1. Resident #1 reported feeling uncomfortable around her presence, does not want her looking at her. On 7/30/24 at 12:36 PM Staff H CNA stated Resident #1 has told her that Staff A has yelled rudely at her, but Staff H has not witnessed this. Resident #1 has also reported Staff A is rough with her while doing cares. The resident reported Staff A wipes roughly. When they go in to complete cares, Resident #1 will say ow, I am sore down there because Staff A had cared for her the previous night. They have told Staff E, Staff C, the Administrator, ADON and DON. They tell staff they will speak with those that are higher up and make sure Resident #1 is ok. When Resident #1 told her what was going, that's when it was suggested Resident #1 call State about this. On 7/30/24 at 1:16 PM Staff I CNA stated Resident #1 had reported to her that Staff A do not treat her well. Staff A does not listen to what Resident #1 wants or what she has to say. Resident #1 has reported to her Staff A has called her not nice things like: she was white trash but that was all Staff I could remember. Resident #1 reported to her that Staff A will not ask to wipe her, she just does it, she is not careful while wiping Resident #1 and is rough. Staff I has heard Resident #1 reporting soreness to her peri-area in the mornings but has not seen any marks. After Resident #1 talked with her she reported these concerns to Staff C and Staff E and they indicated it would be reported to the ADON and DON. When asked how Resident #1 is doing since Staff A returned back to work, she stated the resident is scared and stressed. Staff A is not allowed to take care of Resident #1 since this was reported. On 7/30/24 at 1:32 PM Staff C LPN stated when Resident #1 first admitted to the facility, it took her a bit to get comfortable with staff. Resident #1 was never mean but she did click with a few staff members right away. Resident #1 would come to Staff C for support until she got used to other staff members. Resident #1 would not want Staff A to do her peri-cares and recently had heard Resident #1 turned in concerns about Staff A. Resident #1 reported to her she felt management was not hearing her, like things were not changing and they were not listening to her. Staff C states specially she came in to work on a Wednesday and stated the night before (Tuesday) she asked Staff A to not wipe her and Staff A said, I don't give a f***, she did it anyway's. When Staff A first went in the resident's room, Resident #1 stated the staff member stated I am not putting up with her shit tonight. Staff C continued to talk with Resident #1 to give her support and comfort. Resident #1 went to talk therapy then was ready to talk with the Administrator about what she told Staff C. The resident stated when she spoke with the ADON she told her she would have a talk with Staff A about her attitude from that night. Staff A was suspended and when she returned she was not allowed to take care of Resident #1. When Staff A is in the facility, Resident #1's whole demeanor changes. The first shift staff members will stay until 7-7:30 PM to assist staff with her cares since Staff A is not allowed to care for her. On 7/30/24 at 1:51 PM Staff G stated Resident #1 told her last week that Staff A said to her she wished she never came here. Resident #1 reported last week while Staff A and Staff were assisting with getting the resident ready for bed, Staff A's tone was aggressive. Resident #1 told Staff A no and Staff A said, I don't f***ing care and helped anyway. The resident complained that Staff A was very rough with cares. When Staff G would care for the resident the day after Staff A did, she did not notice any marks but would complain of her peri-area being irritated and sore. When Staff G would work with Staff A she stated she was awful; very defiant with anything that was asked of her, she is very loud and sarcastic. Her mom is the ADON and she would even cuss at her while residents were present. Staff A has always been that way, but it has progressively gotten worse. The ADON would tell Staff A to knock her attitude off, watch your language but Staff A would just roll her eyes and walk away. Staff G denies ever hearing inappropriate comments made to Resident #1 by Staff A, she just knew Resident #1 did not want her taking care of her. When asked how Resident #1 acts now that Staff A is back to work, she stated other CNA's have reported that Resident #1 would not leave their sight while Staff A worked. She would park herself up front with other staff when she was usually out and about throughout the facility. Now Resident #1 is fixated on being with staff when Staff A is working. Staff G stated the resident used to sit in her room to listen to music, but she has not done that the last few days. The day shift staff stay over in to the evening shift to assist with Resident #1's cares when Staff A is working. This has upset Resident #1 because she does not feel like staff are listening to her and does not like going to bed before 7:00 PM just because Staff A is working. Resident #1 reported to Staff G that she feels like she has no choices or rights at this point. She mentioned this has been reported to a lot of people but nothing is being done. That's why she contacted outside entities. On 7/30/24 at 2:41 PM Staff D stated after Resident #1 voiced concerns, she reported it. On Wednesday 7/24/24 she had given the resident a bath. During her bath, the resident was bawling, Staff D indicated she had to hold back her own tears. Resident #1 asked Staff A to not do peri-cares and she did them anyway's. The resident reported Staff A will go in to help her but works very fast and does not respect what Resident #1 says. Staff A told her to shut the f*** up and that she did not care about her bullshit. When asked if any other residents voiced concerns about Staff A, she stated while assisting Resident #4 she wanted her feet moved. Staff A told her to shut the f*** up and I don't care about your bullshit. Staff D looked at Staff A and said she had crossed the line and it was not funny nor was it a joke. Staff A stated it's fine, I gave her a good bath and shaved her legs. Staff A spends a lot of time on her phone. When residents try to talk with her she will not pay attention. She will yell at nurses and her mom, who is the ADON. Will tell her to shut up in front of residents while in the dining room. The DON is aware of their concerns, she has told her about them. When they try to report concerns to the ADON, she gets mad at staff. Staff D stated Resident #1 will walk in to the building in a bad mood, then she is disrespectful with residents. These residents would be happier without her here because she is so disgusting and horrible to the residents. On 7/30/24 at 2:59 PM Staff B stated she worked the night of the alleged incident. Resident #1 reported she was ready for bed. Staff B informed her she will need to get help, Staff A was doing a bath at that time. Resident #1 then stated, I told you two f***ing hours ago I wanted to go to bed. Staff A stated I am not dealing with your shit. Resident #1 stated and I am not dealing with your f***ing attitude. Once they got her to bed, Staff B asked if she was ok and Resident #1 stated it does not f***ing matter. She then looked at Staff A and said you are not f***ing touching me. Staff B indicated Resident #1 did not need her brief changed. Once they left the room, Staff B told the ADON what had happened. The ADON told her she would talk to her. She works with Staff A and there are times she thinks she is joking but she's not. Staff B stated she did not think the comment she made to Resident #1 had meaning behind it. She was having a tough day that day. On 7/30/24 at 3:21 PM Staff F CNA stated Resident #1 came to her, Staff G CNA and Staff D scared of Staff A because she had been physically and verbally abusive to her. Resident #1 stated Staff A called her a bitch and wished she was never born. She had told Staff A not do care on her and Staff A said I don't f***ing care and did them anyway's. Staff E denies observing this but stated Staff A can be really nasty to residents, really mean. If they are assisting Resident #4, the resident will ask for something and Staff A would say I don't care, it's not my problem. Her mom is the ADON and she will tell her to shut the f*** up in front of residents. When asked if residents had voiced[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility investigative file review, resident and staff interviews, and facility policy review the facility failed to report 1 of 3 resident's (Resident #1) allegation of abuse to the appropriate staff members to ensure timely reporting to the State Agency. On 7/23/24 at roughly 8:30 PM Staff A and Staff B had assisted Resident #1 with getting ready for bed. Resident #1 told staff she was upset and yelling that she had asked two hours prior to be put to bed. Staff explained to her they were assisting others with baths, passing the snack cart out and assisting others to bed. Resident #1 yelled I asked you two f***ing hours ago. Staff A replied with I am not putting up with your shit tonight. Resident #1 replied I am not dealing with your attitude either. Staff B reported this to the Assistant Director of Nursing (ADON) (Staff A's mother) and she indicated she would go talk to Resident #1. After speaking with Staff A and Resident #1, the ADON continued with her duties: neuro checks on a resident and found that another resident had fallen on the floor. On 7/24/24 at 3:00 PM Staff C Licensed Practical Nurse (LPN) went to the Administrator's office with Resident #1 to talk about the concerns that was reported to her by Staff D CNA. The facility then reported the allegation to the State Agency (SA) on 7/24/24 at 5:13 PM. The facility reported a census of 26 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 7/30/24 at 5:00 PM. The IJ began on 7/23/24, the day Resident #1 reported her concerns. The facility removed the Immediate Jeopardy on 7/31/24 through the following actions: -Staff A, the Assistant Director of Nursing (ADON) and Director of Nursing (DON) were suspended on 7/30/24. -On 7/30/24 the facility began additional re-education for all employees relating to abuse, neglect, and exploitation as well as reporting requirements. The facility originally began reeducation on 7/24/24 following the initial report All employees currently working will be educated immediately. All other employees will be educated prior to their next scheduled shift. -When new team members begin employment, they will receive Dependent Adult Abuse Prevention and Reporting training as part of their initial onboarding. All other employees will receive Dependent Adult Abuse Prevention training annually, and with any allegation or investigation regarding abuse. -The facility has interviewed all alert residents related to abuse. -The Administrator will interview five random residents about abuse weekly for the next 12 weeks. -The Administrator will interview five random staff members per week for 12 weeks to verify knowledge related to abuse and reporting policies. -Regional Director of Clinical Services had reviewed documentation of current residents, retrospectively back to 12:00 AM on 7/19/24 with no findings of abuse evident. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedure. Findings include: According to the admission Minimum Data Set (MDS) assessment tool with a reference date of 6/24/24, documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairments. Resident #1 had an admission date of 6/19/24. The MDS documented she did not display any physical, verbal, or other behavioral symptoms during the review period. The MDS documented she was frequently incontinent of urine and was always incontinent of bowel. The MDS listed the following diagnoses for Resident #1: acute cystitis with hematuria, anemia, neurogenic bladder, multidrug resistant organism, septicemia, urinary tract infection (UTI), cerebral palsy, anxiety, depression, psychotic disorder (other than schizophrenia), post-traumatic stress disorder (PTSD), borderline personality disorder, and mild intellectual disabilities. The Care Plan focus area with an initiation date of 6/19/24 documented Resident #1 had activities of daily living (ADL) performance deficit related to cerebral palsy and musculoskeletal impairment. The Care Plan focus area with an initiation date of 6/24/24 documented she has the potential to have manipulative behaviors at times. Staff are encouraged to explain all procedures to Resident #1 before starting and allow the resident to adjust to changes. Review of the facility's grievances revealed the following grievance was filed on Resident #1's behalf: a) Resident stated when staff entered room, she got upset stated I've been waiting for two hours to go to bed. Resident #1 stated Staff A said we have 20 something residents, please be considerate. Resident stated she continued to be agitated then stated Staff A said I'm not doing this, then walked out. The form was signed and dated by the SSD on 7/23/24. The following Progress Note was documented on 7/24/24 at 5:37 PM by Staff C Licensed Practical Nurse (LPN): this nurse spoke with resident and spent much of the afternoon discussing her feelings about an incident that occurred last night. Resident #1 was visibly upset and had asked this nurse to go with her to talk to the Administrator. Staff C and Administrator told resident that she was heard and that the matter will be looked into. Resident #1 told this nurse that she felt safe at this time and that she did not want a certain person to take care of her. Staff C reassured resident that other staff could meet her needs and she would not have to have cares provided by the person who made her feel uncomfortable. She was informed a bit later by Staff C that there is an investigation and it has been turned in. Resident #1 thanked this nurse for giving her support and reassured that she could come to Staff C at any time and she could tell her anything that was bothering her. They all want her to feel safe. The facility investigation included the following statements: a) Staff A Certified Nursing Assistant (CNA) wrote: she was working 2:00 PM-10:00 PM on 7/23/24. She had just finished the nurse's orders of passing snacks, ice water, doing rounds, and hourly check-ups on certain residents. She went to assist another resident when a CNA told her that the resident they need to lay down was upset. When Staff A arrived to the resident's room she said: hello, I heard that you were upset and I was wondering if there was anything I could do? Immediately the resident started screaming and yelling, I am not f***ing upset (said that two times), you guys waited forever to come lay me down. Staff A explained the resident, I am sorry, myself and the other CNA just got done with nurse's orders and both of us are getting tired, so we understand. After transporting the resident to bed, Staff A went to assist the CNA with rolling the resident. As soon as Resident #1 saw Staff A was touching her, she started yelling and scream don't f***ing touch me (was said about five times) with the occasional word bitch thrown in. After Staff A ensured the other CNA was at a good stopping point, Staff A told that staff member I can't handle this shit. Staff A then walked over to the other side of the room and grabbed a pillow for the resident's head, then stood around the other CNA, staying there to make sure she did not need any other assistance other than touching the resident. b) Staff B CNA wrote the following statement: on 7/23/24 Staff A and I went to assist Resident #1 to bed. At the time we went in, she was very upset and was yelling at the fact that she did ask two hours prior to be put in bed. Staff B and her were busy doing baths, passing snack cart out and putting other residents to bed. Resident #1 yelled I asked you two f***ing hours ago. Staff A replied with I'm not putting up with your shit tonight. Resident #1 then replied with I am not dealing with your attitude either. Resident #1 was screaming while being put in bed due to her being in pain. After being put in bed, Resident #1 looked at Staff A and said you are not f***ing touching me. Staff B told Resident #1 she had to help roll her to get the sling out from under her. Resident #1 rolled her eyes. Due to the resident screaming while being put in bed, Staff B did ask Resident if she was ok. Resident #1 replied, it didn't matter. Resident #1 was assured she did care if she was ok. Resident #1 did not say anything after that, so Staff B walked out. Staff B told the nurse and she said she would go talk to Resident #1 about it. The ADON (nurse on duty that night) did talk to her and Staff A about the next time letting Resident #1 calm down then reproach her. She signed and dated her statement on 7/25/24. c) The ADON wrote the following statement: on the night of 7/23/24 at 9:30 PM she was passing medications down hall 2 when Staff B came to her and stated Resident #1 was upset, she was screaming at staff when entering her room about how long she had been waiting for staff to put her to bed. Staff A and Staff B apologized for the delay and that they were with other residents and doing the best they could. Resident #1 continued screaming at both CNA's telling them how much bullshit it was and that they were terrible. Staff B then stated Staff A made the comment, I can't deal with this right now. Resident #1 then began screaming at Staff A, don't f***ing touch me, don't f***ing touch me, don't f***ing touch me. Staff B she let Resident #1 know Staff A would not be doing her cares, that Staff B would but still needed Staff A's assistance to roll the resident so Staff B could provide cares. Resident #1 then stated why does that matter, no one cares. Staff B reassured her that they indeed do care. The ADON finished her medications a few minutes later and returned to the nurse's station when the Social Service Director (SSD) informed her that Resident #1 made a grievance that she waited two hours to put to bed and that Staff A was rude to her. The SSD stated she had just talked with Resident #1 and had not had a chance to write it up yet. The ADON questioned Staff A and she stated, Resident #1 was screaming at us for taking so long. She tried to explain why and they couldn't really help it but were trying the best they could. Resident #1 continued to scream at them, saying how awful they were. When they got her into bed, Resident #1 started screaming don't f***ing touch me like five times and Staff A said ok Staff B told Resident #1 that she needed her help rolling her to do cares. The ADON asked why the resident was yelling at Staff A not to touch her. Staff A stated because she was mad and does not like me, never has, she is like that with staff she does not like when she is upset. The ADON asked if she stated that she wasn't or can't going to deal with this right now and she indicated she had not made that statement. After question Staff A, the ADON went to speak with Resident #1. Upon entering the resident's room it was noted that resident was not in distress and was in a calm mood. The ADON stated that she had heard the resident was upset and asked what had happened. Resident #1 stated she was upset because she waited two hours to be laid down and told the staff it was bullshit. She added she should not have to wait that long, then Staff A told her she can't deal with this. Resident #1 indicated she did not like people talking like that to her. The ADON stated she understood and that she would speak with Staff A about the way she spoke to Resident #1 and they apologized. The ADON also took accountability for the staff taking so long to lay her down as she tasked them with passing snacks, fresh ice water, and the baths for the evening to ensure all duties were completed in a timely manner. Resident #1 stated that she understood stuff like that happens sometimes. The ADON then reiterated that this did not excuse Resident #1's comment and that it will be addressed. Resident #1 thanked the ADON, stated no when asked if there was anything else she would like to talk about or needed. Resident #1 still seemed to be in a calm, pleasant mood. After the conversation with Resident #1, the ADON went to the nurse's station and realized a resident needed a neuro check completed and went to find another resident on the floor. This nurse instructed Staff A to complete her charting and take out the trash before leaving as it was already 10:00 PM. Staff A was educated on importance of professionalism and instructed that in situations that are overwhelming, she needs to ensure resident safety then leave the room, go to the charge nurse and allow the charge nurse to intervene. d) The Administrator's statement indicated Staff C entered his office shortly before 3:00 PM on 7/24/24. She stated that she had heard from Staff D CNA had reported a concern to her and that Resident #1 wanted to talk with him. Resident #1 requested Staff C to be with her. Resident #1 came in and said she was very upset with Staff A and the way she's been treatment her. Resident #1 stated Staff A was rude to her but did not want to say what Staff A had said to her. She indicated she reported the incident to the ADON and the SSD. We continued talking but she did not feel comfortable saying anymore. She was assured that is was absolutely find bringing her concerns to him and that he really wanted to help. The Administrator told her that he wanted her to be happy here because it's her home. Resident #1 asked if Staff A could not be present in her room or provide her care, he agreed. Resident #1 left the room and Staff C returned after and told him that Resident #1 said Staff A said she was not putting up with her shit tonight and that Staff B heard it too. e) The SSD statement indicated she entered Resident #1's room to do assessments with her. Resident was lying in bed. Once the first assessment was completed, Resident #1 stated she was rude. When asked who was rude, she stated Staff A. When they came in, Resident #1 was upset because she waited two hours to be put to bed. Resident #1 stated Staff A told her there's 20 something other residents and to be considerate. She then stated that Staff A said more but did not state what else was said. Resident #1 stated Staff A said I'm not doing this and walked out of the room. The SSD stated she would write up a grievance and that they would talk to Staff A. Resident #1 thanked her and they finished the assessments. When the SSD left the room, Resident #1 was smiling and appeared content. The facility investigative file included the following summary: a) Resident #1 is a [AGE] year-old cognitively impaired female who was admitted to the facility on [DATE] with a primary diagnosis of acute cystitis without hematuria and spastic diplegic cerebral palsy. b) At 3:00 PM on 7/24/24, Resident #1 reported to the Administer that Staff A had been verbally abusive to her at approximately 9:30 PM on 7/23/24. She could not verbalize the actual statements that Staff A had made to her at that time. When asked if anyone else was present or aware, she stated that Staff B witnessed the incident and that she had reported it to the ADON and SSD the night prior. The DON was immediately notified, and the Administrator initiated an abuse investigation. c) Investigation Findings: 1) On 7/24/24 at approximately 2:00 PM during care, Resident #1 told Staff D that Staff A had yelled at her the night before and that she told her to shut up. She also stated that Resident #1 had reported this to the ADON and the SSD. Staff D immediately reported this to Staff C charge nurse. 2) Staff C followed up with Resident #1 after she finished her talk therapy, at approximately 2:45 PM. Resident #1 told Staff C that Staff A had cursed at her. According to Resident #1's statement to her, Staff A had told her they did not have time for her shit. At that time, she brought Resident #1 to the Administrator, initiating the abuse investigation. Resident #1's initial statement to the Administrator was that Staff A had been verbally abusive to her. When asked what she had said, Resident #1 stated she could not repeat it. She stated it was too terrible for her to report. She also stated that she told Staff A to not touch her after she assisted her to bed. Resident #1 repeated that she no longer felt comfortable with Staff A providing her care. Resident #1 stated she reported her concerns to the ADON and the SSD and Staff B had witnessed all their interactions that night. 3) Staff B stated that Resident #1 was upset and yelling at both staff as they entered her room. They had a hectic night and she had to wait longer than she wanted to be assisted to bed. Staff B confirmed that Staff A told Resident #1 that she wasn't putting up with her shit tonight. She reported this to her charge nurse, ADON that night. 4) The ADON stated that Staff B did inform her of the incident but that Staff A had said she could not deal with this right now to the resident. Staff B stated to her that Resident #1 was upset throughout her cares, but they had tried to reassure her. The ADON followed up with Resident #1 and found her to be calm and not in distress. The ADON let her know that if Staff A had been rude to her that that was not acceptable and that she would follow up with Staff A to address the incident. Resident #1 had no further concerns at that time and stated stuff like that happens sometimes. At no time was Resident #1 upset or voicing concerns about verbal abuse. 5)The SSD stated that the evening of 7/23/24, Resident #1 had brought concerns that Staff A had been rude. When she asked what had happened, Resident #1 told her she had to wait two hours to be put to bed and that Staff A had told her that she needed to be more considerate of the other residents. She also stated that Staff A had said, I am not doing this and walked out of the room. The SSD told her she would fill out a grievance form for her and the team would follow up with Staff A. Resident #1 voiced no other concerns at that time and SSD left her smiling and content. On 7/30/24 at 2:18 PM Resident #1 stated she turned Staff A in because she has been very abusive to a lot of people at the facility, herself included. She works the evening shift, 2:00 PM-10:00 PM, is only 16 and the daughter of the ADON. The ADON will cover Staff A's butt and a lot of her family works here too so they will also cover up for her. She gets special treatment because of that. Resident #1 stated from her stand-point Resident #1 is very verbally abusive. When asked what has happened, she indicated Staff A has called her a whore, bitch and white trash. She has called her these things to her face. Staff A has also told Resident #1 is not allowed to have feelings or emotions. Staff A has told her she is not allowed to get her in trouble or say anything. When asked how this made her feel, Resident #1 said it pisses her off when Staff A acts like this. This is supposed to be her home, she's not supposed to feel this way about anyone that works here. When Resident #1 does peri-care she does it very hard. She's never been told of any injuries but is sore after Staff A cares for her. She has asked her to please not care for her. Staff A's response to that was I don't f***ing care, I'll f***ing do it anyway's. Last week, while Staff A and Staff B were assisting her to bed, Staff B told the resident I am not dealing with your shit. Resident #1 indicated she has talked with the Administrator, the ADON, DON and SSD about her concerns. All staff tell her when she reports concerns is, they will talk with her. Staff A is back to working at the facility but she is not allowed to care for Resident #1. Resident #1 reported feeling uncomfortable around her presence, does not want her looking at her. On 7/30/24 at 3:34 PM the ADON stated she was passing medications on hall 2 when Staff B came to her and said just a heads up, Resident #1 is not in a good mood. She was upset because they took so long to get her to bed. Resident #1 was screaming at them and Staff A made a comment that upset her further. When asked what comment it was, she stated I don't know, something along the lines of I can't deal with this shit right now. Resident #1 screamed back at her don't f***ing touch me, don't touch me. Once she was done with her medication pass, she spoke to Staff A. She reported Resident #1 was yelling at them, saying this place was awful, literally screaming in their faces how long she had been waiting. Resident #1 was yelling at Staff A to not touch her. Staff A was asked if she made the comment can't deal with this shit, she could not remember if she cussed. The ADON told her you can't talk like that to residents, if you get frustrated you can't talk like that. The ADON stated it sounds like it was a slip of the tongue kind of thing. She told Staff A to take the trash out and finish charting. The ADON went in to speak with Resident #1. She indicated she was upset because she waiting forever to get to bed. Staff A told Resident #1 she can't deal with this shit right now and Resident #1 told Staff A to not touch her. The ADON explained to the resident what Staff A said was not ok and it would be handled. The ADON explained she told the staff members to get snacks passed and baths done before getting residents to bed. Resident #1 voiced understanding, was fine and did not want to talk about anything else. When asked who she reported this alleged incident to, she stated to be honest she intended to let the DON know but when she got to the nurse's station two other residents needed her attention. She had one resident that had fallen and one that was crawling in and out of bed. She indicated she was notified of the allegation on 7/23/24 roughly at 9:30-9:40 PM. The DON found out about the allegation the next morning but not from her, from someone else. When asked what she should have done with the information that Staff B shared with her, she acknowledged she should have contacted the DON right away. On 7/30/24 at 2:59 PM Staff B stated she worked the night of the alleged incident. Resident #1 reported she was ready for bed. Staff B informed her she will need to get help, Staff A was doing a bath at that time. Resident #1 then stated, I told you two f***ing hours ago I wanted to go to bed. Staff A stated I am not dealing with your shit. Resident #1 stated and I am not dealing with your f***ing attitude. Once they got her to bed, Staff B asked if she was ok and Resident #1 stated it does not f***ing matter. She then looked at Staff A and said you are not f***ing touching me. Staff B indicated Resident #1 did not need her brief changed. Once they left the room, Staff B told the ADON what had happened. The ADON told her she would talk to her. She works with Staff A and there are times she thinks she is joking but she's not. Staff B stated she did not think the comment she made to Resident #1 had meaning behind it. She was having a tough day that day. On 7/31/24 at 2:54 PM the SSD stated when Staff A and B exited Resident #1's room, she went in to her room to complete assessments for her MDS. Resident #1 told the SSD that her and Staff A got in to it. When asked what happened, the resident told her, Staff A and Staff B came in and she was upset. The resident indicated she yelled because she had to wait to be put to bed. Staff A told her to please be considerate of the 20 other residents in the facility. The resident reported more words were exchanged. Staff A said I am not doing this tonight and left the room. The SSD stated she filled out a grievance on it as she did not think it was abuse. She informed Resident #1 that she would fill out a grievance and let the ADON know. The SSD denied that Resident #1 reported Staff A had cursed that day. On 7/31/24 at 12:51 PM the DON stated she was made aware of the alleged incident on 7/24/23, it had taken place on the evening shift of 7/23/24. Staff C had reported to her that Resident #1 was in the Administrators office informing him of the events that took place on 7/23/24. On 8/2/24 at 2:39 PM the Administrator stated a CNA had reported that Resident #1 complained about Staff A being rude to her the night before. After Resident #1 completed talk therapy, she came to his office and talked with her. She was very nervous and could not give a lot of information at that time. She indicated Staff A was rude, very upset by it and did not want her taking care of her anymore. After they spoke with Resident #1 she reported Staff A was not going to put up with her shit. This cued him to start looking in to this. The DON was not aware of this and the only thing they knew of was a grievance on Resident #1's behalf. The SSD completed the grievance and said it was filed the night before but it did not have, not putting up with her shit, on the form. They had confirmed that Staff A had used very inappropriate language. Staff A denied saying this but to her co-worker out of frustration because the nurse was riding them hard that night. The next day Resident #1's story changed when she spoke with the DON and Staff E. She had denied Staff A had said she was not going to put up with her shit but added new allegations of verbal stuff. Resident #1 stated Staff A told her she wished she was, not born. The Administrator stated in his mind at this point, he was convinced something had happened. Whatever happened was inappropriate and not intended to be abusive. What happened was affecting Resident #1 so they educated Staff A and gave her a final warning before returning back to work. When asked if the ADON should have reported this on 7/23/24 he stated in retrospect, she should have dug more in to what had happened. He stated no matter what, if someone has a concern, he should be contacted directly. The facility provided a document titled F609, Reporting of Abuse Allegations. All suspected violations and all substantiated incidents of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another health care provider, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, abuse, including injuries of unknown source, and misappropriation of resident property. Should a suspected violation or a reasonable suspicion or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse, or suspected crimes, or suspected evidence of humiliating or demeaning photographs or recordings) be reported, the facility Administrator, or his/her designee in their absence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, family interview, resident interview, staff interview and facility policy review the facility failed to protect residents from alleged sexual abuse for 3 of 5 residents reviewed (Resident #4, #5, and #6). The State Agency (SA) informed the facility of the Immediate Jeopardy (IJ) on 7/27/23 at 2:00 PM that began as of 1/24/23 at 2:42 PM. The Facility Staff removed the immediacy on 7/28/23 through the following actions: a. On 7/18/23 Regional Director of Operations (RDO), Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Social Worker ad-hoc meeting to discuss potential root cause of occurrence. During the meeting a root cause analysis was performed regarding probable nonconsensual sexual activity between resident to resident and to identify areas of opportunity. Root cause analyis performed and determined to be related to poor decision making on Resident #6 behalf and inability for him to know that this resident had mental incapability. b. On 7/18/23 the following actions occurred: the families of Resident #5 and #6 were notified of the incident, Ombudsman notified, police notified, hospice for Resident #6 notified, incident was reported to state agency, Medical Director ordered Resident #5 to go to Emergency Department for evaluation and treatment with the order completed as directed, and Resident #5 had psychiatric evaluation. c. On 7/27/23 Administrator called state agency to report the incident that occurred on 1/24/23. Administrator initiated ANE (Elder Abuse and Exploitation) training to include behavior training and non-pharmacological interventions. RCA (Root Cause Analysis) was completed on 7/28/23. Ad hoc QAPI (Quality Assurance and Performance Improvement) meeting was held 7/28/23. d. As of 7/21/23 Resident #5 remains on 1:1. e. On 7/18/23 all residents with a BIMS (Brief Interview of Mental Status) of 13 or higher were interviewed for any distress with intervention put in place for the 1 resident with distress. Resident #10 stated that he did not like her coming into his room and no further complaints have been voiced. All residents with a BIMS of 12 and below were assessed for signs and symptoms of distress, crying, agitation, verbal or physical aggression with none noted. f. On 7/28/23 Regional Director re-educated the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Social Worker on abuse, resident rights, Elder Justice Act, The National Consumer Voice for Quality Long Term Care Sexual Abuse in Nursing Homes. g. Beginning 7/18/23 staff was re-educated on abuse, resident rights, Elder Justice Act, The National Consumer Voice for Quality Long Term Care Sexual Abuse in Nursing Homes. All staff including agency have completed the required Allegations of Compliance in-services. Employees will not be able to accept a work assignment until the in-services are completed. New hires and employees on LOA (Leave of Absence) will not be placed on the schedule until the in-services are completed. h. Beginning on 7/18/23, in addition, Licensed Nurses and Interdisciplinary Team (IDT) will be educated on monitoring the effectiveness of interventions as they related to inappropriate sexual behavior for 5 days after an alleged incident. IDT will monitor by discussing at morning meeting. Licensed Nurses will document effectiveness of interventions on MAR (Medication Administration Record) for 5 days each shift. i. DON/designee will audit MARs each shift for 5 days after interventions are in place. Monitoring will continue for 8 weeks, then monthly for 3 months. LNHA (Licensed Nursing Home Administrator) will report findings in QAPI meetings monthly for 3 moths or until a period of compliance is achieved. j. LNHA will submit all reports of alleged abuse weekly to RDO to review to ensure the process meets regulatory guidelines. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #4 revealed a Brief Interview of Mental Status (BIMS) score of 4 out of 15 which indicated severely impaired cognition. The MDS documented a diagnoses to include amnesia. The Care Plan for Resident #4 revised on 2/6/23 documented the resident has a behavior problem (having multiple episodes) related to unrealistic expectations. The Care Plan directed staff as follows: -Anticipate and meet the resident needs. -Caregivers to provide opportunity for positive interaction, attention, stop and interact as passes by. -Monitor behavior episodes and attempt to determine underlying cause. The Care Plan dated 6/9/23 documented the resident has the potential to be verbally aggressive related to the aging process/confusion. The Care Plan directed staff as follows: -Assess and anticipate resident needs. -Give the resident as many choices as possible about care and activities. The Care Plan lacked any indication of sexual behaviors. The Progress Note for Resident #4 documented the following: On 1/24/23 at 12:12 PM the Director of Nursing (DON) went to a female resident room to inform her that it was lunch time. Upon entering the room, Resident #4 was leaning over female residents bed, groping the females breasts and kissing her intimately. The DON informed the resident to leave her room and asked the female resident if she was okay and if she had consented to that encounter. The female did nod her head yes. The DON went to residents room and educated him on the importance of consent and explained that some people may not be able to make proper decisions for themselves. Fax sent to Primary Care Provider (PCP) to update. Residents daughter also notified of encounter. In an interview on 7/26/23 at 11:18 AM, the resident's daughter reported that the resident was accused of touching a female resident, the resident has always been lovey in behavior. She stated the facility hasn't informed her that anything has happened between this resident and other residents since the new company took over in 11/22. In an interview on 7/26/23 at 2:31 PM, Staff A, CNA, reported that the resident's nickname among staff was Captain [NAME] Pants, because he can get inappropriate with staff. She stated the staff remind him to behave and he hasn't been an issue since before the beginning of May. She added before that he was touchy feely. She stated he would sit on the couch and grope female residents but he never would go past first base. She stated he would touch them outside of their clothes and would touch their breasts outside of their clothes. The aide stated she remembered him with Resident #3 touching her at times. She stated they separated them and redirected them. In an interview on 7/26/23 at 2:16 PM, the DON when she observed the 2 residents involved in the sexually inappropriate behavior on 1/24/23, she knew the residents were confused, and they were easily separated and redirected. The DON reported that the 2 residents were not able to consent to sexual activity and that their families did not give consent for the residents to engage in sexual activity. The DON reported that she talked to previous Administrator about the incident on 1/24/23. 2. The MDS dated [DATE] for Resident #5 revealed the resident had short term and long term memory problems, had severely impaired cognitive skills for daily decision making, and had inattention and disorganized thinking behavior present that fluctuates. The MDS documented diagnoses to include non-traumatic brain dysfunction, Alzheimer's disease, and schizophrenia. The Care Plan revised on 7/20/23 for Resident #5 documented the resident is at risk for wandering and elopement related to impaired safety awareness. The Care Plan directed staff as follows: -Ensure a safe distance from other residents who have a tendency to become agitated with her actions. -Follow facility elopement policy and procedures. -Identify pattern of wandering: purposeful, aimless or escapist; looking for something; or need more exercise? -Monitor location with one on one supervision at all times. Document wandering behaviors and attempted diversion interventions. The Care Plan revised on 7/31/23 for Resident #5 documented the resident has a behavior problem of sitting on the floor and going into other resident's rooms related to cognitive impairment. The Care Plan directed staff as follows: -Anticipate and meet the resident's needs. -Caregivers to provide opportunities for positive interaction, attention, and to stop and interact as passes by. -Psyche referral as needed for behavior and medication management. The Care Plan lacked any indication of sexual behavior. The Progress Notes for the resident documented the following: On 7/17/23 at 10:29 PM CNA paged nurse to resident's room. CNA reported to this nurse that she had walked in on resident and another resident during an inappropriate act. CNA had already started to separate residents and this nurse took the other resident out of the room and delegated cna to stay with Resident #5 until nurse could get back and perform assessment. Male resident escorted to nurses station and this nurse went back to resident's room. Skin assessment completed along with psycho-social eval completed. resident stated to this nurse when asked if she was okay with what happened and she stated she didn't mind it. Skin assessment revealed no skin breaks, marks or vaginal bleeding. Resident stated that she was not injured or hurt. Resident was not showing any obvious signs of being upset or distressed, not crying or agitated. She was not verbally or physically aggressive. Half hour checks completed by staff on resident to ensure safety. Resident found to be wandering a few times and redirected back to her room. Contacted Administrator, DON and ADON immediately after incident at approx 10:21 PM after separating the residents. On 7/18/23 at 9:39 AM DON and ADON spoke with resident's brother at 9:32 AM. DON updated brother on incident between resident and a male resident. Brother stated that he wanted facility to do what they think is right and make sure his sister is okay. Brother aware and gave consent for resident to be seen at local hospital for evaluation per orders from the resident's physician that were received at 9:39 AM. The ED (Emergency Department) Provider Note for the resident signed by a physician on 7/18/23 at 11:32 AM documented the following: -Per staff report, another resident went into patient's room, took off his clothes, and laid on top of her. SANE (Sexual Assualt Nurse Examiner) nurse reports patient denied sexual intercourse. She stated patient told him to stop, then CNA walked by room. CNA reports telling other resident to leave room. Per CNA report, he left patient's room and was sent to a different hallway. Patient has no complaints at this time. -Description of Assault: Patient was in her room, male stated he wanted to do sex, patient stated, get outta here. He took his and her clothes off. She stated this occurred at another facility. Asked to clarify and then she stated it happened in her room. Patient was asked multiple times and in different ways if there was penile penatration, patient denies each time. (vaginally, orally, anally). Staff CNA at the nursing home walked in and found male on top of the patient. She stated that male was undressed and patient undressed waist down. CNA told male to leave room and get dressed. Male got up, left, dressed, and was escorted to a different hallway in facility. Nursing Home Facility called and reported incident to SA and called law enforcement to report. -Activities Following the Assault: Patient account: I told him get off, get off. Some people walked in and said get outta there. He dressed up and got outta the room. Patient was brought to ED for assessment. Interviewed by SANE RNs and law enforcement. Brother called and consent was obtained for external exam done and to defer the internal exam. -Assessment of General Appearance Note Full body skin assessment performed with unremarkable findings. Adult brief observed to be clean and free from bloody/bodily fluids. In an interview on 7/26/23 at 12:25 PM, Resident #11 reported that Resident #5 came into her room several times and was combative. Resident #11 yelled down the hall for someone to get the resident out of her room. When she tried to corral her towards the door, Resident #5 came at her in a threatening way. Resident #11 did not see her be sexually inappropriate but stated she felt she could be. She stated the way Resident #5 looked at her made her uncomfortable. She stated she told whoever was in charge that she couldn't sit with her because she made her uncomfortable. She stated Resident #5 came into her room and sat on the sofa and the way she looked at her made her uncomfortable. She stated the resident invited her to her room too. In an interview on 7/26/23 at 1:17 PM, the resident's brother reported that he was not informed of the incident on 1/24/23 of a sexual interaction with another male resident or any other incidents of inappropriate sexual behavior. He was only informed by the facility of the incident of sexual abuse that occurred 7/17/23. In an interview on 7/26/23 at 2:16 PM, the DON stated when she observed Resident #4 and Resident #5 involved in the sexually inappropriate behavior on 1/24/23, she knew the residents were confused, and they were easily separated and redirected. The DON reported that the two residents were not able to consent to sexual activity and that their families did not give consent for the residents to engage in sexual activity. The DON reported that she talked to previous Administrator about the incident on 1/24/23. 3. The MDS dated [DATE] for Resident #6 revealed a BIMS score of 12 out of 15 which indicated moderately impaired cognition. The MDS revealed the resident had diagnoses of history of malignant neoplasm of bronchus and lung (lung cancer), and malignant neoplasm of supraglottis (throat cancer). The Progress Notes for Resident #6 documented the following: On 7/17/23 at 10:30 PM aide (CNA) called nurses station to have nurse come to room [ROOM NUMBER] (Resident #5's room) at 10:18 PM. Upon entering room found Resident #6 siting in his wheelchair. CNA reported inappropriate sexual incident between the residents. Nurse delegated one CNA to stay with female resident in room and nurse took Resident #6 back to nurses station. Completed assessment with no injury noted and contacted the DON, ADON and Administrator. Moved resident to 115 consented to move and put on half hourly checks. No signs of psycho-social distress, he was not crying, agitated or verbally or physically aggressive. Res was compliant and cooperative with staff and followed directions without incident. Staff continued half hour checks on resident throughout remainder of shift and report given to day nurse on incident. On 7/19/23 at 1:12 AM resident has been 1:1 with staff -out to main lounge with staff to watch TV and just be out of his room. Head down-moving slow tonight-Stated he was told he could have company today and the sheriff came. Nothing more said. On 7/19/23 at 7:59 AM resident refused breakfast this morning after resident stated he doesn't feel like getting out of bed. administrator asked resident if he was feeling ok resident stated no he is feeling depressed. SW will follow up with any new concerns. On 7/21/23 at 10:48 AM SW spoke with this resident today. SW counseled resident on inappropriate behaviors. Resident stated to this social worker that he is very sorry he knows what he did was wrong and that if he could take it back, he would in a heartbeat and won't ever do it again. In an interview on 7/25/23 at 4:19 PM, the resident reported he was walking the hall the evening of 7/17/23 when Resident #5 stopped him and told him that she loved him and that she wanted to try him. The resident reported that he hadn't had sex in five to six years and thought he would try to even though he has erectile dysfunction. He stated he was unable to penetrate Resident #5's vagina. A CNA found them trying to have sex and he was moved to his current room. Reported he has had staff with him a lot and that they needed to stop with the increased supervision because he didn't like it. The resident reported that if he knew what would happen, he never would have took Resident #5 up on her offer. The Physician Progress Notes on 7/17/23 at 10:18 PM revealed a witness statement signed by Staff B, CNA, that documented the following: I was passing my waters when I walked into Resident #5's room and saw Resident #6 on top of Resident #5/inside the resident. Resident #6 had zero clothes on, Resident #5 was only undressed from the waist down. When opening the door Resident #6 was mid-thrust when both residents turned to look at me (Staff B). While in shock, I very calmly asked Resident #6 to please get off of her. I then proceeded to pull out my phone to call the nurse and tell her to get down to Resident #5's room. The nurse and another staff member got to the room in about 10 seconds; which was how long it took Resident #6 to follow directions and get dressed. Resident #6 then followed the nurse to the nurse's station, the staff member stayed with Resident #5, and I continued to pass waters. In an interview on 8/2/23 at 5:04 PM, Staff B reported that while she was passing waters, she got to Resident #5's room and saw Resident #6 in mid thrust while he was lying on top of Resident #5. She called the nurse and while she waited for the nurse to arrive, Resident #6 got dressed. During the night, Resident #5 started wandering, looking for Resident #6's room, when she saw that Resident #6 was not in his room, she wandered the facility trying to find Resident #6. Resident #5 wandered a lot for her normal behavior. The Abuse Prevention Program dated 7/23 revealed: 1. Reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. 2. Residents will protected from further abuse, neglect, exploitation or mistreatment while the investigation is in process. 3. Should an incident or suspected incident of resident abuse, mistreatment, misappropriation, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. 4. The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; g. Interview the resident's roommate, family members, and visitors, as able or as appropriate to the situation; h. Review all events leading up to the alleged incident. 5. The Administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation. 8. The results of the investigation will be recorded on approved documentation forms. 9. The investigator will give a copy of the completed documentation to the Administrator. 10. The Administrator will inform the resident and his/her representative (sponsor) of the results of the investigation and corrective action taken. 11. The Administrator will report all alleged and final abuse investigations to the state agency per state guidelines. 12. Should the abuse rise to the level of a crime, follow reporting guidelines in Reporting Abuse to State Agencies and Other Entities/Individuals 13. Inquiries concerning abuse reporting and investigation should be referred to the Administrator or to the Director of Nursing Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, family interview, resident interview, staff interview and facility policy review the facility failed to protect residents from alleged sexual abuse for 2 of 5 residents reviewed (Resident #4 and #5). The State Agency (SA) informed the facility on 7/27/23 at 2:00 PM of the Immediate Jeopardy (IJ) that began as of 1/24/23 at 2:42 PM. The Facility Staff removed the immediacy on 7/28/23 through the following actions: a. Root Cause Analysis was completed 7/28/23. Root Cause findings: Administrator did not report the incident to the appropriate agency within 2 hours. b. On 7/28/23 Regional Director re-educated the Director of Nursing (DON), Assistant Director of Nursing ADON), and Social Worker on abuse, resident rights, Elder Justice Act, The National Consumer Voice for Quality Long Term Care Sexual Abuse in Nursing Homes, and abuse reporting guidelines and investigations. c. LNHA (Licensed Nursing [NAME] Administrator), DON (Director of Nursing) and/or designee will monitor 24/72 hour report 5 times per week for any allegations of abuse. Evidence of monitor reports will be kept in a binder. Any negative findings will be reported to QAPI (Quality Assurance and Performance Improvement) weekly for 8 weeks, then monthly for 3 months. NHA (Nursing Home Administrator) will report findings in QAPI monthly for 3 months or until a period of compliance is achieved. d. LNHA or DON will monitor and audit all reports of alleged abuse and missing residents are investigated thoroughly. RDO/designee will review alleged abuse and elopement investigations after completion by NHA per occurrence. RDO/designee will monitor weekly for 8 weeks, then monthly for 3 months. NHA will report findings in QAPI weekly for 8 then monthly for 3 months. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #4 revealed a Brief Interview of Mental Status (BIMS) score of 4 out of 15 which indicated severely impaired cognition. The MDS documented a diagnoses to include amnesia. The Care Plan for Resident #4 revised on 2/6/23 documented the resident has a behavior problem (having multiple episodes) related to unrealistic expectations. The Care Plan directed staff as follows: -Anticipate and meet the resident needs. -Caregivers to provide opportunity for positive interaction, attention, stop and interact as passes by. -Monitor behavior episodes and attempt to determine underlying cause. The Care Plan dated 6/9/23 documented the resident has the potential to be verbally aggressive related to the aging process/confusion. The Care Plan directed staff as follows: -Assess and anticipate resident needs. -Give the resident as many choices as possible about care and activities. The Care Plan lacked any indication of sexual behaviors. The Progress Note for Resident #4 documented the following: On 1/24/23 at 12:12 PM the Director of Nursing (DON) went to a female resident room to inform her that it was lunch time. Upon entering the room, Resident #4 was leaning over female residents bed, groping the females breasts and kissing her intimately. The DON informed the resident to leave her room and asked the female resident if she was okay and if she had consented to that encounter. The female did nod her head yes. The DON went to residents room and educated him on the importance of consent and explained that some people may not be able to make proper decisions for themselves. Fax sent to Primary Care Provider (PCP) to update. Residents daughter also notified of encounter. On 1/30/23 at 9:12 PM the resident continues on increase dose of Namenda with no signs and symptoms of any adverse reactions noted, multiple behaviors noted tonight- found trying to get resident from room [ROOM NUMBER] (Resident #5) to let him go up under her shirt-this nurse separated them-yelling about taking his pill-why does he have to take them-yelling about blanket-staff went immediately downstairs to get it stood shouting and stomping at nurse's station until she got back up stairs with it. On 3/23/23 at 2:42 PM Care Plan Meeting: attended ADON, SSD (Social Services Director), Activity Director, resident's daughter , resident. Discussed residents care, wt at 139, daughter please resident is starting to gain some. resident c/o (complained of) staff telling resident not to sit too close to female residents staff discussed resident inappropriately touching other residents at times. No other concerns at this time. Plan is for resident to remain in facility contrary to residents belief, daughter is unable to provide the care he needs. Family has no concerns at this time. On 4/9/23 at 2:48 PM resident touching a female resident thigh and rubbing her shoulders and kissed her. On 4/16/23 6:19 PM resident sitting on couch in lounge, seen trying to get his hands up underneath another resident shirt. Residents separated, and he went to his room, yelling about it being cold in here. In an interview on 7/26/23 at 11:18 AM, the resident's daughter reported that the resident was accused of touching a female resident, the resident has always been lovey in behavior. She stated the facility hasn't informed her that anything has happened between this resident and other residents since the new company took over in 11/22. In an interview on 7/27/23 at 1:16 PM Resident #12 reported that she has observed the resident touch Resident #3's breast and genitals. Resident #12 has observed the resident take his penis out of his slacks and Resident #3 touched the resident's penis. Resident #12 reported that she saw this before the resident had COVID in 4/23. In an interview on 7/26/23 at 2:31 PM, Staff A, CNA, reported that the resident's nickname among staff was Captain [NAME] Pants, and he can get inappropriate with staff. She stated staff remind him to behave. She stated he hasn't had any issues since before the beginning of May but before that he was touchy feely. He would sit on the couch and grope female residents. She stated he never would go past first base, he would touch them outside of their clothes including their breasts. She stated she remembered him with Resident #3 touching her at times. She stated staff separated them and redirected them. In an interview on 7/26/23 at 2:16 PM, the DON reported that the other resident involved in the 1/24/23 incident was Resident #5. She stated she talked to the previous Administrator about the incident on 1/24/23 and was informed the incident didn't need to be reported to the SA. She stated she didn't know they had to be reported. 2. The MDS dated [DATE] for Resident #5 revealed the resident had short term and long term memory problems, had severely impaired cognitive skills for daily decision making, and had inattention and disorganized thinking behavior present that fluctuates. The MDS documented diagnoses to include non-traumatic brain dysfunction, Alzheimer's disease, and schizophrenia. The Care Plan revised on 7/20/23 for Resident #5 documented the resident is at risk for wandering and elopement related to impaired safety awareness. The Care Plan directed staff as follows: 1. Ensure a safe distance from other residents who have a tendency to become agitated with her actions. 2. Follow facility elopement policy and procedures. 3. Identify pattern of wandering: purposeful, aimless or escapist; looking for something; or need more exercise? 4. Monitor location with one on one supervision at all times. Document wandering behaviors and attempted diversion interventions. The Care Plan revised on 7/31/23 for Resident #5 documented the resident has a behavior problem of sitting on the floor and going into other resident's rooms related to cognitive impairment. The Care Plan directed staff as follows: 1. Anticipate and meet the resident's needs. 2. Caregivers to provide opportunities for positive interaction, attention, and to stop and interact as passes by. 3. Psyche referral as needed for behavior and medication management. The Care Plan lacked any indication of sexual behavior. The Progress Notes for the resident documented the following: On 6/10/23 at 3:46 PM multiple residents approached nurse to express concern d/t (due to) resident being in their rooms while they were not. Resident had multiple different candy items that she was hiding and eating which were not hers. Resident also walked by medication cart and stole applesauce in the middle of medication pass. Resident educated but ineffective as resident continued with behavior throughout the whole shift. On 7/17/23 at 10:29 PM CNA paged nurse to resident's room. CNA reported to this nurse that she had walked in on resident and another resident during an inappropriate act. CNA had already started to separate residents and this nurse took the other resident out of the room and delegated cna to stay with Resident #5 until nurse could get back and perform assessment. Male resident escorted to nurses station and this nurse went back to resident's room. Skin assessment completed along with psycho-social eval completed. resident stated to this nurse when asked if she was okay with what happened and she stated she didn't mind it. Skin assessment revealed no skin breaks, marks or vaginal bleeding. Resident stated that she was not injured or hurt. Resident was not showing any obvious signs of being upset or distressed, not crying or agitated. She was not verbally or physically aggressive. Half hour checks completed by staff on resident to ensure safety. Resident found to be wandering a few times and redirected back to her room. Contacted Administrator, DON and ADON immediately after incident at approx 10:21 PM after separating the residents. On 7/18/23 at 9:39 AM DON and ADON spoke with resident's brother at 9:32 AM. DON updated brother on incident between resident and a male resident. Brother stated that he wanted facility to do what they think is right and make sure his sister is okay. Brother aware and gave consent for resident to be seen at local hospital for evaluation per orders from the resident's physician that were received at 9:39 AM. The ED (Emergency Department) Provider Note for Resident #5 signed by a physician on 7/18/23 at 11:32 AM revealed: -Per staff report, another resident went into patient's room, took off his clothes, and laid on top of her. SANE (Sexual ASSUALT Nurse Examiner) nurse reports patient denied sexual intercourse. She states patient told him to stop, then CNA walked by room. CNA reports telling other resident to leave room. Per CNA report, he left patient's room and was sent to a different hallway. Patient has no complaints at this time. -Description of Assault: Patient was in her room, male said he wanted to do sex patient said, get outta here. He took his and her clothes off. She stated this occurred at another facility. Asked to clarify and then said In my room. Patient was asked multiple times and in different ways if there was penile penetration, patient denies each time. (vaginally, orally, anally). Staff CNA at nursing home walked in and found male on top of the patient. She stated that male was undressed and patient undressed waist down. CNA told male to leave room and get dressed. Male got up, left, dressed, and was escorted to a different hallway in facility. Nursing Home Facility called and reported incident to the SA and called law enforcement to report. -Activities Following the Assault: Patient account: I told him get off, get off. Some people walked in and said get outta there. He dressed up and got outta the room. Patient was brought to ED for assessment. Interviewed by SANE RNs and law enforcement. Brother called and consent was obtained for external exam done and to defer the internal exam. -Assessment of General Appearance Note Full body skin assessment performed with unremarkable findings. Adult brief observed to be clean and free from bloody/bodily fluids. In an interview on 7/26/23 at 12:25 PM, Resident #11 reported that Resident #5 came into her room several times and was combative. The resident yelled down the hall for someone to get the resident out of her room. When she tried to corral her towards the door, the resident came at her in a threatening way. Resident #11 did not see her be sexually inappropriate but she felt she could be. Resident #11 stated she told whoever was in charge that she couldn't sit with her because she made her uncomfortable. She stated the resident would come into her room and sit on the sofa and look at her and it was creepy and made her uncomfortable. In an interview on 7/26/23 at 1:17 PM, the resident's brother reported that he was not informed of the 1/24/23 incident or any other incidents of inappropriate sexual behavior or the resident's issues wandering. He stated he was informed by the facility of the incident of sexual abuse that occurred 7/17/23. In an interview on 7/26/23 at 2:16 PM, the DON reported that the residents involved in the incident she charted on 1/24/23 were Residents #4 and #5. She stated she knew the residents were confused and that their families did not give approval for them to have sexual behavior at the facility. She stated she reported the incident to the facility Administrator who advised her that the incident did not need to be investigated. The Progress Note for Resident #5 lacked documentation of any incident on 1/24/23 of a sexual interaction with a male resident. The Progress Note is in the clinical record for Resident #4. The facility policy Compliance with Reporting Allegations of Abuse/Neglect/Exploitation with revision date of 7/23 revealed: 1. The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. 2. New employees will be educated by the department manager, or designee, on issues related to abuse prohibition practices and abuse reporting requirements during initial orientation. Annual education and training will be provided to all existing employees. Front line supervisors will provide education as situations arise. 3. The facility will identify events, occurrences, patterns and trends that may constitute: sexual Abuse, the non-consensual sexual contact of any type with a resident. 4. Alleged violation: A situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property 5. Investigation: The facility will investigate all allegations and types of incidents as listed above in accordance to facility procedure for reporting/response as described below. 6. Protection: The facility will protect residents from harm during an investigation. 7. The Licensed Nurse will: a. Respond to the needs of the resident and protect him/her from further incident. b. Remove the accused employee from resident care areas. c. Notify the Administrator or designee. d. Notify the attending physician, resident's family/legal representative, and Medical Director. e. Monitor and document the resident's condition, including response to medical treatment or nursing interventions. f. Document actions taken in the medical record. g. Complete an incident report is indicated. h. Revise the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, family interviews, resident interviews, staff interviews and facility policy review the facility failed to provide sufficiency of staff (including both quantity and competency of staff) to care for the behavioral health of 5 of 5 residents reviewed (Resident #3, #4, #5, #6, and #10). The State Agency (SA) informed the facility on 7/27/23 at 2:00 PM of the Immediate Jeopardy (IJ) that began as of 1/24/23 at 2:42 PM. The Facility Staff removed the Immediate Jeopardy on 7/28/23 through the following actions: a. On 7/18/23 order received to increase monitoring of behaviors for Resident #5. b. On 7/18/23 Resident #5 assessed by Primary Care Physician. c. On 7/28/23 obtained an order pharmacy medication review for Resident #5. d. Resident #5 has 1 on 1 supervision. e. Residents #3 and #4 placed on different halls and will be monitored twice weekly by direct care staff to observe any kind of distress or changes in behaviors. f. Resident #6 seen by psych and screened for depression, anxiety, PTSD (Post Traumatic Stress Syndrome), and personality disorder on 7/24/23 with no significant findings per physician. g. On 7/28/23 a stop sign picture was placed on Resident #10's door. h. On 7/28/23 facility conducted an ad hoc QAPI (Quality Assurance and Performance Improvement) meeting. It was determined that direct care staff were not appropriately competent and did not exhibit the skills to provide nursing and related services to assure resident safety and and attain their highest practicable physical, mental, and psychosocial well being. i. On 7/18/23 all residents with a BIMS (Brief Interview of Mental Status) of 13 or higher were interviewed for any distress with intervention put in place for the 1 resident with distress. All residents with a BIMS of 12 and below were assessed 7/18/23 for signs and symptoms of distress, crying, agitation, verbal or physical aggression with none noted. j. On 7/28/23 Regional Director re-educated the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Social Worker on the policy for Behavioral Health Service for F740, F741, F742, F743, and F949. Also included in re-education was the Critical Element Pathways for Dementia and CMS (Centers for Medicare and Medicaid) Powerpoint for Nursing Homes which includes 483.40 Behavioral Health Services overview of F740, F741, F742, F743, F744, and F755. k. On 7/28/23 education was provided to current direct care staff on the policies related to F740, F741, F742, F743, and F949. This includes the staff competencies for residents living with behavioral health needs such as care of cognitively impaired residents, mental health and social services needs, knowledge of behavioral health care and services and demonstrate attempts to access professional behavioral health resources and take reasonable steps to seek alternative sources for services not covered by Medicare or Medicaid. Remaining direct care staff and agency staff not available will not be permitted to take an assignment until education is completed. l. Upon hire and annually all direct care staff will receive education on F741 that includes competencies and skill sets to provide nursing services to assure resident safety and to provide the highest practicable physical, mental, and psychosocial well-being of each resident. Competency is established by observing the staff's ability to use this knowledge thorough the demonstration of skill and implementation of specific, person-centered interventions identified in the care plan to meet resident's behavioral health needs. Additionally, competency involves staff's ability to communicate and interact with residents in a way that promotes psychosocial and emotional well-being, as well as meaningful engagements. m. Administrator and DON will monitor and audit all direct care staff through observation twice weekly to ensure competency of skill sets for 3 months and report findings to QAPI monthly for 3 months or until a period of compliance is achieved. The scope lowered from a K to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #3 revealed the resident had short term and long term memory problems, had severely impaired cognitive skills for daily decision making, and had inattention and disorganized thinking behavior present that fluctuates. The resident had diagnoses of anxiety, intellectual disabilities, and down's syndrome. The Care Plan for Resident #3 dated 11/16/22 documented the resident has a behavior problem of attention seeking and making false allegations related to mental disabilities. The care plan directed staff as follows: 1. Anticipate and meet the resident's needs. 2. If reasonable, discuss the resident's behavior. Explain/reinforce why the behavior is inappropriate and/or unacceptable. The Care Plan for Resident #3 dated 1/5/23 documented the resident is a wanderer and wanders aimlessly at times significantly intruding on the privacy of others or activities. The care plan directed staff as follows: 1. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation. Resident prefers: Coloring, IPad, Puzzles, cartoons. 2. Monitor for fatigue and weight loss. 3. Wander alert: wander-guard bracelet placed. The Care Plan for the resident dated 3/31/23 documented the resident has the potential to be physically aggressive related to mental illness. The Care Plan directed staff as follows: 1. Triggers for physical aggression are others touching her walker. Behavior is de-escalated by re-direction. 2. When the resident becomes agitated: intervene before agitation escalates; guide her from source of distress; engage calmly in conversation; if response is aggression, staff to walk away and approach later. The Progress Notes for the resident documented the following: On 1/14/23 at 5:33 PM Physician notified via fax regarding resident behaviors. Staff observed her licking her wall. Staff have not been able to keep her out of other resident rooms or to use her walker. Observed crawling down the hall. On 1/14/23 at 10:53 PM resident wandering facility and being silly dancing in the hall way at bedtime. Resident easily redirected with staff. Resident went to bed around 10:00 PM. On 1/15/23 at 3:41 PM resident wandering facility without walker. Easily redirected most of the time. On 1/16/23 at 10:10 PM update returned in regards to licking her wall-not being able to keep her out of others rooms, her not using FWW (4 wheeled walker), keeps half crawling down the hallway. Get psychiatric evaluation put on calendar for tomorrow. On 1/16/23 at 11:48 PM resident started on increased dose of risperadol. Continues to have multiple behaviors of being in other resident rooms, walking without walker, and standing in the middle of doorways. On 1/17/23 at 10:10 PM resident continues to have increased wandering in facility and into other resident rooms. On 3/16/23 at 10:08 AM reported to Social Worker (SW) another resident walked by this resident. The other resident put a hand on the resident's walker trying to get around her when Resident #3 slapped the other resident's hand and began yelling. Staff intervened and separated but later Resident #3 attempted to run her walker into the same resident. On 3/26/23 at 3:29 PM resident stood in doorway of hall 2 when a male resident attempted to go down the hall. Resident #3 stood in place, stuck her tongue out and started yelling at him. He asked her to move and she refused. Staff intervened and informed her she needed to move to allow others to go by. Resident #3 started crying and stated the male resident hit her. No physical contact observed between the two residents. On 3/27/23 at 6:02 PM resident grabbed a male resident's walker when he was coming into the facility and yelled at him that it was her walker. Staff intervened and separated the two. On 3/27/23 at 11:15 AM SW unable to complete BIMS and mood assessment. Resident recently displaying more behaviors of being verbally and physically aggressive. On 3/28/23 at 10:16 AM SW and Activity Director discussed increased behaviors and need for activities the resident would be interested in. Discussed with family. On 4/9/23 at 2:50 PM resident seeking male resident and asking him to marry her. Resident found sitting on male resident lap kissing him in the family room. On 4/11/23 at 1:54 PM resident required much one on one at meals due to wanted to leave and do other activities. Staff had to redirect resident to table and remind to eat. The Care Plan for Resident #3 lacked any interventions for sexual behaviors. The Plan of Care Note on 6/9/23 at 12:22 PM documented attendees: ADON, Activity Director, CDM (Certified Dietary Manager) resident's sister, SSD. Resident's discharge plan is to remain long term at this time. Advanced directives is a DNR (Do Not Resuscitate) . At this time there is not acute medical conditions main diagnoses: General anxiety, and down syndrome. At this time resident has no skin conditions of concern. Resident weight has remained the same in the last month. Resident does wander from table to table even after multiple attempts of re-direction. Resident is not able to complete a BIMS assessment due to being cognitively impaired. Resident is incontinent of bladder most of the time. At this time resident is not doing therapy. Resident is independent but does need queuing and redirection. resident wanders but is usually pretty good about staying out of other resident's rooms. Resident attends most activities. Family concerns sister (POA) suggests we increase resident's Remeron and decrease Risperdal as she believes it will help with this resident's appetite. In an interview on 7/26/23 at 12:33PM, the resident's sister reported that it was hard for the resident to verbally express herself due to her diagnosis of down's syndrome. The sister stated the resident acted out sexually after she had COVID-19. Staff reported she hid in a male resident's room, Resident #4, and told staff that she was horny. The resident was moved to a different room and had her medication changed. The sister reported she has not been informed by the facility of any additional incidents involving inappropriate sexual behavior. 2. The Minimum Data Set (MDS) dated [DATE] for Resident #4 revealed a Brief Interview of Mental Status (BIMS) score of 4 out of 15 which indicated severely impaired cognition. The MDS documented a diagnoses to include amnesia. The Care Plan for Resident #4 revised on 2/6/23 documented the resident has a behavior problem (having multiple episodes) related to unrealistic expectations. The Care Plan directed staff as follows: -Anticipate and meet the resident needs. -Caregivers to provide opportunity for positive interaction, attention, stop and interact as passes by. -Monitor behavior episodes and attempt to determine underlying cause. The Care Plan dated 6/9/23 documented the resident has the potential to be verbally aggressive related to the aging process/confusion. The Care Plan directed staff as follows: -Assess and anticipate resident needs. -Give the resident as many choices as possible about care and activities. The Care Plan lacked any indication of sexual behaviors. The Progress Note for Resident #4 documented the following: On 1/24/23 at 12:12 PM the Director of Nursing (DON) went to a female resident room to inform her that it was lunch time. Upon entering the room, Resident #4 was leaning over female residents bed, groping the females breasts and kissing her intimately. The DON informed the resident to leave her room and asked the female resident if she was okay and if she had consented to that encounter. The female did nod her head yes. The DON went to residents room and educated him on the importance of consent and explained that some people may not be able to make proper decisions for themselves. Fax sent to Primary Care Provider (PCP) to update. Residents daughter also notified of encounter. On 1/30/23 at 9:12 PM resident continues on increase dose of Namenda with no signs and symptoms of any adverse reactions noted, multiple behaviors noted tonight- found trying to get resident from room [ROOM NUMBER] (Resident #5) to let him go up under her shirt-this nurse separated them-yelling about taking his pill-why does he have to take them-yelling about blanket-staff went immediately downstairs to get it stood shouting and stomping at nurse's station until she got back up stairs with it. On 3/23/23 at 2:42 PM Care Plan Meeting: attended ADON, SSD (Social Services Director), Activity Director, resident's daughter, resident. Discussed residents care, wt at 139, daughter please resident is starting to gain some. resident c/o (complained of) staff telling resident not to sit too close to female residents staff discussed resident inappropriately touching other residents at times. No other concerns at this time. Plan is for resident to remain in facility contrary to residents belief, daughter is unable to provide the care he needs. Family has no concerns at this time. On 4/9/23 at 2:48 PM resident touching a female resident thigh and rubbing her shoulders and kissed her. On 4/16/23 6:19 PM resident sitting on couch in lounge -seen trying to get his hands up under [NAME] another resident shirt-residents separated, and he went to his room -yelling about it being cold in here. In an interview on 7/26/23 at 11:18 AM, the resident's daughter reported that the resident was accused of touching a female resident, and the resident had always been lovey in behavior. She stated the facility hadn't informed her of anything that has happened between this resident and other residents since the new company took over in 11/22. In an interview on 7/27/23 at 1:16 PM Resident #12 reported that she had observed the resident touch Resident #3's breast and genitals. Resident #12 has observed the resident take his penis out of his slacks and Resident #3 touched the resident's penis. Resident #12 reported that she saw this before the resident had COVID in 4/23. In an interview on 7/26/23 at 2:31 PM, Staff A, CNA, reported that the resident's nickname among staff was Captain [NAME] Pants, and that he can get inappropriate with staff. The aide stated staff remind him to behave. The aide stated he hasn't been an issue since before the beginning of May but before that he was touchy feely. He would sit on the couch and grope female residents. He never would go past first base. He would touch them outside of their clothes and touch breasts outside of clothes. She stated she remembered him with Resident #3 touching her at times and staff separated them and redirected them. In an interview on 7/26/23 at 2:16 PM, the DON reported that she talked to previous Administrator about the incident on 1/24/23 and directed the incident didn't need to be reported to the SA and that she didn't know they had to be reported. 3. The MDS dated [DATE] for Resident #5 revealed the resident had short term and long term memory problems, had severely impaired cognitive skills for daily decision making, and had inattention and disorganized thinking behavior present that fluctuates. The MDS documented diagnoses to include non-traumatic brain dysfunction, Alzheimer's disease, and schizophrenia. The Care Plan revised on 7/20/23 for Resident #5 documented the resident is at risk for wandering and elopement related to impaired safety awareness. The Care Plan directed staff as follows: 1. Ensure a safe distance from other residents who have a tendency to become agitated with her actions. 2. Follow facility elopement policy and procedures. 3. Identify pattern of wandering: purposeful, aimless or escapist; looking for something; or need more exercise? 4. Monitor location with one on one supervision at all times. Document wandering behaviors and attempted diversion interventions. The Care Plan revised on 7/31/23 for Resident #5 documented the resident has a behavior problem of sitting on the floor and going into other resident's rooms related to cognitive impairment. The Care Plan directed staff as follows: 1. Anticipate and meet the resident's needs. 2. Caregivers to provide opportunities for positive interaction, attention, and to stop and interact as passes by. 3. Psyche referral as needed for behavior and medication management. The Care Plan lacked any indication of sexual behavior. The Progress notes for the resident documented wandering in the facility and/or wandering into resident's rooms on the following: 1. 1/30/23 2. 2/1/23 3. 2/12/23 4. 2/19/23 5. 3/30/23 6. 4/9/23 7. 4/17/23 8. 4/19/23 9. 7/23/23 The Progress Notes for the resident documented the following: On 6/10/23 at 3:46 PM multiple residents approached nurse to express concern d/t (due to) resident being in their rooms while they were not. Resident had multiple different candy items that she was hiding and eating which were not hers. Resident also walked by medication cart and stole applesauce in the middle of medication pass. Resident educated but ineffective as resident continued with behavior throughout the whole shift. On 7/17/23 at 10:29 PM CNA paged nurse to resident's room. CNA reported to this nurse that she had walked in on resident and another resident during an inappropriate act. CNA had already started to separate residents and this nurse took the other resident out of the room and delegated cna to stay with Resident #5 until nurse could get back and perform assessment. Male resident escorted to nurses station and this nurse went back to resident's room. Skin assessment completed along with psycho-social eval completed. resident stated to this nurse when asked if she was okay with what happened and she stated she didn't mind it. Skin assessment revealed no skin breaks, marks or vaginal bleeding. Resident stated that she was not injured or hurt. Resident was not showing any obvious signs of being upset or distressed, not crying or agitated. She was not verbally or physically aggressive. Half hour checks completed by staff on resident to ensure safety. Resident found to be wandering a few times and redirected back to her room. Contacted Administrator, DON and ADON immediately after incident at approx 10:21 PM after separating the residents. On 7/18/23 at 9:39 AM DON and ADON spoke with resident's brother at 9:32 AM. DON updated brother on incident between resident and a male resident. Brother stated that he wanted facility to do what they think is right and make sure his sister is okay. Brother aware and gave consent for resident to be seen at local hospital for evaluation per orders from the resident's physician that were received at 9:39 AM. The ED (Emergency Department) Provider Note for Resident #5 signed by a physician on 7/18/23 at 11:32 AM revealed: -Per staff report, another resident went into patient's room, took off his clothes, and laid on top of her. SANE (Sexual ASSUALT Nurse Examiner) nurse reports patient denied sexual intercourse. She states patient told him to stop, then CNA walked by room. CNA reports telling other resident to leave room. Per CNA report, he left patient's room and was sent to a different hallway. Patient has no complaints at this time. -Description of Assault: Patient was in her room, male said he wanted to do sex patient said, get outta here. He took his and her clothes off. She stated this occurred at another facility. Asked to clarify and then said In my room. Patient was asked multiple times and in different ways if there was penile penetration, patient denies each time. (vaginally, orally, anally). Staff CNA at nursing home walked in and found male on top of the patient. She stated that male was undressed and patient undressed waist down. CNA told male to leave room and get dressed. Male got up, left, dressed, and was escorted to a different hallway in facility. Nursing Home Facility called and reported incident to the SA and called law enforcement to report. -Activities Following the Assault: Patient account: I told him get off, get off. Some people walked in and said get outta there. He dressed up and got outta the room. Patient was brought to ED for assessment. Interviewed by SANE RNs and law enforcement. Brother called and consent was obtained for external exam done and to defer the internal exam. -Assessment of General Appearance Note Full body skin assessment performed with unremarkable findings. Adult brief observed to be clean and free from bloody/bodily fluids. In an interview on 7/26/23 at 12:25 PM, Resident #11 reported that Resident #5 came into her room several times and was combative. The resident yelled down the hall for someone to get the resident out of her room. When she tried to corral her towards the door, the resident came at her in a threatening way. Resident #11 did not see her be sexually inappropriate but she felt she could be. Resident #11 stated she told whoever was in charge that she couldn't sit with her because she made her uncomfortable. She stated the resident would come into her room and sit on the sofa and look at her and it was creepy and made her uncomfortable. In undated, untitled documents the following residents reported they did not feel safe because Resident #5 wandered into their rooms: 1. Resident #13 2. Resident #10 3. Resident #11 In an interview on 7/26/23 at 1:17 PM, the resident's brother reported that he was not informed of the 1/24/23 incident or any other incidents of inappropriate sexual behavior or the resident's issues wandering. He stated he was informed by the facility of the incident of sexual abuse that occurred 7/17/23. In an interview on 7/26/23 at 2:16 PM, the DON reported that the residents involved in the incident she charted on 1/24/23 were Residents #4 and #5. She stated she knew the residents were confused and that their families did not give approval for them to have sexual behavior at the facility. She stated she reported the incident to the facility Administrator who advised her that the incident did not need to be investigated. The Progress Note for Resident #5 lacked documentation of any incident on 1/24/23 of a sexual interaction with a male resident. The Progress Note is in the clinical record for Resident #4. 4. The MDS dated [DATE] for Resident #6 revealed a BIMS score of 12 out of 15 which indicated moderately impaired cognition. The MDS revealed the resident had diagnoses of history of malignant neoplasm of bronchus and lung (lung cancer), and malignant neoplasm of supraglottis (throat cancer). The Progress Notes for Resident #6 documented the following: On 7/17/23 at 10:30 PM aide (CNA) called nurses station to have nurse come to room [ROOM NUMBER] (Resident #5's room) at 10:18 PM. Upon entering room found Resident #6 siting in his wheelchair. CNA reported inappropriate sexual incident between the residents. Nurse delegated one CNA to stay with female resident in room and nurse took Resident #6 back to nurses station. Completed assessment with no injury noted and contacted the DON, ADON and Administrator. Moved resident to 115 consented to move and put on half hourly checks. No signs of psycho-social distress, he was not crying, agitated or verbally or physically aggressive. Res was compliant and cooperative with staff and followed directions without incident. Staff continued half hour checks on resident throughout remainder of shift and report given to day nurse on incident. On 7/19/23 at 1:12 AM resident has been 1:1 with staff -out to main lounge with staff to watch TV and just be out of his room. Head down-moving slow tonight-Stated he was told he could have company today and the sheriff came. Nothing more said. On 7/19/23 at 7:59 AM resident refused breakfast this morning after resident stated he doesn't feel like getting out of bed. administrator asked resident if he was feeling ok resident stated no he is feeling depressed. SW will follow up with any new concerns. On 7/21/23 at 10:48 AM SW spoke with this resident today. SW counseled resident on inappropriate behaviors. Resident stated to this social worker that he is very sorry he knows what he did was wrong and that if he could take it back, he would in a heartbeat and won't ever do it again. In an interview on 7/25/23 at 4:19 PM, the resident reported he was walking the hall the evening of 7/17/23 when Resident #5 stopped him and told that she loved him and that she wanted to try him. The resident reported that he hadn't had sex in five to six years and thought he would try to even though he has erectile dysfunction. He stated he was unable to penetrate Resident #5's vagina. A CNA found them trying to have sex and he was moved to his current room. Reported he has had staff with him a lot and that they needed to stop with the increased supervision because he didn't like it. The resident reported that if he knew what would happen, he never would have took Resident #5 up on her offer. 5. The MDS dated [DATE] for Resident #10 revealed a BIMS score of 15 out of 15 which indicated intact cognition. The resident had diagnoses of non-traumatic brain dysfunction, Parkinson's disease and cerebrovascular accident (CVA), TIA (Transient Ischemic Attack), or stroke. In an undated, untitled document, the resident reported he did not feel safe at the facility because Resident #5 came into his room often at night and that she comes and goes into his room whenever she feels like it. In an interview on 7/27/23 at 10:59 AM, the resident reported that Residents #3 and #5 wander into his room during the night, this interferes with his ability to sleep, and he is scared of what they might do to him while he's sleeping. He stated he told management who said they would talk to the two residents, but the wandering continued. The Progress Note for the resident on 7/27/23 at 12:15 PM revealed: Physician seen resident today on rounds, resident stated concerns of not sleeping well lately, New order for Melatonin 5mg PO (oral) HS (every bedtime) PRN (as needed). Added to MAR (Medication Administration Record), resident aware POA (Power of Attorney) called, voice mail left. The MAR for July 2023 revealed an order dated 7/27/23 for Melatonin oral tablet, 5 milligrams (mg) every HS as needed for trouble with sleep. The Behavior Health Services policy dated 7/23 revealed: 1. Residents of our community will receive necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and care plan. 2. Highest practicable physical, mental, and psychosocial well-being : The highest possible level of functioning and well-being, limited by the individual's recognized pathology and normal aging process. Highest practicable is determined through comprehensive resident assessment and by recognizing and competently and thoroughly addressing the physical, mental or psychosocial needs of the individual. 3. Identify the population of the following residents in the facility assessment. Those with with Mental disorders; Psychosocial disorders, or Substance use disorders (SUD), and those with a history of trauma and/or post traumatic stress disorder (PTSD). 4. Assess the resident upon admission, and at least quarterly and with change in condition, utilizing the available PASARR (Preadmission Screening and Resident Review), the MDS and other assessments available, for needed behavioral services that include: Necessary care and services that are person centered to reflect the resident's goals for care, while maximizing their dignity, autonomy, privacy, socialization, independence, choice and safety. 5. Review the assessment, diagnoses and treatment ordered by qualified behavioral health professionals, such as physicians including psychiatrists or neurologists and resulting evidenced based interventions. 6. Assess residents with mental or psychosocial adjustment difficulty, or have a history of trauma and/or PTSD for necessary care and services, appropriate person-centered care plan and individualized treatment to meet their needs. 7. Interview the resident or representative for history and prior level of functioning. 8. Interview and evaluate the resident or representative for stressors or triggers and address on care plan. Evaluate the frequency, urgency, intensity, duration, and impact of the resident's expressions or indications of distress as well as the location, surrounding or situation in which they occurred. 9. Review physician orders for use of medications for behavioral issues and consultations to behavioral health services. 10. Convene an IDT and create a person centered plan of care to support # 1, 2, 3 and 4 above. 1. Apply a person centered approach to care which includes knowledge of each individuals' daily routine, lifelong patterns, lifestyles, interests, preferences, and choices. 12. Revise the plan of care at least quarterly and with change in condition. 13. Interact and communicate with residents in a manner that promotes mental and psychosocial well-being. 14. Provide meaningful activities, including those that address the resident's customary routines, interests and preferences, which promote engagement and positive meaningful relationships between residents, staff, families and other resident in the community. Note, residents living with mental health and SUD's may require different activities based upon their assessment. 15. Provide and atmosphere and environment that is conducive to mental and psychosocial well-being. 16. Utilize non-pharmacological interventions for behaviors prior to initiating pharmacological interventions, for example: Adequate hydration and nutrition; Exercise and pain relief; Individualized sleep and dining routines including schedules for use of the bathroom; Dietary interventions such as increasing fiber to prevent and reduce constipation; Adjusting the environment to be more individually preferred and homelike (soft lights, preventing glare; unobstructed pathways, eliminating overhead paging); Consistent staff; Individualized and meaningful activities based upon lifelong interests or activity patterns; Music, art, massage, or aromatherapy, reminiscing, electronics, computers, essential oils; Providing activities out of doors in sunshine and fresh air; Activities that support the resident's spiritual needs; Meditation, yoga and associated physical activity; Activities that decrease stress and increase awareness of actual surroundings, for example verbal reassurance, Access to therapies, such as psychotherapy, behavior modification, cognitive behavioral therapy; problem solving therapy; Providing de-escalating and coping skills; and Assisting to find programs to assist with substance abuse counseling 17. Assess through the admissions and MDS process upon admission, quarterly and with condition change for individualized behavioral health needs and address the following common disorders: Depression, Anxiety and Anxiety Disorders, Schizophrenia; Bi-Polar Disorders; Substance Abuse Disorders, and PTSD. 18. Provide competency based education for the direct care staff as outlined in the facility assessment, MDS Data, resident assessments, individual plans of care and needs of residents as a whole for those with a history of trauma and/or post-traumatic stress disorder. Include education at a minimum on specific mental disorders, psychosocial disorders, PTSD or substance abuse disorders (as determined by the community need). 19. Provide competency based education and implement procedures on the use of non-pharmacological interventions listed above. 20. Provide competency based education for non-direct care staff, whom may assist residents with behavioral health needs, based upon the facility population and need. 21. Document the resident's a[TRUNCATED]