**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 37 residents with 17 sampled for review. The sample included one cognitively intact dependent Resident (R) 17 for reporting an allegation of abuse. Based on observation, interview, and record review, the facility failed to report an allegation of sexual assault when R17 reported a sexual assault by 2 male perpetrators on 05/16/24. On 05/24/24 the resident went to the hospital for chest pain and reported to hospital staff she was sexually assaulted in the facility. On 05/29/24 the resident readmitted to the facility. The hospital notified the facility of resident's report of sexual assault 05/24/24 and on discharge 5/29/24. The facility failed to respond to R17's allegation of abuse, investigate the allegation of abuse, did not report to the state agency, and did not notify law enforcement until 07/16/24, when R17 reported the sexual assault to the surveyor during survey. This failure placed the resident in immediate jeopardy and at risk for continued negative impact on her physical, mental, and psychosocial well-being. Findings included: - Review of Resident (R) 17's undated Physician Orders, documentation included diagnoses of traumatic subdural hemorrhage (bleeding in the brain due to trauma), anxiety disorder, (mental or emotional reaction characterized by apprehension, uncertain and irrational fear), need for assistance with personal care, lack of coordination, and problem related to care provider dependency. The Annual Minimum Data Set (MDS) dated [DATE], included a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The resident did not exhibit behaviors. She reported feeling down, depressed, or hopeless for two to six days of the look back period and noted the resident would isolate socially at times. The resident experienced hallucinations (sensing things while awake that appear to be real, but the mind created) and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and rejected evaluation and/or cares one to three days of the look back period. She received antidepressant medication (class of medication used to treat depression). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/12/24, included the resident had impaired cognitive function, impaired thought processes, experienced confusion, and behaviors. The Care Plan, (CP), dated 07/09/24, included interventions initiated on 04/17/24, which instructed staff to provide a translator as necessary to communicate with the resident and further documented the majority of facility staff spoke Spanish. An intervention initiated 04/17/24 instructed staff to monitor/record/report to R17's health care provider as needed when the resident had feelings such as labile mood or agitation, felt threatened by others or thoughts of harming someone. During an interview on 07/16/24 at 01:02 PM, R17 spoke in Spanish to Dietary Staff (DS) BB, who translated the interview to English on behalf of the resident. R17 stated two men sexually assaulted her in the facility. She said she had bruises and bite marks across her breast and abdomen when she made the report to the nurses (at the facility). Upon inquiry, she stated the nurses did not respond to her report of assault nor assess her for injury. She said she was in her room at the facility when the two men forced her on the bed and that was where it happened. The resident sat in her wheelchair, cried, and pointed towards her bed while describing the event. She was anxious, tearful, and her hands were trembling. She reported nobody did anything in response to her allegation. She confirmed law enforcement had not talked with her and she did not feel safe in the facility. During an interview on 07/16/24 at 01:50 PM, DS BB stated she remembered hearing something about the resident (R17) reporting she was assaulted in the facility to someone at the local hospital, but that was a couple of months ago and she was not sure of the details. DS BB stated she did not recall any staff education (regarding resident abuse) provided by the facility at the time. Review of the Electronic Medical Record (EMR) Progress Notes (PN), dated 05/16/24 at 05:00 PM, revealed R17 complained of bilateral (both) breast pain due to a sexual assault that occurred at the facility a long time ago according to the resident. She did not recall when it happened. The resident had never reported any abuse since she admitted to the facility. She stated the people who assaulted her bit her at that time and she had several bruises on her breast and abdomen. The nurse performed a skin assessment, and the assessment was within normal limits. The nurse notified the Director of Nursing (DON), Social Services Designee (SSD), and Personal Care Physician (PCP) of the situation. The EMR PN dated 05/24/24 at 04:30 PM, documentation included the facility nurse spoke to the hospital nurse who reported the resident (R17) admitted from the emergency room (ER) on 05/22/24 for complaints of left sided chest pain. The hospital nurse informed the facility they made an adult protective service (APS) report due to the resident's complaint of sexual assault. The facility would follow up with the resident's PCP and to determine if a consult with cardiologist was required. The EMR PN dated 05/24/24 at 05:42 PM, documented upon return to the nursing facility, the resident was very aggressive and complained much of the night. She refused to have her call light turned off after cares. She banged on the door, yelled, and cried. The EMR PN dated 05/29/24 at 07:46 AM, revealed during a recent hospitalization, the resident (R17) reported to ER staff that she was being sexually abused at the nursing home. Review of the facility EMR documentation above revealed the resident (R17) reported sexual assault by two male perpetrators on 05/16/24. On 05/24/24, the resident went to the hospital for chest pain and reported to hospital staff she was sexually assaulted in the facility. On 05/29/24, the resident readmitted to the facility. The hospital notified the facility of the resident's report of sexual assault on 05/24/24 and on discharge on [DATE]. The facility failed to respond to R17's allegation of abuse, investigate the allegation of abuse, and did not notify law enforcement until 07/16/24, when R17 reported the sexual assault to a state agency surveyor during a recertification survey. Review of the facility Grievance Log for 04/01/24 through 07/16/24 lacked identification of any allegation of abuse nor neglect regarding R17. During an interview on 07/17/24 at 02:44 PM Administrative Staff A confirmed the grievance logs did not include any report of sexual assault for the resident as noted in the 05/16/24 progress notes. The facility followed up on the reported sexual assault on 07/16/24 (approximately two months after the resident originally reported the allegation) when the surveyor brought it to her attention. Administrative Staff A reported she started at the facility as the Administrator on 06/10/24 and she was not aware of the report until 07/17/24. Administrative Staff A said she expected the Social Worker/SSD to track resident grievances, but the SSD informed her she did not maintain the grievance log as it was kept in the old Administrators office. She reported the SSD and the DON were employed during the time of the sexual assault allegation by R17 and the facility failed to respond to the resident's allegations of abuse on three different occasions. Administrative Staff A reported the facility should report, investigate, and notify law enforcement of allegations of sexual assault to ensure protection of the resident making the allegation, as well as the other residents of the facility. On 07/17/24 at 02:49 PM, Social Service Staff X stated she was just aware of the resident's allegation of abuse related to sexual assault. She stated the staff should protect the resident first then report any allegations of abuse to their supervisor and the state agency, initiate an investigation, and notify law enforcement. The nursing staff should assess the resident for injury, call the physician, family, and law enforcement. The facility should provide education for the staff and also question other residents and staff to get clarification on how they feel about their safety. Social Service Staff X confirmed the allegations of abuse were not reported or investigated when staff were made aware of the allegations on 05/16/24, 05/24/24, and 05/29/24. The facility failed to respond to the resident's allegation of abuse as they should. The facility policy Abuse and Neglect policy, dated 07/06/2023, documentation included the purpose of the policy was to ensure that residents are not subjected to abuse by anyone, including but not limited to, location employees, and/or other residents. Alleged or suspected violations involving any mistreatment, neglect, exploitation, or abuse including injuries of unknown origins will be reported immediately to the administrator. In the absence of the administrator from the location, the following individuals have the administrative authority of the administrator for purposes of immediate reporting of alleged violations: the director of nursing services or the supervisor of social services and both also have the authority to call law enforcement. The location will have evidence that all alleged or suspected violations are thoroughly investigated, and they will prevent further potential abuse while the investigation is in progress. Results of all investigations will be reported to the administrator or designated representative and to other officials in accordance with state law, including to the state survey and certification agency. The facility failed to report, allegations of abuse/sexual assault to the appropriate state agency to ensure protection of the R17 as well as the other residents of the facility. This failure placed the resident in immediate jeopardy and at risk for continued negative impact on her physical, mental, and psychosocial well-being. On 07/18/24 at 03:30 PM, Administrative staff A was provided the Immediate Jeopardy (IJ) template for the failure to respond appropriately to R17's allegations of sexual assault. The IJ was first to exist on 05/16/24, and the facility submitted an acceptable plan for removal of the immediate jeopardy on 07/18/24 at which included the following: 1. On 07/16/24, R17 was assessed for any abuse, neglect, or trauma. 2. All nursing staff education initiated on 07/16/24 for Recognizing and Reporting Abuse and Neglect Allegation by the Clinical Learning and Development Specialist. 3. Trauma Informed care assessment completed on 07/17/24 and R17's care plan was updated to reflect new trauma informed care interventions. 4. On 07/17/24, Law enforcement contacted and R17 interviewed. 5. Nursing Home Leadership were educated on Recognizing and Reporting Abuse and Neglect Allegation conducted by Regional Clinical Services Director on 7/18/24. 6. All above education will be completed by 7/18/24 or prior to next working shift. By 7/18/24, facility will review all residents at risk for Trauma informed care and address care plan interventions as needed. 7. Angel Rounding (leadership resident rounding touchpoint) will be initiated 7/18/24 to identify areas of concern and ensure resident safety. The surveyor verified the facility implemented the above corrective measures on -site on 07/22/24. The deficient practice remained at a scope and severity level of a D, following the implementation of the removal plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 37 residents with 17 sampled for review. The sample included one cognitively intact dependent Resident (R) 17 reviewed for investigating an allegation of abuse related to sexual assault. Based on observation, interview and record review, the facility failed to thoroughly investigate R17's allegations of sexual assault and failed to protect R17 from potential further sexual abuse. The resident reported sexual assault by 2 male perpetrators on 05/16/24. On 05/24/24 the resident went to the hospital for chest pain and reported to hospital staff she was sexually assaulted in the facility. On 05/29/24 the resident readmitted to the facility. The hospital notified the facility of resident's report of sexual assault 05/24/24 and on discharge 5/29/24. The facility failed to respond to R17's allegation of abuse, investigate the allegation of abuse, and did not notify law enforcement until 07/16/24 when R17 reported the sexual assault to the surveyor during survey. This failure placed the resident in immediate jeopardy and at risk for continued negative impact on her physical, mental, and psychosocial well-being. Findings included: - Review of Resident (R) 17's undated Physician Orders, documentation included diagnoses of traumatic subdural hemorrhage (bleeding in the brain due to trauma), anxiety disorder, (mental or emotional reaction characterized by apprehension, uncertain and irrational fear) , need for assistance with personal care, lack of coordination, and problem related to care provider dependency. The Annual Minimum Data Set (MDS) dated [DATE], included a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The resident did not exhibit behaviors. She reported feeling down, depressed, or hopeless for two to six days of the look back period and noted the resident would isolate socially at times. The resident experienced hallucinations (sensing things while awake that appear to be real, but the mind created) and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and rejected evaluation and/or cares one to three days of the look back period. She received antidepressant medication (class of medication used to treat depression). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/12/24, included the resident had impaired cognitive function, impaired thought processes, experienced confusion, and behaviors. The Care Plan, (CP), dated 07/09/24, included interventions initiated on 04/17/24, which instructed staff to provide a translator as necessary to communicate with the resident and further documented the majority of facility staff spoke Spanish. An intervention initiated 04/17/24 instructed staff to monitor/record/report to R17's health care provider as needed when the resident had feelings such as labile mood or agitation, felt threatened by others or thoughts of harming someone. During an interview on 07/16/24 at 01:02 PM, R17 spoke in Spanish to Dietary Staff (DS) BB, who translated the interview to English on behalf of the resident. R17 stated two men sexually assaulted her in the facility. She said she had bruises and bite marks across her breast and abdomen when she made the report to the nurses (at the facility). Upon inquiry, she stated the nurses did not respond to her report of assault nor assess her for injury. She said she was in her room at the facility when the two men forced her on the bed and that was where it happened. The resident sat in her wheelchair, cried, and pointed towards her bed while describing the event. She was anxious, tearful, and her hands were trembling. She reported nobody did anything in response to her allegation. She confirmed law enforcement had not talked with her and she did not feel safe in the facility. During an interview on 07/16/24 at 01:50 PM, DS BB stated she remembered hearing something about the resident (R17) reporting she was assaulted in the facility to someone at the local hospital, but that was a couple of months ago and she was not sure of the details. DS BB stated she did not recall any staff education (regarding resident abuse) provided by the facility at the time. Review of the Electronic Medical Record (EMR) Progress Notes (PN), dated 05/16/24 at 05:00 PM, revealed R17 complained of bilateral (both) breast pain due to a sexual assault that occurred at the facility a long time ago according to the resident. She did not recall when it happened. The resident had never reported any abuse since she admitted to the facility. She stated the people who assaulted her bit her at that time and she had several bruises on her breast and abdomen. The nurse performed a skin assessment, and the assessment was within normal limits. The nurse notified the Director of Nursing (DON), Social Services Designee (SSD), and Personal Care Physician (PCP) of the situation. The EMR PN dated 05/24/24 at 04:30 PM, documentation included the facility nurse spoke to the hospital nurse who reported the resident (R17) admitted from the emergency room (ER) on 05/22/24 for complaints of left sided chest pain. The hospital nurse informed the facility they made an adult protective service (APS) report due to the resident's complaint of sexual assault. The facility would follow up with the resident's PCP and to determine if a consult with cardiologist was required. The EMR PN dated 05/24/24 at 05:42 PM, documented upon return to the nursing facility, the resident was very aggressive and complained much of the night. She refused to have her call light turned off after cares. She banged on the door, yelled, and cried. The EMR PN dated 05/29/24 at 07:46 AM, revealed during a recent hospitalization, the resident (R17) reported to ER staff that she was being sexually abused at the nursing home. Review of the facility EMR documentation above revealed the resident (R17) reported sexual assault by two male perpetrators on 05/16/24. On 05/24/24, the resident went to the hospital for chest pain and reported to hospital staff she was sexually assaulted in the facility. On 05/29/24, the resident readmitted to the facility. The hospital notified the facility of the resident's report of sexual assault on 05/24/24 and on discharge on [DATE]. The facility failed to respond to R17's allegation of abuse, investigate the allegation of abuse, and did not notify law enforcement until 07/16/24, when R17 reported the sexual assault to a state agency surveyor during a recertification survey. Review of the facility Grievance Log for 04/01/24 through 07/16/24 lacked identification of any allegation of abuse nor neglect regarding R17. During an interview on 07/17/24 at 02:44 PM Administrative Staff A confirmed the grievance logs did not include any report of sexual assault for the resident as noted in the 05/16/24 progress notes. The facility followed up on the reported sexual assault on 07/16/24 (approximately two months after the resident originally reported the allegation) when the surveyor brought it to her attention. Administrative Staff A reported she started at the facility as the Administrator on 06/10/24 and she was not aware of the report until 07/17/24. Administrative Staff A said she expected the Social Worker/SSD to track resident grievances, but the SSD informed her she did not maintain the grievance log as it was kept in the old Administrators office. She reported the SSD and the DON were employed during the time of the sexual assault allegation by R17 and the facility failed to respond to the resident's allegations of abuse on three different occasions. Administrative Staff A reported the facility should report, investigate, and notify law enforcement of allegations of sexual assault to ensure protection of the resident making the allegation, as well as the other residents of the facility. On 07/17/24 at 02:49 PM, Social Service Staff X stated she was just aware of the resident's allegation of abuse related to sexual assault. She stated the staff should protect the resident first then report any allegations of abuse to their supervisor and the state agency, initiate an investigation, and notify law enforcement. The nursing staff should assess the resident for injury, call the physician, family, and law enforcement. The facility should provide education for the staff and also question other residents and staff to get clarification on how they feel about their safety. Social Service Staff X confirmed the allegations of abuse were not reported or investigated when staff were made aware of the allegations on 05/16/24, 05/24/24, and 05/29/24. The facility failed to respond to the resident's allegation of abuse as they should. The facility policy Abuse and Neglect policy, dated 07/06/2023, documentation included the purpose of the policy was to ensure that residents are not subjected to abuse by anyone, including but not limited to, location employees, and/or other residents. Alleged or suspected violations involving any mistreatment, neglect, exploitation, or abuse including injuries of unknown origins will be reported immediately to the administrator. In the absence of the administrator from the location, the following individuals have the administrative authority of the administrator for purposes of immediate reporting of alleged violations: the director of nursing services or the supervisor of social services and both also have the authority to call law enforcement. The location will have evidence that all alleged or suspected violations are thoroughly investigated, and they will prevent further potential abuse while the investigation is in progress. Results of all investigations will be reported to the administrator or designated representative and to other officials in accordance with state law, including to the state survey and certification agency. The facility failed to ensure R17 remained free from sexual abuse when they failed to acknowledge an allegation, initiate an investigation, report the allegation to law enforcement and/or the state agency, and protect her from further abuse after she alleged, she was sexually assaulted by two men in her room at the facility. The facility failed to report and thoroughly investigate reported allegations of abuse/sexual assault to the appropriate state agency to ensure protection of the R17 as well as the other residents of the facility. The facility failed to thoroughly investigate R 17's allegations of abuse/sexual assault to ensure safety and protection of the R17 as well as the other residents of the facility. On 07/18/24 at 03:30 PM, Administrative staff A was provided the Immediate Jeopardy (IJ) template for the failure to respond appropriately to R17's allegations of sexual assault. The IJ was first to exist on 05/16/24, and the facility submitted an acceptable plan for removal of the immediate jeopardy on 07/18/24 at which included the following: 1. On 07/16/24, R17 was assessed for any abuse, neglect, or trauma. 2. All nursing staff education initiated on 07/16/24 for Recognizing and Reporting Abuse and Neglect Allegation by the Clinical Learning and Development Specialist. 3. Trauma Informed care assessment completed on 07/17/24 and R17's care plan was updated to reflect new trauma informed care interventions. 4. On 07/17/24, Law enforcement contacted and R17 interviewed. 5. Nursing Home Leadership were educated on Recognizing and Reporting Abuse and Neglect Allegation conducted by Regional Clinical Services Director on 7/18/24. 6. All above education will be completed by 7/18/24 or prior to next working shift. By 7/18/24, facility will review all residents at risk for Trauma informed care and address care plan interventions as needed. 7. Angel Rounding (leadership resident rounding touchpoint) will be initiated 7/18/24 to identify areas of concern and ensure resident safety. The surveyor verified the facility implemented the above corrective measures on -site on 07/22/24. The deficient practice remained at a scope and severity level of a D, following the implementation of the removal plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 37 residents, with 17 residents sampled, which included four residents reviewed for Trauma Informed Care. Based on observation, interview, and record review, the facility failed to acknowledge and respond appropriately to R17's allegations of sexual assault and her display of behaviors, which align to a trauma response, based on reasonable person concept, when the resident expressed feelings of fear, anger, and aggressiveness associated with her reported allegation of sexual assault while a resident of the facility. This failure placed R17 in Immediate Jeopardy (IJ) and at risk for untreated trauma and the negative impact to her mental, physical, and psychosocial well-being. Findings included: - Review of Resident (R) 17's undated Physician Orders, documentation included diagnoses of traumatic subdural hemorrhage (bleeding in the brain due to trauma), anxiety disorder, (mental or emotional reaction characterized by apprehension, uncertain and irrational fear), need for assistance with personal care, lack of coordination, and problem related to care provider dependency. The Annual Minimum Data Set (MDS) dated [DATE], included a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The resident did not exhibit behaviors. She reported feeling down, depressed, or hopeless for two to six days of the look back period and noted the resident would isolate socially at times. The resident experienced hallucinations (sensing things while awake that appear to be real, but the mind created) and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and rejected evaluation and/or cares one to three days of the look back period. She received antidepressant medication (class of medication used to treat depression). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/12/24, included the resident had impaired cognitive function, impaired thought processes, experienced confusion, and behaviors. The Care Plan, (CP), dated 07/09/24, included interventions initiated on 04/17/24, which instructed staff to provide a translator as necessary to communicate with the resident and further documented the majority of facility staff spoke Spanish. An intervention initiated 04/17/24 instructed staff to monitor/record/report to R17's health care provider as needed when the resident had feelings such as labile mood or agitation, felt threatened by others or thoughts of harming someone. During an interview on 07/16/24 at 01:02 PM, R17 spoke in Spanish to Dietary Staff (DS) BB, who translated the interview to English on behalf of the resident. R17 stated two men sexually assaulted her in the facility. She said she had bruises and bite marks across her breast and abdomen when she made the report to the nurses (at the facility). Upon inquiry, she stated the nurses did not respond to her report of assault nor assess her for injury. She said she was in her room at the facility when the two men forced her on the bed and that was where it happened. The resident sat in her wheelchair, cried, and pointed towards her bed while describing the event. She was anxious, tearful, and her hands were trembling. She reported nobody did anything in response to her allegation. She confirmed law enforcement had not talked with her and she did not feel safe in the facility. During an interview on 07/16/24 at 01:50 PM, DS BB stated she remembered hearing something about the resident (R17) reporting she was assaulted in the facility to someone at the local hospital, but that was a couple of months ago and she was not sure of the details. DS BB stated she did not recall any staff education (regarding resident abuse) provided by the facility at the time. Review of the Electronic Medical Record (EMR) Progress Notes (PN), dated 05/16/24 at 05:00 PM, revealed R17 complained of bilateral (both) breast pain due to a sexual assault that occurred at the facility a long time ago according to the resident. She did not recall when it happened. The resident had never reported any abuse since she admitted to the facility. She stated the people who assaulted her bit her at that time and she had several bruises on her breast and abdomen. The nurse performed a skin assessment, and the assessment was within normal limits. The nurse notified the Director of Nursing (DON), Social Services Designee (SSD), and Personal Care Physician (PCP) of the situation. The EMR PN dated 05/24/24 at 04:30 PM, documentation included the facility nurse spoke to the hospital nurse who reported the resident (R17) admitted from the emergency room (ER) on 05/22/24 for complaints of left sided chest pain. The hospital nurse informed the facility they made an adult protective service (APS) report due to the resident's complaint of sexual assault. The facility would follow up with the resident's PCP and to determine if a consult with cardiologist was required. The EMR PN dated 05/24/24 at 05:42 PM, documented upon return to the nursing facility, the resident was very aggressive and complained much of the night. She refused to have her call light turned off after cares. She banged on the door, yelled, and cried. The EMR PN dated 05/29/24 at 07:46 AM, revealed during a recent hospitalization, the resident (R17) reported to ER staff that she was being sexually abused at the nursing home. Review of the facility EMR documentation above revealed the resident (R17) reported sexual assault by two male perpetrators on 05/16/24. On 05/24/24, the resident went to the hospital for chest pain and reported to hospital staff she was sexually assaulted in the facility. On 05/29/24, the resident readmitted to the facility. The hospital notified the facility of the resident's report of sexual assault on 05/24/24 and on discharge on [DATE]. The facility failed to respond to R17's allegation of abuse, investigate the allegation of abuse, and did not notify law enforcement until 07/16/24, when R17 reported the sexual assault to a state agency surveyor during a recertification survey. Review of the facility Grievance Log for 04/01/24 through 07/16/24 lacked identification of any allegation of abuse or neglect regarding R17. During an interview on 07/17/24 at 02:44 PM Administrative Staff A confirmed the grievance logs did not include any report of sexual assault for the resident as noted in the 05/16/24 progress notes. The facility followed up on the reported sexual assault on 07/16/24 (approximately two months after the resident originally reported the allegation) when the surveyor brought it to her attention. Administrative Staff A reported she started at the facility as the Administrator on 06/10/24 and she was not aware of the report until 07/17/24. Administrative Staff A said she expected the Social Worker/SSD to track resident grievances, but the SSD informed her she did not maintain the grievance log as it was kept in the old Administrators office. She reported the SSD, and the DON were employed during the time of the sexual assault allegation by R17, and the facility failed to respond to the resident's allegations of abuse on three different occasions. Administrative Staff A reported the facility should report, investigate, and notify law enforcement of allegations of sexual assault to ensure protection of the resident making the allegation, as well as the other residents of the facility. On 07/17/24 at 02:49 PM, Social Service Staff X stated she was just aware of the resident's allegation of abuse related to sexual assault. She stated the staff should protect the resident first then report any allegations of abuse to their supervisor and the state agency, initiate an investigation, and notify law enforcement. The nursing staff should assess the resident for injury, call the physician, family, and law enforcement. The facility should provide education for the staff and also question other residents and staff to get clarification on how they feel about their safety. Social Service Staff X confirmed the allegations of abuse were not reported or investigated when staff were made aware of the allegations on 05/16/24, 05/24/24, and 05/29/24. The facility failed to respond to the resident's allegation of abuse. The facility policy Abuse and Neglect policy, dated 07/06/2023, documentation included the purpose of the policy was to ensure that residents are not subjected to abuse by anyone, including but not limited to, location employees, and/or other residents. Alleged or suspected violations involving any mistreatment, neglect, exploitation, or abuse including injuries of unknown origins will be reported immediately to the administrator. In the absence of the administrator from the location, the following individuals have the administrative authority of the administrator for purposes of immediate reporting of alleged violations: the director of nursing services or the supervisor of social services and both also have the authority to call law enforcement. The location will have evidence that all alleged or suspected violations are thoroughly investigated, and they will prevent further potential abuse while the investigation is in progress. Results of all investigations will be reported to the administrator or designated representative and to other officials in accordance with state law, including to the state survey and certification agency. The facility failed to acknowledge and respond appropriately to R17's allegations of sexual assault and her display of behaviors, which align to trauma response, based on reasonable person concept, when the resident expressed feelings of fear, anger, and aggressiveness associated with her reported allegation of sexual assault while a resident of the facility. On 07/18/24 at 03:30 PM, Administrative staff A was provided the Immediate Jeopardy (IJ) template and were notified the facility failed to acknowledge and respond appropriately to R17's allegations of sexual assault and her display of behaviors, which align to trauma response, based on reasonable person concept, when the resident expressed feelings of fear, anger, and aggressiveness associated with her reported allegation of sexual assault while a resident of the facility. This failure placed R17 in immediate jeopardy and at risk for untreated trauma and the negative impact to her mental, physical, and psychosocial well-being. The IJ was first to exist on 05/16/24, and the facility submitted an acceptable plan for removal of the immediate jeopardy on 07/18/24 at which included the following: 1. On 07/16/24, R17 was assessed for any abuse, neglect, or trauma. 2. All nursing staff education initiated on 07/16/24 for Recognizing and Reporting Abuse and Neglect Allegation by the Clinical Learning and Development Specialist. 3. Trauma Informed care assessment completed on 07/17/24 and R17's care plan was updated to reflect new trauma informed care interventions. 4. On 07/17/24, Law enforcement contacted and R17 interviewed. 5. Nursing Home Leadership were educated on Recognizing and Reporting Abuse and Neglect Allegation conducted by Regional Clinical Services Director on 7/18/24. 6. All above education will be completed by 7/18/24 or prior to next working shift. By 7/18/24, facility will review all residents at risk for Trauma informed care and address care plan interventions as needed. 7. Angel Rounding (leadership resident rounding touchpoint) will be initiated 7/18/24 to identify areas of concern and ensure resident safety. The surveyor verified the facility implemented the above corrective measures on -site on 07/22/24. The deficient practice remained at a scope and severity level of a D, following the implementation of the removal plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 37 residents with 17 residents sampled, which included three residents reviewed for abuse and neglect. Based on observation, interview, and record review, the facility deprived Resident (R) 7 care when the facility failed to ensure call lights were working appropriately to address the care needs of all residents residing on one of the four halls. On 07/16/24, during initial screening, multiple residents reported issues with call light response times and the surveyor observed a 42-minute call light response time for R 7. The facility reported they had issues with the call light system for months and used staff at the nurses' station to watch the system; however, on 07/17/24 at 07:25 AM, no staff were at the nurses' station watching the call light system. This failure placed the residents in immediate jeopardy. In addition, the facility failed to ensure staff identified and responded appropriately to all allegations of abuse and reporting for R21 who had a large bruise across her chest. On 07/16/24, R21's family member stated the facility reported to her that R21 had a bruise located across her lower chest. Furthermore, the facility failed to respond appropriately to R17 allegations of sexual assault. This failure which placed the residents at risk for abuse and continued negative impact on their physical, mental, and psychosocial well-being. Findings Included: - Resident (R) 7's Electronic Health Record (EHR) revealed diagnoses, which included metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), muscle weakness, anxiety disorder, and history of falling. The 12/07/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. R7 had a total mood severity score of two, indicating minimal depression. R7 was independent with eating. R7 required supervision assistance with activities of daily living (ADL), with dressing personal hygiene, transfer, and mobility. R7 required maximal assistance with bathing and toileting. R7 was occasionally incontinent of bladder. R7 had no falls. The 06/07/24 Quarterly MDS documented a BIMS score of 15, indicating intact cognition. R7 was independent with eating, oral care, personal hygiene, and upper body dressing. R7 required supervision with toileting and bathing and required moderate assistance with transfers. R7 had no falls. The 12/07/23 Urinary Incontinence and Indwelling Catheter Care Area Assessment documented R7 had bladder incontinence related to his benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections) and weakness. The 07/18/24 Care Plan documented R7 had an ADL self-care performance deficit. The Care Plan instructed staff to provide R7 with required one staff assistance for transfers between surfaces and were instructed to use a walker and a gait belt dated 06/13/24. The Care Plan included the staff to provide a call light and place within R7's reach, dated 01/03/23. The 05/24/24 Physician Order included the staff were to ensure R7's tab alarm was working every day, due to frequent falls. Review of R7's Progress Notes from 01/01/24 to 07/18/24 lacked documentation regarding call lights. On 07/16/24 at 09:20 AM, R7 stated staff took a long time to answer his call light. R7 stated it could take the staff over 45 minutes to answer. On 07/16/24, observation revealed R7's call light was on at 09:18 AM, and staff failed to answer the call light until 10:00 AM, a total of 42 minutes. On 07/16/24 at 09:59 AM, Certified Nurse Aide (CNA) M stated she answered the call light for R7 a couple of minutes ago and had forgot to shut it off. CNA M entered R7's room and canceled the call light. Resident (R) 27's Electronic Health Record (EHR) revealed diagnoses, which included after care following a joint replacement surgery, presence of unspecified artificial knee joint, low back pain and migraines. The 05/20/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. R27 had a total mood severity score of 00, indicating no depression. R27 was independent with eating, oral care, toileting, dressing, personal hygiene and mobility. R27 required supervision assistance with activities of daily living (ADL) with bathing. R27 was frequently incontinent of bladder. R27 had pain occasionally with the worst pain level of 10. The 07/03/24 Entry MDS documented a BIMS of 15, and no depression. R27 required moderate assistance with her ADLs with lower dressing, footwear, transfers, and standing. The resident was non ambulatory and required maximal assistance with toileting and bathing. R27 was occasionally incontinent of bladder and documented frequently complained of pain with the worst pain level of nine. The 05/20/24 Functional Abilities Care Area Assessment documented R27 was awaiting knee surgery and was not ambulatory. The 05/20/24 Pain CAA documented R27 had chronic pain related to her diagnosis. The Care Plan reviewed on 07/18/24, documented R27 had recent surgery on her right knee and instructed staff to provide the resident with required one staff assistance with dressing, toileting, transfers, and incontinent care, dated 07/01/24. The 07/13/24 Physician Orders included Hydrocodone-Acetaminophen Oral Tablet, 10-325 milligram (mg) tablet, one tablet, by mouth, five times a day scheduled at the following times, 12:00 AM, 06:00 AM, 12:00 PM, 04:00 PM and 08:00 PM for chronic pain. The Progress Notes reviewed from 06/27/24 to 07/19/24 documented the following: On 06/27/24 at 02:47 PM, R27 readmitted from the hospital after she received a right total knee replacement. On 06/29/24 at 04:42 PM, R27 complained of right knee pain rated at a 10. No medication had been delivered from pharmacy and no answer from the physician. R27 requested to go to emergency room and was transferred. On 06/29/24 at 06:36 PM, R27 returned from the hospital, she had received pain medications and returned with a script and stated her a pain level was five. On 07/03/24 at 06:12 PM, R27 rated her pain at 10, she stated she had scheduled pain medication and stated it worked for her. On 07/06/24 at 10:56 AM, R27 noted to have redness, warm and pain to her left lower leg. R27's physician made aware waited on new orders. On 07/06/24 at 02:33 PM, Physician had not called facility back with new orders. R27 requested to go to the hospital if the facility did not hear back from the physician. On 07/06/24 at 03:28 PM, R27 was sent to hospital, evaluated in emergency room and was admitted with cellulitis (skin infection caused by bacteria). On 07/12/24 at 05:24 PM, R27 readmitted at 12:30 PM and rated her pain at a seven out of 10. On 07/13/24 AT 04:31 PM, received a new physician order to increase hydrocodone-acetaminophen 10-325 mg changed from four times a day to five times a day per physician. During an interview on 07/16/24 at 12:34 PM, R27 stated her call light did not always work, the light above the door in the hallway did not light up, and staff told her the call light did not activate their pager. R27 stated she had to yell loudly for staff to come assist her and stated this occurred on all three shifts and would at times, have to wait over 45 minutes for staff to answer her call light. On 07/16/24 at 04:00 PM, R27 yelled out the surveyor's name from her room when the surveyor walked by her room. R27 was in her bed. R27 had a frown on her face of discomfort and stated that her call light had been on for over 20 minutes, and no staff had answered it yet. R27 stated she was in pain and needed pain medication. During an interview on 07/16/24 at 04:01 PM, CNA N stated the C hall call lights did not alarm to all of the pagers and the call light system had not been working correctly for several months. During an interview on 07/16/24 at 04:05 PM, Licensed Nurse (LN) G and LN H both confirmed R 27's call light was activated 20 minutes prior when they observed the call light computer screen located in the nurses' station. LN G and LN H stated the call light system has not worked properly for months. During an interview on 07/16/24 at 04:35 PM, Administrative Nurse D stated the call light system had just been looked at recently by a company and had been working properly. Administrative Nurse D expected the aides to always have a working pager and walkie talkie on them when working. On 07/16/24 at 04:35 PM, Administrative Staff A, confirmed she would look into the call light system and update the surveyor. On 07/16/24 at 05:30 PM, CNA O stated she had a pager, but it was not on. CNA O then stated the pager battery was dead. On 07/16/24 at 05:30 PM, CNA P stated she had the float pager on her and had received alerts from A, B, and D hall call lights. Observation with CNA P of her pager history revealed no C hall call lights were received to her pager. On 07/16/24 at 05:30 PM, CNA N stated she always carried a call light pager. On 07/16/24 at 05:30 PM, CNA M stated she did not have a pager on her. CNA M stated she gave the C hall pager to another aide at 04:30 PM today. On 07/16/24 at 05:35 PM, CMA R stated she received the C hall pager at 04:30 PM and cleared the history off the pager. CMA R stated the call light system on C hall did not always work, but the nurses have the call light screen in the nurses' station and would call the staff on the walkie talkies to assist the residents when residents would activate their call light. Observation on 07/16/24 at 05:35 PM, revealed R27 activated her call light, the alert went to the C hall pager, but did not go to any other pager, including the float pager. During an observation on 07/16/24 at 05:40 PM, the call light computer screen in the nurses' station with a history of the longest call light activated time was 62 minutes. Administrative Staff A confirmed that was not an acceptable time for a resident's call light to go unanswered. Administrative Staff A stated the call light should also go to the float pager and confirmed R27's call light did not go to that pager at 05:35 PM. Review of the call light reports from 07/15/24 documented the following extended call light response times: Room C-38, the call light was on for 43 minutes, 36.8 minutes, and 89.42 minutes. Room B-21, the call light was on for 51.17 minutes. Room B-26, the call light was on for 30 minutes. Room B-27, the call light was on for 65.58 minutes. Room A-7, the call light was on for 43 minutes, and Room B-19, the call light was on for 33 minutes. Review of the call light reports from 07/16/24 documented the following extended call light response times: Room A-7, the call light was on for 32 minutes, 36.15 minutes. Room B-23, the call light was on for 31 minutes. Room B-21, the call light was on for 61 minutes. Room B-27, the call light was on for 51 minutes. Room C-37, the call light was on for 47 minutes, 56 minutes, and 43 minutes. Room C-38, the call light was on for 42 minutes. Room D-23, the call light was on for 46 minutes, and Room A-8, the call light was on for 38 minutes. On 07/16/24 at 06:05 PM, Administrative Staff A stated the facility call light plan was the facility would have a staff member at the nurses' station to monitor the call light computer screen and notify staff members by walkie talkie when a call light had been activated. Administrative Staff A stated she contacted the call light company for instructions to re-program the float pager later in the evening as the company was not available to assist at the time of the call. On the morning of 07/17/24 at 07:25 AM, observation of the facility nurse's station revealed no staff were present at the nurse's station to monitor the computer screen for call lights. On 07/17/24 at 07:30 AM, CNA Q stated she did not have a pager but had a walkie talkie. CNA Q stated she was the bath aide and did not need to carry a pager. On 07/17/24 at 07:40 AM, LN I stated the Administrator re-programmed the float pager last night, and all staff were to have a pager and a walkie talkie. LN N stated no one educated or alerted them that a staff member was to watch the call light computer screen. On 07/17/24 at 08:05 AM, B hall CNA MM lacked a call light pager, however had a walkie talkie on her. On 07/17/24 at 08:05 AM, A hall CNA NN had her call light pager and walkie talkie on her, and the pager history showed the call lights activated on the A hall earlier in the morning. On 07/17/24 at 08:05 AM, C and D hall CNA M had both C and D hall call pagers and a walkie talkie on her. CNA M stated she had cleared the history on both the pagers that morning. On 07/17/24 at 08:05 AM, CNA Q stated she now had the float pager on her, and the float pager had no history on it. On 07/17/24 at 08:11 AM, R27 activated her call light. The call light did activate the pager for C hall and float pager, but it did not vibrate or sound when activated per CNA M and CNA Q. CNA M stated the pager should sound or vibrate. On 07/17/24 at 08:35 AM, Administrative Staff A stated she gave verbal education last night after the float pager was re-programmed and stated the aides were to carry the float pager so there would be two working pagers for the call lights being activated. Administrative Staff A stated she did not complete a written education. The facility Call Light policy, dated 08/01/23 documented staff were to ensure the resident always had a method of calling for assistance and would promptly answer resident's call lights. On 07/17/24 at 06:14 PM, Administrative Staff A was provided the Immediate Jeopardy (IJ) template for the failure to provide needed services to residents due to the lack of a functioning call system in place to address the care needs of all residents. The facility submitted an acceptable plan for removal of the immediate jeopardy on 07/18/24 at 07:54 AM which included the following: 1. All residents were immediately checked on to address any needs. Continual resident rounding was conducted to monitor and assess resident needs until all pagers were verified functioning appropriately. 2. All pagers were checked to ensure they were functioning properly, and all CNAs and CMAs were checked to ensure they were wearing their functioning pagers. 3. Immediate education was conducted with all CNAs, CMAs, and Charge nurses to ensure all CNAs, CMAs an assigned Charge nurse were wearing their pager during their shift. 4. Walkie talkies will be implemented for increased communication for resident care needs. Walkie talkies will be carried by all nursing staff during their shift to assist in call light response time. 5. Call light company contacted on 07/16/24 and corrected float pager, ensuring this pager received resident call lights from all hallways. What systematic changes were implemented to ensure deficient practice does not recur: 1. Walkie talkies will be carried by all nursing staff during their shift to assist in call light response time. 2. Order was placed for additional pagers. When additional pagers arrive to facility, all nursing staff will carry pagers including Nursing Leadership, during their shift to assist in call light responses. 3. At beginning of each shift, a huddle will be conducted by the charge nurse to ensure all CNAs & CMAs are carrying pagers on their person. 4. Nursing home leadership will implement Angel Rounding, a resident rounding interview and observation system to ensure resident care needs are addressed including call light response times The surveyor verified the facility implemented the above corrective measures on-site on 07/18/24 at 04:00 PM. The deficient practice remained at a scope and severity level of an E, following the implementation of the removal plan. - The Electronic Health Records (EHR) documented Resident (R)21 had the following diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following an intracranial hemorrhage (a type of stroke that causes bleeding in the head), lack of coordination and traumatic brain injury (TBI-an injury to the brain caused by external forces). The 02/15/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 99, indicating severely impaired cognition, the depression not scored and lacked staff interview. R21 had behaviors that included hitting and yelling. R21 required supervision for eating and oral care. Moderate assistance with activities of daily living (ADLs), with toileting hygiene, showering and dressing. R 21 required maximal assistance with transfers, personal hygiene, and bed mobility. R21 was dependent on staff for wheelchair mobility. R21 was always incontinent of bladder. The resident had no falls. The 02/15/24 Functional Abilities Care Area Assessment (CAA) documented R21 was dependent on staff with all ADLs. The 05/17/24 Quarterly MDS documented a BIMS score of 99, and the depression was not scored. R21 had behaviors of yelling and hitting. R21 required total dependence of staff for toileting, showering, dressing, hygiene, transfers, and dressing. R21 required maximal assistance for oral care and bed mobility. R21 required supervision for eating. R21 was frequently incontinent of bowel and bladder. On 07/17/24 the Care Plan documented R21 required a full lift with two persons assist, dated 03/21/24. Staff instructed to complete weekly skin assessment by licensed nurse, document the findings and report concerns to the physician, dated 08/03/22. On 07/17/24 the Physician Orders documented to complete weekly skin assessments, document the findings and report concerns to the physician, ordered on 06/29/23. The Progress Notes reviewed 01/01/24 to 07/18/24, documented the following: On 03/21/24 at 08:58 PM, R21 had an old bruise noted across her lower chest area, under arms and left shoulder area. Bruised areas were various colors of purple and yellow. The bruise determined to be from inappropriate gait belt (belt used to help transfer or stabilize during activity) used by staff. Review of the Skin Observation in EHR dated 03/18/24, documented R21's skin check was completed - no skin conditions observed/skin condition resolved. The Skin Observation in EHR dated 03/25/24, documented skin check was completed - no skin conditions observed/skin condition resolved. On 07/16/24 at 12:02 PM, R21 seated in her wheelchair in the main dining room eating her lunch. Noted a personal alarm on wheelchair attached to the handle of the wheelchair and clipped to R21's shirt. On 07/16/24 at 12:40 PM, R21 seated in her wheelchair yelling out come here a few times and waving her right arm. On 07/16/24 at 12:47 PM, a phone interview with R21's family member stated she received a phone call from the facility on 03/21/24 at 10:00 PM from a staff nurse and was notified that R21 had a bruise on her chest, and that it might have been caused by a gait belt. The family member stated they went to the facility the next day and observed a large bruise located on R21. The bruise was across the chest from armpit to armpit, with several different colors of healing. The family member stated they spoke to the Administrator that was no longer employed there and the SSD, and asked why she is just being notified of a bruise that looked to be healing. The family member stated that the Administrator would have the Director of Nurses call her about the bruise. The family member stated she talked to Administrative Nurse D on 03/25/24 and was informed the bruise was caused by a gait belt and that R21 was now a full body mechanical lift to avoid using a gait belt. On 07/17/24 at 05:30 PM, Administrative Staff A was requested to locate incident reports that was requested by a surveyor earlier in the morning from Administrative Nurse D. Administrative Staff A was notified that R21 had a bruise across her chest noted on 03/21/24. On 07/17/24 at 05:35 PM, Administrative Staff A stated that no investigation was completed, that the bruise occurred when family transferred R21 by themselves. Administrative Staff A stated there was a progress note in the EHR. The progress notes reviewed with Administrative Staff A and confirmed there was no progress note that mentioned the family caused the bruise. On 07/18/24 at 09:30 AM, no documentation received about the above concern from Administrative Staff A or Administrative Nurse D. On 07/18/24 at 04:00 PM, Social Service Staff X could not recall a conversation about a bruise on R21. On 07/22/24 at 02:40 PM, Administrative Nurse D stated there was no investigation or report completed about the bruise on R21 as the thought it was caused by a gait belt. Confirmed no staff education completed after the bruise was noted. Administrative Nurse D stated the skin observations should have included the bruise. The facility policy dated 07/06/23 Abuse and Neglect documented the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The facility failed to ensure staff identified and responded appropriately to all allegations of abuse and reporting for this resident that had a large bruise across her chest. - Review of Resident (R) 17's undated Physician Orders, documentation included diagnoses of traumatic subdural hemorrhage (bleeding in the brain due to trauma), anxiety disorder, (mental or emotional reaction characterized by apprehension, uncertain and irrational fear) , need for assistance with personal care, lack of coordination, and problem related to care provider dependency. The Annual Minimum Data Set (MDS) dated [DATE], included a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The resident did not exhibit behaviors. She reported feeling down, depressed, or hopeless for two to six days of the look back period and noted the resident would isolate socially at times. The resident experienced hallucinations (sensing things while awake that appear to be real, but the mind created) and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and rejected evaluation and/or cares one to three days of the look back period. She received antidepressant medication (class of medication used to treat depression). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/12/24, included the resident had impaired cognitive function, impaired thought processes, experienced confusion, and behaviors. The Care Plan, (CP), dated 07/09/24, included interventions initiated on 04/17/24, which instructed staff to provide a translator as necessary to communicate with the resident and further documented the majority of facility staff spoke Spanish. An intervention initiated 04/17/24 instructed staff to monitor/record/report to R17's health care provider as needed when the resident had feelings such as labile mood or agitation, felt threatened by others or thoughts of harming someone. During an interview on 07/16/24 at 01:02 PM, R17 spoke in Spanish to Dietary Staff (DS) BB, who translated the interview to English on behalf of the resident. R17 stated two men sexually assaulted her in the facility. She said she had bruises and bite marks across her breast and abdomen when she made the report to the nurses (at the facility). Upon inquiry, she stated the nurses did not respond to her report of assault nor assess her for injury. She said she was in her room at the facility when the two men forced her on the bed and that was where it happened. The resident sat in her wheelchair, cried, and pointed towards her bed while describing the event. She was anxious, tearful, and her hands were trembling. She reported nobody did anything in response to her allegation. She confirmed law enforcement had not talked with her and she did not feel safe in the facility. During an interview on 07/16/24 at 01:50 PM, DS BB stated she remembered hearing something about the resident (R17) reporting she was assaulted in the facility to someone at the local hospital, but that was a couple of months ago and she was not sure of the details. DS BB stated she did not recall any staff education (regarding resident abuse) provided by the facility at the time. Review of the Electronic Medical Record (EMR) Progress Notes (PN), dated 05/16/24 at 05:00 PM, revealed R17 complained of bilateral (both) breast pain due to a sexual assault that occurred at the facility a long time ago according to the resident. She did not recall when it happened. The resident had never reported any abuse since she admitted to the facility. She stated the people who assaulted her bit her at that time and she had several bruises on her breast and abdomen. The nurse performed a skin assessment, and the assessment was within normal limits. The nurse notified the Director of Nursing (DON), Social Services Designee (SSD), and Personal Care Physician (PCP) of the situation. The EMR PN dated 05/24/24 at 04:30 PM, documentation included the facility nurse spoke to the hospital nurse who reported the resident (R17) admitted from the emergency room (ER) on 05/22/24 for complaints of left sided chest pain. The hospital nurse informed the facility they made an adult protective service (APS) report due to the resident's complaint of sexual assault. The facility would follow up with the resident's PCP and to determine if a consult with cardiologist was required. The EMR PN dated 05/24/24 at 05:42 PM, documented upon return to the nursing facility, the resident was very aggressive and complained much of the night. She refused to have her call light turned off after cares. She banged on the door, yelled, and cried. The EMR PN dated 05/29/24 at 07:46 AM, revealed during a recent hospitalization, the resident (R17) reported to ER staff that she was being sexually abused at the nursing home. Review of the facility EMR documentation above revealed the resident (R17) reported sexual assault by two male perpetrators on 05/16/24. On 05/24/24, the resident went to the hospital for chest pain and reported to hospital staff she was sexually assaulted in the facility. On 05/29/24, the resident readmitted to the facility. The hospital notified the facility of the resident's report of sexual assault on 05/24/24 and on discharge on [DATE]. The facility failed to respond to R17's allegation of abuse, investigate the allegation of abuse, and did not notify law enforcement until 07/16/24, when R17 reported the sexual assault to a state agency surveyor during a recertification survey. Review of the facility Grievance Log for 04/01/24 through 07/16/24 lacked identification of any allegation of abuse nor neglect regarding R17. During an interview on 07/17/24 at 02:44 PM Administrative Staff A confirmed the grievance logs did not include any report of sexual assault for the resident as noted in the 05/16/24 progress notes. The facility followed up on the reported sexual assault on 07/16/24 (approximately two months after the resident originally reported the allegation) when the surveyor brought it to her attention. Administrative Staff A reported she started at the facility as the Administrator on 06/10/24 and she was not aware of the report until 07/17/24. Administrative Staff A said she expected the Social Worker/SSD to track resident grievances, but the SSD informed her she did not maintain the grievance log as it was kept in the old Administrators office. She reported the SSD and the DON were employed during the time of the sexual assault allegation by R17 and the facility failed to respond to the resident's allegations of abuse on three different occasions. Administrative Staff A reported the facility should report, investigate, and notify law enforcement of allegations of sexual assault to ensure protection of the resident making the allegation, as well as the other residents of the facility. On 07/17/24 at 02:49 PM, Social Service Staff X stated she was just aware of the resident's allegation of abuse related to sexual assault. She stated the staff should protect the resident first then report any allegations of abuse to their supervisor and the state agency, initiate an investigation, and notify law enforcement. The nursing staff should assess the resident for injury, call the physician, family, and law enforcement. The facility should provide education for the staff and also question other residents and staff to get clarification on how they feel about their safety. Social Service Staff X confirmed the allegations of abuse were not reported or investigated when staff were made aware of the allegations on 05/16/24, 05/24/24, and 05/29/24. The facility failed to respond to the resident's allegation of abuse as they should. The facility policy Abuse and Neglect policy, dated 07/06/2023, documentation included the purpose of the policy was to ensure that residents are not subjected to abuse by anyone, including but not limited to, location employees, and/or other residents. Alleged or suspected violations involving any mistreatment, neglect, exploitation, or abuse including injuries of unknown origins will be reported immediately to the administrator. In the absence of the administrator from the location, the following individuals have the administrative authority of the administrator for purposes of immediate reporting of alleged violations: the director of nursing services or the supervisor of social services and both also have the authority to call law enforcement. The location will have evidence that all alleged or suspected violations are thoroughly investigated, and they will prevent further potential abuse while the investigation is in progress. Results of all investigations will be reported to the administrator or designated representative and to other officials in accordance with state law, including to the state survey and certification agency. The facility failed to ensure R17 remained free from sexual abuse when they failed to acknowledge an allegation, initiate an investigation, report the allegation to law enforcement and/or the state agency, and protect her from further abuse after she alleged, she was sexually assaulted by two men in her room at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 40 residents, with four residents sampled, including three residents reviewed for risk of elopement (an incident in which a cognitively impaired resident with poor or impaired decision- making ability/safety awareness leaves the facility without the knowledge of staff). Based on observation, record review, and interview, the facility failed to provide adequate supervision and a safe environment, as free of accident hazards as possible, to prevent the elopement of cognitively impaired and independently mobile Resident (R)2. The facility staff knew R2 was an elopement risk and R2 had been upset and voiced she wanted to go home. The facility staff then left R 2 unsupervised near the front entrance. The facility staff had knowledge the front doors had malfunctioned and did not require a code to be entered to open the door, however, reported the WanderGuard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) still functioned. On 03/19/24 at 07:10 PM, R2 exited the facility via the front doors without staff awareness and the WanderGuard system failed to alarm. Facility staff did not know R2 eloped until a neighbor brought her to the front entrance at 07:24 PM, fourteen minutes later. This deficient practice placed R2 in immediate jeopardy. Findings included: - The Medical Diagnosis tab in the electronic medical record (EMR) for R2 included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), altered mental status, restlessness and agitation, and dementia (progressive mental disorder characterized by failing memory, confusion). The Quarterly Minimum Data Set (MDS) dated [DATE], assessed R2 with a short-term and long-term memory loss and impaired decision making. The Significant Change MDS dated 03/08/24 assessed R2 with a Brief Interview of Mental Status (BIMS) score of zero, indicating severe cognitive impairment. R2 used a wheelchair for mobility. The Cognitive Loss/Dementia Care Area Assessment dated 03/24/24 revealed R2 had a diagnosis of Alzheimer's disease and required staff to give one command at a time, cue to task at hand, speak in simple direct sentences, and repeat as needed. The Care Plan dated 03/07/24, revealed R2 was at risk for elopement related to increased wandering and a WanderGuard used to alert staff to movement when close to the exit doors. The staff were to check the WanderGuard daily to ensure it was in place. The care plan indicated R2 had a behavior symptom related to her dementia as evidenced by wandering. Staff were to minimize R2's potential for wandering behaviors by offering toileting, snacks, and interaction which may divert attention or prevent wandering behavior. The Elopement Risk assessment dated [DATE] assessed R2 as an elopement risk. The Physician Order tab included an order dated 04/14/22 for R2 to have a WanderGuard in place and to check for placement every day. The Work History Report dated 12/02/23 through 03/31/24 revealed the magnetic exit locks, doors, locks, and gates (elopement) testing and inspection (receivers) task completed by Maintenance Staff U on 03/13/24. The report lacked an area to document if there were any issues. The Progress Note dated 03/19/24 at 07:38 PM, revealed R2 had been hanging around the front lobby and crying, demanding that she goes home. R2 was able to get out of the front door because of the broken lock, and a visitor brought her back into the building. The Progress Note dated 03/20/24 at 01:22 AM, revealed R2 eloped from the building during shift change, the door lock was broke, and entry/exit was possible with no staff mediation. R2 had been crying in the lobby area demanding she go home. The WanderGuard system did not sound, however, R2 had a WanderGuard in place and returned to the facility uninjured, accompanied by a person from a nearby residence. R2 had told the neighbor she was from the facility. R2 was in her wheelchair with her orthopedic boot (device used to protect broken bones and other injuries of the lower leg, ankle, or foot) on her right lower extremity. Licensed Nurse (LN) G assessed R2 for injuries and R2 returned to her room. The Progress Note dated 03/20/24 at 10:39 AM revealed R2 eloped at approximately 07:10 PM last evening. On 03/27/24 at 01:37 PM, observation of the area R2 traversed after she exited the facility revealed a sidewalk in front of the facility that went around to the south side, an area of the sidewalk on the south side had an uneven surface approximately two inches all the way across, and an area of dirt/grass around a tree for approximately 25 feet from the facility sidewalk before reaching a paved area in front of the neighbor's residence. R2 traveled approximately 140 feet from the front entrance to the neighbor's residence without staff knowledge. On 03/27/24 at 01:44 PM, observation revealed R2 resting in her bed with a WanderGuard bracelet in place to her left ankle. On 03/27/24 at 01:45 PM, when R2 asked if she had gone outside after supper last week, she stated no it was cold, cold, cold. On 03/27/24 at 01:29 PM, Maintenance Staff U stated he checked the doors every week or two, whenever it came due in the electronic system, and did not recall any door malfunctions with his last door check completed prior to R2's elopement on 03/19/24. Maintenance Staff U stated he checks each WanderGuard used, weekly. Maintenance Staff U stated the WanderGuard system works fine and when checked the day after the elopement, the system was fine and so was R2's WanderGuard device. On 03/27/24 at 02:00 PM, Certified Medication Aide (CMA) R stated on 03/19/24 she worked 04:00 PM to 10:00 PM and R2 had been upset all day, had been asking staff to take her out, and she last saw R2 around 06:20 PM or 06:30 PM and R2 was crying. CMA R stated she provided R2 reassurance and that was the last time she had seen R2. CMA R stated there was a meeting at 07:00 PM for CMAs and Certified Nurse Aides (CNA) on 03/19/24, which she said she was approximately 10 minutes late getting to, and she never heard an alarm sound around the time R2 eloped. On 03/27/24 at 02:53 PM, CNA M stated she was on duty on 03/19/24 when R2 eloped. CNA M last saw R2 around 06:50 PM to 07:00 PM at the nurse's station talking to LN G and the resident was crying and saying she wanted to go home. CNA M stated R2 started crying after supper, and she observed her starting to walk and reminded she was not supposed to be up walking and needed to sit down (due to recent foot surgery). CNA M stated at one-point R2 was just past the fishpond headed to the front door and she moved R2. R2 had tried to call a friend or family and when they did not answer, it made R2 cry more and she kept saying she wanted to go home. CNA M stated after assisting other residents to lay down, she and CNA N sat in a chair at the fishpond area to chart and a guy had entered the facility and had R2 outside. They brought R2 inside and took to her to the nurse's station. On 03/27/24 at 03:07 PM, CNA N stated she was on duty on 03/19/24 when R2 eloped. CNA N stated R2 had been upset off and on and was talking about going home. CNA N stated she attempted to keep an eye on her and around 07:00 PM, she observed R2 in the hallway and entering her room. CNA N assisted another resident, then helped another staff member with cares, and did not have a chance to see if R2 was still in her room. CNA N stated after that she was in the fishpond area and a young man came in the facility and appeared to be looking for someone, she stood up to hear him better and observed R2 outside with the young man's mother, who said R2 told them she came from here. CNA N stated she brought R2 inside and then to the nurse and informed the nurse of the elopement. CNA N stated she did not hear the WanderGuard system sound when R2 eloped, which was usually a loud sound able to be heard down the hall when in a room. CNA N stated she knew the door was not locking and did not require a code to open since the previous week and as far as she knew it had been fixed. On 03/27/24 at 03:18 PM, Maintenance Staff V stated the magnetic lock was shut off to the door because the circuit board in the keypad was bad, which did not affect the Wanderguard system as it required to be shut off with a switch at a different location. On 03/27/24 at 03:50 PM, Administrative Nurse D stated she expected the staff to do one-to-one with R2 when she was upset that evening, on 03/19/24, and saying she wanted to go home. On 03/27/24 at 04:07 PM, LN G stated from the time she arrived for duty on 03/19/24 at 06:00 PM until she went to obtain vital signs at 07:00 PM, R2 was sitting in the nurse's office door. R2 was crying, wanted to call her aunt who did not answer and that caused R2 to start cussing and demanding to be taken home. LN G stated she told R2 this was where she lived, asked her to calm down, and said she could go to her room. LN G stated another CNA (she could not recall which CNA) moved R2 to the fishpond area to see if she would calm down and that was when LN G went down the hall to obtain vital signs. LN G stated around 07:20 PM, she came back to the nurse's desk to document the vital signs and did not know R2 was gone. LN G stated CNA N informed her a man brought R2 back to the facility from his house. LN G stated she assessed R2 for injuries in her room and tried to get her interested in the television. LN G stated she did not hear the WanderGuard system alarm and stated at the time the magnetic locks were broken; however, the WanderGuard system had been functioning because the day before R4 tried to get out and it sounded. LN G stated R2's WanderGuard was in place to her ankle and R2 did not verbalize wanting to go home after she returned to the facility. LN G stated there were not any extra WanderGuards to replace R2's, so she locked the exterior door so nobody could go in or out without her unlocking it. LN G stated the door had been malfunctioning and it allowed anyone to go in or out without entering a code on the keypad. On 03/27/24 at 04:44 PM, observation revealed R2 propelled her wheelchair independently using her left leg. Her right leg had an orthopedic boot in place and her foot rested on the pedal of the wheelchair. On 03/27/24 at 04:45 PM, Administrative Nurse D moved R2 up to the front door, informed R2 there would be a loud noise, and opened the door. When the WanderGuard system sounded, R2 placed her hand up to her ears. On 03/28/24 at 08:42 AM, Maintenance Staff U stated when he checked the WanderGuard devices on 03/13/24, all of the devices worked. On 03/28/24 at 09:25 AM, observation of the facility video footage (lacked audio) dated 03/19/24 at 07:09 PM, revealed R2 propelled herself in the wheelchair from the hall she resided on and went to the front door using both hands to push the door open, and she exited the facility at 07:10 PM. R2 did not cover her ears when she left the facility. There was no further activity at the front door until 07:24 PM, when a male opened the door and came inside and looked around and at 07:25 PM, he exited the door with two staff behind him. One of the staff, CNA N, observed punching a code on the keypad on the exterior prior to exiting. On 03/28/24 at 09:40 AM, Administrative Staff A stated on the video footage from another camera, she could see R2 standing up and pushing her wheelchair to the neighbor's house. The facility policy Elopement dated 07/11/23 revealed measures would be put into place to minimize risk of elopement that were individualized to resident needs and identified on the care plan. The facility failed to provide adequate supervision and a safe environment to cognitively impaired R2, identified as an elopement risk, who was upset and voiced wanting to go home, and eloped from the facility in her wheelchair on 03/19/24 at 07:10 PM for 14 minutes, without staff knowledge. On 03/28/24 at 01:10 PM, Administrative Staff A was provided the Immediate Jeopardy template and notified of the facility's failure to provide adequate supervision when R2 was upset and voiced wanting to go home and eloped from the facility on 03/19/24 at 07:10 PM. The immediate jeopardy was determined to first exist on 03/19/24 at 07:09 PM, and the surveyor verified the facility identified and implemented corrective actions completed on 03/20/24 at 08:30 PM, when the facility completed the following: 1. The facility locked the front door and checked R2's WanderGuard for functioning and sounding the alarm properly on 03/19/24 at 07:30 PM. 2. Nursing conducted a full assessment of R2 on 03/19/24 at 07:35 PM. 3. Maintenance checked R2's WanderGuard receiver and tested okay along with checking with resident at front door sounding the WanderGuard system on 03/20/24 at 09:00 AM. 4. Nursing completed elopement risk assessments on all residents, checked all care plans of residents at risk for elopement to ensure interventions in place for exit-seeking symptoms, and updated the Treatment Administration Record to check twice daily to ensure the WanderGuard is in place on 03/20/24 at 10:00 AM. 5. The Director of Nursing conducted the Preventing Elopement Focus Audit on 03/20/24 at 11:00 AM. 6. Maintenance contacted technician to reset the magnetic lock keypads on 03/20/24 at 12:00 PM. 7. The facility had a Quality Assurance Performance Improvement meeting on 03/20/24 at 01:00 PM. 8. Maintenance replaced circuit board so the magnetic lock would automatically lock and open with a keypad on 03/20/24 at 08:00 PM. 9. The facility staff were educated to make a radio communication when a resident was exit seeking and make sure resident was comfortable, needs met, diversional activities offered, and kept in view during this time on 03/20/24 at 08:30 PM. Due to the corrective actions implemented prior to the onsite visit, the deficient practice was deemed past non-compliance and existed at a J scope and severity.