**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to protect two (2) of twenty-one (21) residents (Resident #18 and Resident #20) from sexual abuse. On 06/23/2022, Resident #16 was observed by staff in the hallway, across from the nurse's station, kissing Resident #20 and groping Resident #18's breast. The facility, however, failed to assess and revise the resident's care plan to identify the potential risks to other residents related to Resident #16's behaviors. Additionally, interviews with staff revealed sexual abuse was not considered as the residents' Brief Interview for Mental Status (BIMS) score was low, or below eight (8), which indicated severe cognitive impairment. Further, the allegation of abuse was reported to the Director of Nursing (DON), however, staff were informed by the DON that the incident was not reportable or investigated as abuse because the residents did not appear to show that the sexual activity was unwanted. Subsequently, on 12/18/2022, Resident #16 was found by staff in his/her room on top of Resident #18, kissing and humping the resident on Resident #16's recliner chair. Further staff interviews revealed the sexual behavior in Resident #16's room did not appear to be unwanted by both residents. It was because this type of inappropriate unwanted sexual contact would reasonably cause anyone to have psychosocial harm, it can be determined that the reasonable person in the residents position would have experienced severe psychosocial harm, as a result of sexual abuse. The facility's failure to have an effective system in place to ensure each resident remained free from abuse, has caused or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 01/27/2023 at 42 CFR §483.21, Comprehensive Care Plans (F656), at the highest scope and severity (S/S) of a J; 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR §483.70, Facility assessment (838), at the highest S/S of a K; and 42 CFR §483.90, Maintain all mechanical, electrical, and resident care equipment in safe operating condition (F908), at the highest scope and severity S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689). The Immediate Jeopardy was determined to exist on 01/22/2023. The facility was notified of the Immediate Jeopardy on 01/27/2023. Additionally, Immediate Jeopardy was identified on 02/22/2023 and was determined to exist on 01/16/2022 in the areas of 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, F610) at the highest S/S of a J; 42 CFR §483.21, Comprehensive Care Plans (F656) at the highest S/S of a J; 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR §483.40, Behavioral Health Services (F744) at the highest S/S of a K; 42 CFR §483.70 Administration (F835 and F838) at the highest scope and severity (S/S) of a J; and 42 CFR §483.75, Quality Assurance and Performance Improvement (F865), at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610); 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689); and 42 CFR §483.40 Behavioral Health Services (F744). The facility was notified of the Immediate Jeopardy on 02/22/2023 and is Ongoing. The findings include: Review of the facility's policy titled, Abuse Prevention, revised on 01/25/2018 and reviewed on 09/09/2022, revealed each resident had the right to be free from verbal, sexual, physical, and mental abuse. Per the policy, sexual abuse was defined as, non-consensual sexual contact of any type with a resident. Further review revealed the residents' care plan would be revised to reflect new interventions to minimize reoccurrence and to treat any injury or harm identified through the assessment of the resident; other residents who may have potentially been affected, or were at risk, would be identified, and a plan of care would be developed or revised as appropriate to ensure safety. Review of the facility's policy titled Process to Report and Investigate Allegations of Abuse dated 02/02/2018, revealed that as soon as the facility was aware of an allegation of abuse or other reportable incident, staff should ensure the residents were safe, gather as much information as possible from the person reporting the allegation; notify the Administrator, Director of Nursing (DON), Social Service Director (SSD) immediately; make sure the residents responsible party and physician were notified of the allegation; and if another resident was involved and alleged to have caused the incident, an employee would be assigned to monitor one-on-one (1:1) until initial evaluation could be completed; once the evaluation was completed, the facility would contact the physician with the results for possible new orders to discharge or continue care; if the resident remained at the facility, the resident would be placed on fifteen (15) minute checks for the next seventy-two (72) hours; and the care team would update the care plan as appropriate. 1. Review of Resident #16's Progress Note dated 06/23/2022 at 11:13 PM, documented by Licensed Practical Nurse (LPN) #2, revealed he came out of the South Medication Room and saw Resident #16 standing in the center of the South Hall with his/her tongue down a resident's [Resident #20] throat while at the same time groping another resident's [Resident #18] breast. Further review revealed that when Resident #16 saw LPN#2, he/she stopped and acted nonchalant as though nothing had happened. Review of Resident #16's Progress Note, dated 12/18/2022 at 9:07 PM, documented by LPN #4, revealed the LPN was informed by State Registered Nursing Assistant (SRNA), [SRNA #10], that she was informed during report, from a previous shift, about an incident between Resident #18 and Resident #16. Continued review of the progress note revealed LPN #4 notified the SSD of the incident and the resident was placed on fifteen (15) minute checks. Record review revealed the facility admitted Resident #16 on 02/05/2015 with diagnoses to include Unspecified Dementia and Generalized Anxiety Disorder. Review of Resident #16's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS) score of ten (10), indicating the resident was moderate cognitive impairment. Continued review, under Section E of the MDS, revealed the resident did not exhibit behaviors, to include hitting, kicking, pushing, scratching, grabbing, abusing others sexually. or wandering. Review of Resident #16's Annual MDS, dated [DATE], revealed the resident was assessed to have a BIMS score of ten (10), which indicated moderately cognitive impairment. Continued review, under Section E of the MDS, revealed the resident did not exhibit behaviors, to include hitting, kicking, pushing, scratching, grabbing, abusing others sexually, or wandering. Review of Resident #16's Comprehensive Care Plan, initiated on 02/05/2015 revealed the resident was care planned for altered mood, depression, and anxiety with psychoactive medication use. Further review revealed the resident had episodes of crying, with increased his/her depression. The goal of the care plan was for the resident to display a stable mood over the next ninety (90) days, with interventions to include assessing, monitoring and documenting mood/behaviors. There was no evidence; however, to support the facility revised the resident's care plan to include the resident's sexually inappropriate behaviors with increased supervision, to ensure the safety of the resident. Interview with Registered Nurse (RN) #1, on 02/15/2023 at 4:36 PM, revealed Resident #16 was sexually inappropriate. She stated on one occasion, the resident asked her for a washcloth. RN #1 revealed she went to the linen closet to grab the resident his/her washcloth and the resident walked into the linen closet, kissing her directly in the mouth. The RN revealed she told the resident never to do that again, adding, I was off guard. She stated she told a couple of girls but did not report the incident. 2. Review of Resident #18's Progress Notes, late entry dated 06/23/2022 at 11:13 PM, revealed Licensed Practical Nurse (LPN) #2 came out of the south hall medication room and witnessed a resident (Resident #16), kissing another resident (Resident #20), while groping this resident's (Resident #18) breast. Continued review of the progress note revealed the resident just stood there, letting [Resident #16] touch him/her. Further review revealed the resident did not appear to resist nor did he/she show any signs of physical, emotional, or psychological distress. Continued review of the progress note revealed that when the resident [Resident #16] saw the nurse, he/she stopped and went to his/her room and this resident [Resident #18] started walking the hallway, which was normal for him/her. Review of Resident #18's Progress Note, dated 12/18/2022 at 9:14 PM, revealed the Licensed Practical Nurse (LPN) #4 was informed by State Registered Nursing Assistant (SRNA), [SRNA #10], that she was told in report from a previous shift about an incident between Resident #18 and Resident #16. Continued review of the progress note revealed LPN #4 notified the SSD of the incident and the resident was placed on fifteen (15) minute checks. Review of Resident #18's medical record revealed the facility admitted the resident on 09/10/2021, with diagnoses to include Unspecified Dementia, Major Depressive Disorder, and Anxiety Disorder. Review of Resident #18's Quarterly Minimum Data Set (MDS) Assessment, dated 06/09/2022, revealed Resident #18 was assessed to have a Brief Interview for Mental Status (BIMS) score of three (3), indicating the resident had severe cognitive impairment. Continued review of the MDS, under Section E for Behaviors, revealed the facility had assessed the resident to have no behaviors or not behaviors directed towards others. These behaviors included hitting, kicking, pushing, scratching, grabbing, or abusing others sexually. Further review revealed the facility had assessed the resident to wander daily. Review of Resident #18's Quarterly MDS Assessment, dated 12/01/2022, revealed the facility assessed the resident to have a BIMS score of 00 (zero), which indicated severe cognitive impairment. Further review, under Section E for Behaviors, revealed the resident was assessed to have behaviors which included hitting, kicking, pushing, scratching, grabbing, or abusing others sexually, one (1) to three (3) days, within the review period. Continued review revealed the resident was assessed to wander four (4) to six (6) days, but less than daily. Review of Resident #18's Comprehensive Care Plan, revised on 06/16/2022, revealed the resident was care planned for altered mood/behavior related to Dementia with Behavioral Disturbance, Anxiety, and Depression. Further review of the care plan revealed the resident wandered in/out of other residents' rooms, took their snacks, and tended to take and eat off other's trays. The goal of the care plan was for the resident to display a stable mood over the next ninety (90) days with interventions to include assessing, monitoring and documenting the resident's mood/behaviors, monitoring the resident's habit of wandering in/out of other residents' rooms, taking their snacks, and eating food off other residents' meal trays, explain the inappropriate behavior to the resident and remind him/her to refrain from going into other's rooms without invitation. There was no evidence; however, to support the resident's care plan was revised to include his/her inappropriate sexual behavior, to include increased supervision, to ensure the safety of the resident. Interview with Family Member #3, on 02/16/2023 at 12:34 PM, revealed Resident #18 did not know who he was. He further stated that if the resident was in his/her right mind, no one would have touched him/her in a sexual way. Per the interview, the Family Member revealed he was distraught after discovering the facility did not do anything to prevent or protect the resident from abuse. Interview with State Registered Nursing Assistant (SRNA) #15, on 02/14/2023 at approximately 12:30 PM, revealed on 12/18/2022, she was walking down Resident #16's hall and looked into Resident #16's room and noticed Resident #18 sitting in Resident #16's recliner. She further stated Resident #16 was observed with his/her hands under Resident #18's shirt fondling and kissing him/her. SRNA #15 revealed she reported the incident to Registered Nurse (RN) #1 as Resident #18 was not capable of making the decision to participate in the sexual contact. SRNA #15 stated she believed the circumstance to be sexual abuse and should have been reported. She further stated that abuse was not generally reported when the residents' BIMS were low. Interview with State Registered Nursing Assistant (SRNA) #10, on 02/17/2023 at 8:52 PM, revealed she normally worked the night shift, on weekends. Per the interview, she stated she did not witness the incident between Resident #16 and Resident #18, on 12/18/2022. SRNA #10 revealed someone told her about the incident. Per the interview, Resident #18 often wandered into other residents' rooms, searching for food. Interview with LPN #4, on 02/14/2023 at approximately 8:00 AM, revealed on 12/18/2022, he was informed by State Registered Nursing Assistant (SRNA) #10, that during report/change in shifts, she was informed Resident #16 was observed on top of Resident #18 in a chair. Further, he stated he thought this would have been abuse and reported it to the Social Service Director (SSD). He stated he and SRNA #10 filled out an incident report; however, was told the allegation, did not meet. According to LPN #4, this had been an issue for years, not reporting abuse. He stated there had been a handful of residents with inappropriate touching and had made sexual comments. Further, he stated most of the residents had some form of dementia and he could not understand how a low BIMS score could have allowed residents to be abused. Interview with Registered Nurse (RN) #1, on 02/15/2023 at 4:36 PM, revealed staff reported the incident between Resident #16 and Resident #18 on 12/18/2022; however, she did not mention it because she had already reported the resident multiple times. She further stated, this has gone on for some time. Interview with the Social Service Director (SSD), on 02/14/2023 at 1:52 PM, revealed she was the abuse coordinator. Per the interview, she revealed the facility based its decision to report and investigate abuse based upon the residents' diagnosis of dementia. The SSD revealed the facility determined to investigate abuse based on the resident's reaction to the behavior and whether the resident was bothered by the behavior or not. Further, she stated Resident #16 had sexual behaviors. She stated LPN #4 called her at home, sometime in December, and reported Resident #16 was observed kissing Resident #18. She stated Resident #18 was not oriented. Per the interview, the SSD stated she advised the staff to put the residents on fifteen (15) minute checks. The SSD revealed she did not notify the resident's responsible party, but should have. Continued interview revealed the incident should have been reported to State Agency and investigated, thoroughly, to ensure the safety of the residents. 3. Review of Resident #20's progress note, dated 06/24/2022, revealed the resident was up wandering the halls. Per the note, the resident was noted to be anxious, confused, and agitated. Further review revealed the resident tried all exits looking for his/her children and husband. Continued review of the note revealed the resident was unable to redirect. Review of the resident's Progress Note, dated 06/25/2022 at 1:43 PM, documented by Licensed Practical Nurse (LPN) #2, revealed he came out of the south hall medication room and witnessed a resident [Resident #16] kissing this resident [Resident #20] while groping another resident's [Resident #18's] breast. Continued review of the note revealed the resident [Resident #20] stood there letting the resident [Resident #16] kiss him/her. Per the progress note, the resident [Resident #20] did not appear to resist nor did he/she show any signs of physical, emotional, or psychological distress. LPN #2 documented that when the resident [Resident #16] saw LPN #2 coming, he/she stopped and went to his/her room, and this resident [Resident #20] went to his/her room. Review of Resident #20's medical records revealed the facility admitted Resident #20 on 06/11/2021, with diagnoses to include Major Depressive Disorder, Unspecified Dementia, Anxiety Disorder, and Dysphagia. Review of the resident's Quarterly MDS, dated [DATE], revealed the facility assessed the resident to have a BIMS score of nine (9), which indicated the resident had moderately impaired cognition. Further review, under Section E for Behaviors, revealed the resident did not exhibit any behaviors that included hitting, kicking, pushing, scratching, grabbing, or abusing others sexually. Further review revealed the resident exhibited wandering behaviors that occurred four (4) to six (6) days, but less than daily. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident to have a BIMS score of six (6), which indicated severe cognitive impairment. Continued review, under Section E for Behaviors, revealed the resident exhibited physical behavioral symptoms (hitting kicking, pushing, scratching, grabbing, and/or abusing others) directed towards others. Further review revealed the resident exhibited verbal behavioral symptoms (threatening others, screaming at others, and cursing at others) directed toward others. These behaviors were exhibited one (1) to three (3) days within the review period. Further MDS review revealed the resident exhibited behaviors to include wandering four (4) to six (6) days, but less than daily. Review of Resident #20's Comprehensive Care Plan, revised 08/16/2022, revealed the resident was care planned for altered mood/behavior related to a diagnosis of Anxiety. Further review revealed the resident had episodes of wandering with exit seeking behaviors noted. The goal of the care plan was to stable the resident's mood over the next ninety (90) days. Interventions included assessing, monitoring, and documenting the resident's mood and behavior, and Social Service Director (SSD) would provide 1:1 as needed. The facility; however, failed to revise the resident's care plan to include his/her sexually inappropriate behavior and failed to ensure the care plan was implemented when 1:1 supervision was needed, to ensure the safety of the resident. Interview with Licensed Practical Nurse (LPN) #2, on 02/14/2023 at 6:35 AM, revealed on 06/23/2022, he was in the medication room and observed through the window, Resident #16 kissing Resident #20 and 'groping' Resident #18's breasts. LPN #2 stated when he exited the medication room, Resident #16 and Resident #20 returned to their rooms and he did not immediately report the incident. LPN #2 stated he later notified the Director of Nursing (DON) and she informed him that in order for the resident's sexual activity to be abusive, the behavior had to be unwanted by the residents. LPN #2 further revealed the DON told him to add a note in the resident's medical record stating there was no distress. Further interview with the LPN revealed this was not Resident #16's first time, adding it happened again with another resident. Further, he stated the resident should have been placed on one-to-one (1:1) supervision to ensure the safety of the residents and the residents who wandered into the resident's room. LPN #2 revealed the incident that had occurred between the residents was abuse. Interview with the Director of Nursing (DON), on 02/16/2023 at 9:20 AM, revealed that when she was notified of suspected abuse, she would also notify the Administrator and Social Service Director (SSD) to discuss the concerns. Further, she stated the facility would conduct an investigation related to the allegations/incident and would place the residents on fifteen (15) minute checks or one-to-one (1:1) supervision, while the investigation was being completed. Continued interview revealed employees were trained on abuse on initial hire and annually. Per the interview, the DON revealed she had training on abuse, which was provided in November, with the update of the new regulations. The DON revealed that in her training, she was informed on the resident's capacity to consent in sexual interactions and that the facility could not rely upon the resident's BIMS score. The DON revealed the decision not to investigate or report the allegations were not based on the residents' BIMS score. She stated it was based on whether the residents were harmed by the incident. Continued interview with the DON revealed she was aware Resident #16 had behaved in a sexual way with staff. She stated she did not recall the incident that occurred on 12/18/2022 but remembers Resident #16 and Resident #18 were in a room, and they were kissing. Per the interview, she did not recall if the residents were placed on fifteen (15) minute checks. Additionally, she stated she did not think the resident's actions were abusive because it was determined none of the residents had experienced harm. Continued interview with the Director of Nursing (DON), on 02/16/2023 at 9:20 AM, revealed she was made aware of Resident #16 kissing Resident #20 while groping Resident #18's breast, and should have reported both incidents to the State Agencies. The DON stated she spoke with Resident #16 and informed the resident he/she could not kiss or touch another resident unless that resident asks. Continued interview with the DON revealed that if the residents were unable to consent, then it would have been abuse and the residents deserved to be protected from abuse. The DON revealed it was her expectation that facility staff would follow the facility's policies and to notify her of any allegations of abuse. Further, she stated there should have been an investigation with witness statements to determine abuse. Interview with the Administrator, on 02/16/2023 at 3:10 PM, revealed the Social Service Director (SSD) was the Abuse Coordinator and she would have expected staff to reach out to her regarding any allegations of abuse. The Administrator revealed it would have been her expectation that residents who were in verbal altercations would be placed on fifteen (15) minute checks and if there was an injury involved, then the facility would have conducted an investigation. Per the interview, the Administrator stated the facility considered the immediate reaction of the resident. She stated they determined if the residents were experiencing emotional distress, crying, or any overt reactions of distress, then it was considered abuse. The Administrator stated she was taking the resident's wishes under consideration. The Administrator revealed it would have; however, been her expectation staff would have followed the facility's policies to protect the residents from abuse.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to report suspected abuse violations within the required timeframe and failed to implement its abuse policies and procedures for two (2) of twenty-one (21) sampled residents (Resident #18 and Resident #20). Additionally, the facility failed to identify and report to the State Agencies, resulting in failure to protect the residents from further potential abuse by the alleged perpetrator. 1. On 06/23/2022, Resident #16 was observed by staff in the hallway across from the nurse's station kissing Resident #20 and groping Resident #18's breasts. Resident #16's sexual behavior was reported to the Director of Nursing (DON); however, the incident was not reported to State Agencies as an allegation of abuse. 2. An additional incident occurred on 12/18/2022, when Resident #16 was found by staff on top of Resident #18, in a recliner chair, in Resident #16's room, kissing and humping Resident #18. Staff interviews revealed the Social Service Director (SSD) discussed the concerns with the Administrator and Director of Nursing (DON); however, they did not report the incident because it was not reportable and the residents were in no distress. The facility failed to provide protection for the residents allowing ongoing access to the residents by the alleged perpetrator. Subsequently, the facility staff assumed that the incidents did not need to be reported because the residents had severe cognitive impairment; therefore, the facility failed to ensure reporting. The facility's failure to ensure it reported alleged abuse violations within the required timeframe to ensure the safety of its residents has caused or is likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy (IJ) was identified on 01/27/2023 at 42 CFR §483.21, Comprehensive Care Plans (F656), at the highest scope and severity (S/S) of a J; 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR §483.70, Facility assessment (838), at the highest S/S of a K; and 42 CFR §483.90, Maintain all mechanical, electrical, and resident care equipment in safe operating condition (F908), at the highest scope and severity S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689). The Immediate Jeopardy was determined to exist on 01/22/2023. The facility was notified of the Immediate Jeopardy on 01/27/2023. Additionally, Immediate Jeopardy was identified on 02/22/2023 and was determined to exist on 01/16/2022 in the areas of 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, F610) at the highest S/S of a J; 42 CFR §483.21, Comprehensive Care Plans (F656) at the highest S/S of a J; 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR §483.40, Behavioral Health Services (F744) at the highest S/S of a K; 42 CFR §483.70 Administration (F835 and F838) at the highest scope and severity (S/S) of a J; and 42 CFR §483.75, Quality Assurance and Performance Improvement (F865), at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610); 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689); and 42 CFR §483.40 Behavioral Health Services (F744). The facility was notified of the Immediate Jeopardy on 02/22/2023 and is Ongoing. The findings include: Review of the facility's policy titled, Abuse Prevention, revised on 01/25/2018, and reviewed on 09/09/2022, revealed every resident had the right to be free from verbal, sexual, physical, and mental abuse. Continued review revealed the facility was committed to providing quality resident care in a safe, abuse free environment, and all reported suspicions of resident abuse would be followed up on by the facility's administrator or his/her designee. Further review revealed employees should report alleged abuse immediately to the charge nurse on duty, for the resident's area, and the charge nurse on duty must immediately contact the Administrator, and or the Director of Nursing (DON), and or the Social Services Director (SSD) about any allegations of abuse. Further review revealed allegations of abuse were to be reported immediately in accordance with state law through established procedures, including the state survey and certification agency, and other officials. Further review of the policy revealed the facility would report all alleged violations and all substantiated incidents to the State Agency and to all other required entities as required, and take all necessary corrective actions depending on the results of the investigation, and the facility would analyze the occurrences to determine what changes were needed, if any, to policies and procedures to prevent future occurrences. Review of the facility's policy titled, Process to Report and Investigate Allegations of Abuse, dated 02/02/2018, revealed for actual harm the facility would notify the Office of Inspector General (OIG), the Ombudsman, and the Police within two (2) hours, and for incidents of no actual harm, the facility would report to the same entities within twenty-four (24) hours, but should not wait that long to report. Continued review revealed, as soon as the facility was aware of an allegation of abuse or other reportable incident, staff should ensure the residents were safe, gather as much information as possible from the person reporting the allegation; notify the Administrator, DON, SSD immediately; make sure the residents responsible party and physician were notified of the allegation; and if another resident was involved and alleged to have caused the incident, an employee would be assigned to monitor one on one (1:1) until initial evaluation could be completed; once the evaluation was completed, the facility would contact the physician with the results for possible new orders to discharge or continue care; if the resident remained at the facility, the resident would be placed on fifteen (15) minute checks for the next seventy-two (72) hours; and the care team would update the care plan as appropriate. Review of the facility's policy titled, Reporting Suspected Crimes under the Federal Elder Justice Act, revised 03/10/2017 and reviewed on 10/19/2022, revealed it was the policy of the facility to comply with the Elder Justice Act (EJA) about reporting a reasonable suspicion of a crime under section 1150 B of the Social Security Act (SSA) as established by the Patient Protection and Affordable Care Act (ACA). Continued review revealed staff must report a suspicious crime to the state survey agency and at least one law enforcement entity within a designated time frame by email, fax, or telephone. Further review revealed if the reportable event resulted in serious bodily injury, the staff member shall report the suspicion immediately, but no later than two (2) hours after forming the suspicion; if the reportable event did not result in serious bodily injury, the staff member shall report the suspicion not later than twenty -four (24) hours after forming the suspicion; failure to report in the required time frame would result in disciplinary action, including up to termination; and staff must report suspicion of an incident to the Charge Nurse, Administrator, DON, or SSD. Review of the Social Services Director's (SSD) Job Description, signed and dated by the SSD on 10/26/2020, revealed that when an allegation of suspected abuse, neglect, or exploitation was reported, the SSD would report to the Director of Nursing (DON) and/or Administrator and assist with reporting to the appropriate state agency, as well as the completion of a thorough investigation as assigned. Review of KRS Chapter 209.030, revealed an oral or written report was to be made immediately to the State Agencies upon knowledge of suspected abuse, neglect, or exploitation of an adult. 1. Review of Resident #16's medical record revealed the facility admitted the resident on 02/05/2015, with diagnoses to include Unspecified Dementia and Generalized Anxiety Disorder. Review of Resident #16's Progress Note, dated 06/23/2022 at 11:13 PM, electronically signed by Licensed Practical Nurse (LPN) #2, revealed he came out of the South Medication Room and saw Resident #16 standing in the center of South Hall with his/her tongue down another resident's [Resident #20's] throat while at the same time groping another resident's [Resident #18's] breast. When Resident #16 saw LPN#2, he/she stopped and acted nonchalant like nothing had happened. Review of Resident #16's Progress Note, dated 12/18/2022 at 9:07 PM, electronically signed by LPN #4, revealed he was informed by the State Registered Nursing Assistant (SRNA), in report of an interaction on dayshift between Resident #16 and another resident [Resident #18] in his/her room. Continued review revealed LPN #4 notified the Social Service Director (SSD) of the incident and was told to place Resident #16 on every fifteen (15) minute checks. Review of Resident #16's Progress Note, dated 12/19/2022 at 8:09 PM, electronically signed by the Social Service Director (SSD), revealed that after reviewing F609 and staff statements with the DON and the Administrator, it was determined the incident was not reportable at this time. Interview with Registered Nurse (RN) #1, on 02/15/2023 at 4:36 PM, revealed staff reported the incident between Resident #16 and Resident #18 on 12/18/2022; however, she did not mention it because she had already reported the resident multiple times. 2. Review of Resident #18's medical record revealed the facility admitted the resident on 09/10/2021, with diagnoses to include Unspecified Dementia Major Depressive Disorder, and Anxiety Disorder. Review of Resident #18's Progress Note, dated 06/23/2022, electronically signed by Licensed Practical Nurse (LPN) #2, revealed he came out of the South Hall medication room and witnessed Resident #16 kissing another male/female resident (Resident #20) while groping another male/female's (Resident #18's) breast. Per the note, Resident #18 just stood there letting Resident #16 touch him/her. Continued review revealed the resident, Resident #18, did not appear to resist, nor did he/she show any signs of physical, emotional, or psychological distress. The LPN documented that when the resident saw Resident #16, he/she stopped and went to his/her room and the resident, Resident #18, started walking the hallway which was his/her normal behavior. Interview with the Family Member #3, on 02/16/2023 at 12:34 PM, revealed Resident #18 often did not know who he/she was but if he/she had been in his/her 'right mind', no one would have touched him/her in a sexual way. Per the interview, Family Member #3 and his/her family were distraught at discovering the facility did not prevent the sexual abuse. Interview with State Registered Nursing Assistant (SRNA) #15, on 02/14/2023 at approximately 12:30 PM, revealed on 12/18/2022, she was walking down Resident #16's hall and looked into Resident #16's room and noticed Resident #18 sitting in Resident #16's recliner. She further stated Resident #16 was observed with his/her hands under Resident #18's shirt fondling and kissing him/her. SRNA #15 revealed she reported the incident to Registered Nurse (RN) #1 as Resident #18 was not capable of making the decision to participate in the sexual contact. Per the interview, SRNA #15 revealed the incident was sexual abuse and should have been reported. Interview with the Social Service Director (SSD), on 02/14/2023 at 1:52 PM, revealed she was the abuse coordinator. Per the interview, the SSD revealed the facility determined to investigate abuse based on the resident's reaction to the behavior and whether the resident was bothered by the behavior or not. Further, she stated Resident #16 had sexual behaviors. She stated LPN #4 called her at home, sometime in December, and reported Resident #16 was observed kissing Resident #18. She stated Resident #18 was not oriented. Continued interview revealed the incident should have been reported to State Agencies. Interview with the Director of Nursing (DON), on 02/16/2023 at 11:14 AM, revealed she had been made aware Resident #16 had been observed kissing a resident, Resident #20, while touching another resident's, Resident #18's, breast. The DON stated, looking back on the situation, it would have been considered sexual abuse and the facility should have reported the incident, and interventions should have been put in place for Resident #16 to prevent this from happening to other residents. Per the interview, she expected staff to provide her with all the details of an abuse allegation and document what was seen, who was around, and any other information that would assist her with the full picture of the situation so she could conduct a full investigation and report it. She also stated she expected all staff to follow the facility's policies related to abuse. 3. Review of the admission Record for Resident #20 revealed the facility had admitted Resident #20 on 06/11/2021, with diagnoses to include Major Depressive Disorder, Unspecified Dementia, Anxiety Disorder, and Dysphagia. 3. Review of Resident #20's medical records revealed the facility admitted Resident #20 on 06/11/2021, with diagnoses to include Unspecified Dementia, Anxiety Disorder, and Major Depressive Disorder. Review of Resident #20's Progress Note, dated 06/25/2022 as a late entry, electronically signed by Licensed Practical Nurse (LPN) #2, revealed he came out of the South Hall medication room and saw a male/female resident (Resident #16) kissing this resident while at the same time groping another male/female resident's (Resident #18's) breast. Per the note, (Resident #18) just stood there letting him/her (Resident #16) touch him/her. He/She did not appear to resist, nor did he/she show any signs of physical, emotional, or psychological distress. When the male/female resident (Resident #16) saw me, he/she stopped and went to his/her room and this resident went to his/her room. Interview on 02/14/2023 at 6:35 AM, with Licensed Practical Nurse (LPN) #2, revealed on 06/23/2022, he was in the medication room and observed through the window, Resident #16 kissing Resident #20 and 'groping' Resident #18's breasts. LPN #2 stated when he exited the medication room, Resident #16 and Resident #20 returned to their rooms and he did not immediately report the incident; however, later notified the DON about the incident. Continued interview with LPN #2, revealed the DON informed him the behavior was not abuse, thus could not be reported. Interview on 02/15/2023 at 4:36 PM with Registered Nurse (RN) #1 revealed Resident #16's sexually inappropriate behaviors were common knowledge at the facility and the Abuse Coordinator/SSD had been made aware. Interview with the Director of Nursing (DON), on 02/16/2023 9:20 AM, revealed if she were notified of any type of abuse, she would tell staff to remove the individual that was accused of the abuse and notify the SSD, and the Administrator, so that the incident would be discussed. Further interview revealed she reviewed the regulation for F609. Continued interview with the DON revealed the facility did not take the resident's BIMS into consideration when determining to report. She stated the facility did not report because there was no harm to the residents and thus was not abuse. The DON revealed that looking back, she would have considered the incidents sexual abuse and she should have reported both incidents to the State. Interview with the Administrator, on 02/16/2023 at 3:10 PM, revealed the SSD was the Abuse Coordinator and she would have expected staff to reach out to her regarding any allegations of abuse and would have expected the SSD to notify her and the DON. She further stated staff should be directed by the SSD on whether or not to report an incident. Per the interview, she stated she looked at the immediate reaction of the resident, after the behavior, and if they were in the same manner, then it was determined no emotional distress occurred. Further, she stated that if the resident was crying or had overt reactions of distress, then it would have been considered abuse. The Administrator revealed it would have been her expectation that the facility's policies would have been followed to protect residents from abuse and to report alleged abuse allegations to the abuse coordinator.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure allegations of sexual abuse were thoroughly investigated for three (3) of twenty-one (21) sampled residents (Resident #16, Resident #18, and Resident #20). 1. On 06/23/2022, staff observed Resident #1 across from the nurse's station, kissing Resident #20 while 'groping' Resident #18's breasts. Record review revealed there was no evidence the facility investigated the incident to protect the residents from further abuse. 2. On 12/18/2022, staff found Resident #16 on top of Resident #18, in a recliner chair, in Resident #16's room, kissing and 'humping' Resident #18. Record review and interviews revealed there was no evidence to support the facility conducted a thorough investigation to prevent further abuse. The facility's failure to ensure all allegations of alleged abuse, including sexual abuse were thoroughly investigated has caused or is likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy (IJ) was identified on 01/27/2023 at 42 CFR §483.21, Comprehensive Care Plans (F656), at the highest scope and severity (S/S) of a J; 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR §483.70, Facility assessment (838), at the highest S/S of a K; and 42 CFR §483.90, Maintain all mechanical, electrical, and resident care equipment in safe operating condition (F908), at the highest scope and severity S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689). The Immediate Jeopardy was determined to exist on 01/22/2023. The facility was notified of the Immediate Jeopardy on 01/27/2023. Additionally, Immediate Jeopardy was identified on 02/22/2023 and was determined to exist on 01/16/2022 in the areas of 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, F610) at the highest S/S of a J; 42 CFR §483.21, Comprehensive Care Plans (F656) at the highest S/S of a J; 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR §483.40, Behavioral Health Services (F744) at the highest S/S of a K; 42 CFR §483.70 Administration (F835 and F838) at the highest scope and severity (S/S) of a J; and 42 CFR §483.75, Quality Assurance and Performance Improvement (F865), at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610); 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689); and 42 CFR §483.40 Behavioral Health Services (F744). The facility was notified of the Immediate Jeopardy on 02/22/2023 and is Ongoing. The findings include: Review of the facility's policy titled, Abuse Prevention, revised on 01/25/2018, and reviewed on 09/09/2022, revealed designated staff would immediately review and investigate all reported incidents and/or allegations of abuse; the facility would investigate and report incidents or occurrences in accordance with federal and state regulations and guidelines; outside investigative bodies, such as local police, would be contacted by the Administrator and in accordance with state and local laws; and the Quality Assurance Committee would review for trends and/or patterns related to incidents. Per the policy, abuse was defined as, causing physical pain or injury to an individual, sexual abuse was defined as, non-consensual sexual. Review of the facility's policy titled Process to Report and Investigate Allegations of Abuse dated 02/02/2018, revealed that as soon as the facility was aware of an allegation of abuse or other reportable incident, staff should ensure the residents were safe, gather as much information as possible from the person reporting the allegation; notify the Administrator, Director of Nursing (DON), Social Service Director (SSD) immediately. Review of the Social Services Director's (SSD) Job Description, signed and dated by the SSD on 10/26/2020, revealed that when an allegation of suspected abuse, neglect, or exploitation was reported, the SSD would report to the Director of Nursing (DON) and/or Administrator and assist with reporting to the appropriate state agency, as well as the completion of a thorough investigation as assigned. 1. Review of Resident #16's medical record revealed the facility admitted the resident on, 02/05/2015, with diagnoses to include Generalized Anxiety and Unspecified Dementia. Review of Resident #16's Progress Note, dated 06/23/2022 at 11:13 PM, documented by Licensed Practical Nurse (LPN) #2, revealed he came out of the South med room and saw Resident #16 standing in the center of South Hall with his/her tongue down a male/females (Resident #20) throat while at the same time groping another male/female's (Resident #18) breast. Review of Resident #16's Progress Note, dated 12/18/2022 at 9:07 PM, documented by LPN #4, revealed he was informed by State Registered Nurse Aide (SRNA), in report of an interaction on dayshift between Resident #16 and another resident (Resident #18) in his/her room. Continued review revealed LPN #4 notified the Social Service Director (SSD) of the incident and was told to place Resident #16 on every fifteen (15) minute checks. There was no evidence to support the facility completed a thorough investigation related to Resident #16's incidents of sexual abuse, to ensure the safety of the residents, as per the facility's policy. Interview with the Social Service Director (SSD), on 02/14/2023 at 1:52 PM, revealed. she had been made aware Resident #16 had very sexual behaviors such as kissing, groping, and humping other residents. Continued interview revealed LPN #4 had called her at home and reported an incident involving Resident #16 and she instructed LPN #4 to put the resident on 15-minute checks. Per the interview, she stated she should have conducted an investigation, reported the incident to the State, and should have notified the family of what had occurred. Further interview with the SSD revealed a complete and thorough investigation with witness statements would have ensured residents were kept safe from further abuse. Interview with the Director of Nursing (DON), on 02/16/2023 at 11:14 AM, revealed she had been made aware Resident #16 had been observed kissing Resident #20 while touching Resident #18's breast. The DON stated, looking back on the situation, it would be considered sexual abuse and the facility should have investigated the incident, and interventions should have been put in place for Resident #16 to prevent this from happening to other residents. Per the interview, she discussed Resident #16 with the Social Service Director (SSD) in the past about his/her behaviors of kissing and touching other residents. The DON revealed the resident was told his/her behaviors were not appropriate unless the resident had entered his/her room. The DON stated that to her knowledge she was not aware the resident had been having sexual encounters with residents that were not consensual. She further stated every resident deserved to be protected from abuse rather it was consensual or not and if a resident was not able to consent then it was sexual abuse. 2. Review of Resident #18's medical record, on 09/10/2021, revealed the facility admitted the resident on 09/10/2021, with diagnoses to include Anxiety Disorder, Unspecified Dementia, and Major Depressive Disorder. Review of Resident #18's Progress Note, dated 06/23/2022, electronically signed by Licensed Practical Nurse (LPN) #2, revealed he came out of the South Hall medication room and witnessed Resident #16 kissing another male/female resident (Resident #20) while groping another male/female's (Resident #18) breast. Review of Resident #18's Progress Note, dated 12/18/2022 at 9:14 PM, revealed the Licensed Practical Nurse (LPN) #4 was informed by State Registered Nursing Assistant (SRNA), [SRNA #10], that she was told in report from a previous shift about an incident between Resident #18 and Resident #16. Continued review of the progress note revealed LPN #4 notified the SSD of the incident and the resident was placed on fifteen (15) minute checks. Record review revealed no evidence to support the facility conducted a thorough investigation related to the incidents of abuse, to ensure the safety of the residents. Interview on 02/16/2023 at 12:34 PM, with Family Member #3 revealed Resident #18 often did not know who he/she was but if he/she had been in his/her 'right mind', no one would have touched him/her in a sexual way. Per the interview, Family Member #3 and his/her family were distraught at discovering the facility did not prevent the sexual abuse from occurring. Interview with the Director of Nursing (DON), on 02/16/2023 at 11:14 AM, revealed Resident #18 was a wanderer and loved to sing and dance. Per the interview, Resident #18's spouse was his/her responsible party (RP) because Resident #18 was not cognitively aware and was unable to make his/her own decisions. Continued interview revealed she was not aware of the incident that occurred with Resident #18 being in a recliner with Resident #16 on top of him/her. The DON stated she had been made aware of Resident #18 being in Resident #16's room, and Resident #16 had been observed kissing Resident #18. Per her recollection, Resident #18 had been taken out of Resident #16's room, and staff put the stop sign up on Resident #16's door. The DON further stated, she had been informed both residents were engaged in the behavior, and no one appeared to be in distress. Further interview revealed she did not remember if both residents were placed on 15-minute checks. The DON stated the incident was reported in day shift, however, she did not recall an investigation into the incident. The DON stated, looking at the situation now, the incident was sexual abuse, and it should have been investigated. 3. Review of Resident #20's medical record revealed the facility admitted the resident on 06/11/2021, with diagnoses to include Major Depressive Disorder, Unspecified Dementia, and Anxiety Disorder. Review of Resident #20's Progress Note, dated 06/25/2022 as a late entry, documented by Licensed Practical Nurse (LPN) #2, revealed he came out of the South Hall medication room and saw a male/female resident (Resident #16) kissing this resident (Resident #20) while at the same time groping another male/female resident's (Resident #18) breast. Record review revealed no evidence to support the facility had completed a thorough investigation to ensure the safety of the resident, as per the facility's policy. Interview with the Director of Nursing (DON), on 02/16/2023 at 9:20 AM, revealed if she were notified of any type of abuse, she would tell staff to remove the individual that was accused of abuse and notify the SSD and the Administrator. Per the interview, the DON revealed she discussed the incidents of abuse with the SSD and Administrator and would conduct an investigation and place the resident on fifteen (15) minute checks or one on one (1:1). Continued interview revealed employees were trained on abuse on initial hire and annually. Per the DON, training had been provided in November on abuse per the new regulations that went into effect. The training went over the resident's capacity to consent in sexual interactions. Further interview revealed she had been made aware of Resident #16 kissing Resident #20 while groping Resident #18's breast at the same time. However, could not recall the incident that occurred between Resident #16 and Resident #18, on 12/18/2022. The DON stated that all she knew from that incident was that the residents were kissing. Further interview with the DON revealed, that looking back, the incidents would have been considered sexual abuse and she should have conducted an investigation. Interview with the Administrator, on 02/16/2023 at 3:10 PM, revealed it was her expectation that the facility's policies would have been followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined the facility failed to ensure the resident's comprehensive care plan was implemented for two (2) of twenty-one (21) sampled residents (Resident #1 and Resident #4). 1. On [DATE], the facility-initiated interventions to include the assistance of two (2) staff members for bed mobility and for all transfers. On [DATE], State Registered Nursing Assistant (SRNA) #1 attempted to transfer Resident #1 from his/her Geri-chair to his/her bed, without the assistance of staff, utilizing the mechanical lift. During the transfer, the sling from the mechanical lift broke and Resident #1 fell from the lift and sustained injuries to include fractures identified at the Cervical seven (C7) and Thoracic one (T1) vertebrae and a complete break of his/her right humerus bone. The resident expired on [DATE] as a result of his/her injuries. 2. The facility admitted Resident #4 on [DATE]. The facility care planned the resident for falls and for his/her safety needs to address his/her history of wandering. Further review of the resident's care plan revealed interventions were in place for staff to monitor the resident, complete hourly rounds, and document the resident's wandering behaviors. However, record review revealed there was no evidence to support the facility implemented the resident's care plan to prevent further behaviors, to include threatening other residents, throwing other resident's items, and wandering throughout the facility. The facility's failure to ensure residents' comprehensive care plan was implemented has caused or is likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy (IJ) was identified on [DATE] at 42 CFR §483.21, Comprehensive Care Plans (F656), at the highest scope and severity (S/S) of a J; 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR §483.70, Facility assessment (838), at the highest S/S of a K; and 42 CFR §483.90, Maintain all mechanical, electrical, and resident care equipment in safe operating condition (F908), at the highest scope and severity S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689). The Immediate Jeopardy was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. Additionally, Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, F610) at the highest S/S of a J; 42 CFR §483.21, Comprehensive Care Plans (F656) at the highest S/S of a J; 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR §483.40, Behavioral Health Services (F744) at the highest S/S of a K; 42 CFR §483.70 Administration (F835 and F838) at the highest scope and severity (S/S) of a J; and 42 CFR §483.75, Quality Assurance and Performance Improvement (F865), at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610); 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689); and 42 CFR §483.40 Behavioral Health Services (F744). The facility was notified of the Immediate Jeopardy on [DATE] and is Ongoing. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, revised [DATE], revealed it was the facility's policy to implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs as identified in the resident's comprehensive assessment. Further review of the policy revealed the explanation and guidelines included, qualified staff were responsible for carrying out interventions specified in the care plan, and were notified of their roles, and responsibilities. Review of the facility's State Registered Nursing Assistant (SRNA) job description, undated, revealed SRNA's were responsible for performing tasks in accordance with the facility's policy and procedures and the individual resident's plan of care, which included resident transfer assistance. Continued review of the job description revealed it was the SRNA's responsibility to ensure safe work practices and to follow the facility rules and procedures. Closed record review for Resident #1 revealed the facility admitted the resident on [DATE] with diagnoses that included Thoracic Aortic Aneurysm, Morbid (Severe) Obesity, and Acquired Absence of Right Leg above the Knee. Review of the resident's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact. Review of Resident #1's Comprehensive Care Plan, initiated on [DATE] and revised on [DATE], revealed the resident was care planned for twenty-four (24) hour supervised/assisted care. The goal of the care plan was to have the resident maintain his/her highest level of functional ability within a safe environment over the next ninety (90) days. Further review revealed interventions included to approach the resident in a calm manner; introduce self and explain all procedures when providing care; assist of two (2) staff with the resident's bed mobility, assist with getting the resident into his/her Geri-chair utilizing the Mechanical Lift; and two (2) staff assist for all transfers. The resident's care plan; however, was not followed to have two (2) staff assist with all transfers. Record review of Resident #1's progress note, dated [DATE], signed by Registered Nurse (RN) #1, revealed RN #1 was called to Resident #1's room by a State Registered Nursing Assistant (SRNA) {SRNA #2} and found Resident #1 lying on his/her back on the floor. Continued review of the progress note revealed the lift sling was frayed and broke while in use, with the resident in the lift. Per the progress note, the resident complained of head, back, and shoulder pain. According to the progress note, the nurse notified Emergency Medical Services (EMS) and the resident was transferred to the hospital for evaluation. Review of the facility's Fall Review Assessment, dated [DATE], signed by the Director of Nursing (DON), revealed Resident #1 sustained injuries to his/her vertebral fractures at the levels of Cervical seven (C7) and Thoracic one (T1), hematoma to posterior head, and right humerus fracture. Continued review of the record revealed the cause of the fall was two-fold, the lift sling strap broke, and failure to have two (2) SRNA's in the room. Review of the Coroner's Report, dated [DATE], revealed Resident #1's cause of death was due to, blunt trauma, injuries of the spine and extremity, due to being moved by a Hoyer lift, when a strap broke, dropping the resident approximately four (4) feet to the floor, landing on his/her head. Interview with Family Member #1, on [DATE] at 11:41 AM, revealed Registered Nurse (RN) #1 reported to her, on [DATE], that while the resident was raised in the mechanical lift, the sling that held him/her broke and the resident fell to the ground, hitting his/her head. The family member further stated Resident #1 informed her that only one (1) staff member operated the lift and she thought there had to be two (2) staff to operate the mechanical lift. Interview with State Registered Nursing Assistant (SRNA) #1, on [DATE] at 2:50 PM, revealed on [DATE], she attempted to transfer the resident from his/her Geri-chair into his/her bed independently. Per the interview, the SRNA stated that when the resident was lifted in the air, the right sling strap broke. SRNA #1 revealed the resident fell to the floor, headfirst and she heard a loud thud. She further stated it was important to follow the care plan to avoid injury to the residents. SRNA #1 revealed she should have followed the care plan and had another person to assist her with operating the mechanical lift. Interview on [DATE] at 4:41 PM, with Kentucky Medication Aide (KMA) #2, , revealed she was unaware two (2) staff members were required for the mechanical lift. She added, I have been transferring the residents alone for years. Per the interview, it was the culture of the facility to perform resident care tasks alone. Further, she stated she did not usually review the resident's care plan prior to transfers to determine the assistance required for transfers utilizing the mechanical lift. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 2:14 PM, revealed Resident #1 was care planned for two (2) staff to assist with all transfers. Per the interview, the care plan was important to follow because it guides the staff on how to care for the residents and how to keep the residents safe. Continued interview with LPN #1 revealed not following the care plan could cause residents to sustain fractures and/or death. Interview on [DATE] at 12:11 PM, with Registered Nurse (RN) #1, revealed that on the day of the incident, [DATE], she was at the nurse's station when State Registered Nursing Assistant (SRNA) #2 informed her Resident #1 had fallen out of the sling from the mechanical lift. Further interview revealed she went to Resident #1's room immediately and believed Resident #1 had fractured his/her shoulder based upon the position of his/her arm. Per the interview, Resident #1 sustained a hematoma towards the back of his/her head and was surprisingly calm. RN #1 revealed she was concerned the resident had a head injury and immediately called Emergency Medical Services (EMS). Continued interview revealed Resident #1 was care planned for two (2) staff members to assist with transfers with the mechanical lift and the care plan should have been followed to prevent serious injury and death. Interview with the Minimum Data Set (MDS) Coordinator, on [DATE] at 12:25 PM, revealed she would have expected the nurses and aides to be aware of each resident's care plan and follow it. Per the interview, Resident #1 was care planned for two (2) persons assist and mechanical lift for transfers. She further stated a printed copy of the resident's care plan was in the binder for the SRNA's to follow for each resident. The MDS Coordinator revealed it was important to follow the resident's care plan to prevent the residents from experiencing falls, having broken bones, and/or death. Interview with the Medical Director, on [DATE] at 3:39 PM, revealed it was her expectation that staff would have followed each resident's care plan. Interview with the Director of Nursing (DON), on [DATE] at approximately 12:40 PM, revealed SRNA #1 should have followed Resident #1's care plan to have two (2) SRNA's operate the mechanical lift. Per the interview, it was her expectation that staff would review the residents' care plans prior to providing care. She further revealed this was important to prevent resident injury. Interview with the Administrator, on [DATE] at 2:43 PM, revealed it was her expectation the mechanical lift would have been operated by two (2) trained staff members. Further, she stated the residents' safety was her responsibility. 2. Review of Resident #4's admission record revealed the facility admitted the resident on [DATE] with diagnoses to include Insomnia, Unspecified Dementia with Behavioral Disturbance, Alzheimer's Disease, and Unspecified Psychosis. Review of Resident #4's admission MDS dated [DATE], revealed the facility assessed the resident to have a BIMS score of three (3), which indicated the resident was severely cognitively impaired. Further review of the MDS, under Section E for behaviors, revealed the resident was assessed to have behaviors daily. These behaviors included hitting, kicking, pushing, scratching, grabbing, threatening, and screaming at others. Additionally, the resident was assessed to have behavior symptoms not directed toward others, four (4) to five (5) days a week. These behaviors included physical symptoms such as hitting or scratching self, pacing and rummaging. Further, the resident was assessed for wandering, including intruding on the privacy or activities of others. The resident exhibited these behaviors four (4) to six (6) days, but less than daily. Review of Resident #4's Comprehensive Care Plan, initiated on [DATE], revealed the resident was care planned to be at risk for falls/injury related to a history of wandering. Further review revealed interventions included monitoring the resident for safety needs and the resident was placed on hourly rounds. Continued review of the care plan revealed the resident was care planned for mood/behaviors related to Depression, new diagnoses of Disturbance, Sundowners, and being verbally and physically abusive towards staff. The goal of the care plan was to stabilize the resident's mood for the next ninety (90) days. Interventions included assessing, monitoring, and documenting any displayed mood/behaviors (sad affect, tearfulness, and wandering) and to attempt to redirect the resident when displaying altered behaviors. The facility failed to ensure the resident's care plan was implemented to ensure the effectiveness of the interventions related to wandering. Review of Resident #4's Progress Note, dated [DATE] at 3:22 AM, entered by Licensed Practical Nurse (LPN) #4, revealed Resident #4 was wandering, had increased agitation, and was combative and hit staff with a water pitcher. Continued review revealed the resident had hidden forks and butter knives in his/her drawer and stated to staff he/she would stab them if they kept bothering him/her. Further review revealed staff had been called to the room by Resident #4's roommate multiple times related to the resident throwing the roommate's objects at him/her. Additional review revealed, Resident #4 was observed going in and out of six (6) other residents' rooms and flipped other residents' televisions onto the floor. Per the Progress Note, staff would continue to observe Resident #4's behavior. There was no evidence to support the resident's care plan was implemented to ensure the effectiveness of the resident's interventions related to wandering. Review of the Progress Note, associated with Resident #15, dated [DATE] at 7:30 PM, documented by LPN #4, revealed Resident #15 was discovered on the floor on his/her back on top of the chuck and draw sheet next to the bed facing the doorway with no injures noted. Per the progress note, a wandering resident [Resident #4] had been seen going in and out of Resident #15's room and surrounding rooms minutes prior to finding Resident #15 on the floor. Review of the resident's care plan revealed the facility failed to implement the resident's care plan to ensure the resident's interventions related to wandering were effective. Review of Resident #4's Progress Note, dated [DATE], documented by Licensed Practical Nurse (LPN) #4 revealed the resident was wandering the halls and became agitated and combative, the entire shift. The LPN documented the resident was wandering in and out of rooms and threatened multiple other residents. Further review revealed the resident was aggressive towards staff, asking for his/her purse and grandbaby. LPN #4 noted the resident was throwing items from rooms into the hallway and screaming out. Per the note, the resident was placed on fifteen (15)-minute checks after speaking with the Administrator and Medical Director. However, there was no evidence to support the facility implemented the resident's plan of care to ensure the effectiveness of his/her interventions related to wandering. Interview with the Social Service Director, on [DATE] at 2:36 PM, revealed the nurses were responsible for adding the resident's behaviors to the daily report sheet and the report sheet was to go to the morning meeting for discussion. The SSD stated the facility did not have a process in place to determine if a resident with behaviors needed an assessment or to determine the effectiveness of the resident's care plan. Continued interview with the Social Service Director revealed it was important to ensure the resident's care plan was followed to ensure psychosocial harm had not occurred and to ensure appropriate interventions could be put in place. Interview with the Administrator, on [DATE] at 3:10 PM, revealed it was her expectation to ensure the facility's policies would have been followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident's environment remained free of accident hazards and that residents received adequate supervision and assistance to prevent accidents. The facility failed to identify and evaluate hazards and risks associated with the mechanical lift equipment and slings and further failed to reduce the associated hazards for three(3) of twenty-one (21) sampled residents (Resident #1, Resident #15, and Resident #22). 1. On [DATE], Resident #1 was dropped from the mechanical lift when the lift sling strap broke and the resident fell approximately four (4) feet to the floor during transfer from a Geri chair to his/her bed. Emergency Medical Services (EMS) were called to the scene and Resident #1 was transferred to the local hospital for evaluation. Resident #1 was discharged from the local hospital and was diagnosed to have a Displaced Comminuted Supracondylar Fracture (an injury to the upper arm bone at the narrowest point, above the elbow) of the right humerus, Fracture of the Seventh Cervical (C7) Vertebra (broken neck), Fracture of the First Thoracic (T1) Vertebra (the bone located in the upper part of the back) , and Contusion of the Scalp. The resident was transferred to another hospital and was admitted to an emergency department that was equipped to manage his/her injuries. The resident expired on [DATE], due to complications of his/her injuries. 2. On [DATE], Resident #20 called Registered Nurse (RN) #1 to Resident #15's room. Upon her arrival, she stated Resident #4 was standing over the resident's body, on the floor. RN #1 revealed she shook Resident #15, as the resident had stopped breathing. Interview revealed Resident #4 pulled the nurse's hair and stated, I want to take my baby home. Resident #15 was transported to the hospital with diagnosis to include a head hematoma from a fall from the resident's bed. The facility; however, failed to investigate the resident's fall thoroughly, to determine the root cause of the resident's fall and failed to provide increased supervision for Resident #4, for the safety of the resident, as well as other. Subsequently, on [DATE], Resident #15 was again found on the floor, of his/her room. Resident #4 was observed walking away from Resident #15's room. The facility failed to determine the root cause of the resident's fall, to include identifying Resident #4 as a potential risk. 3. On [DATE] Resident #22 was observed to be transferred from a Geri-chair to his/her bed using a mechanical lift. However, after the transfer had been completed, it was identified that staff had not utilized the sling that was designed for the use with their lifts, which was unsafe and would result in jury to the resident and caregiver. The facility's failure to ensure the residents' environment remained free of accident hazards and that residents received adequate supervision and assistance to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy (IJ) was identified on [DATE] at 42 CFR §483.21, Comprehensive Care Plans (F656), at the highest scope and severity (S/S) of a J; 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR §483.70, Facility assessment (838), at the highest S/S of a K; and 42 CFR §483.90, Maintain all mechanical, electrical, and resident care equipment in safe operating condition (F908), at the highest scope and severity S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689). The Immediate Jeopardy was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. Additionally, Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, F610) at the highest S/S of a J; 42 CFR §483.21, Comprehensive Care Plans (F656) at the highest S/S of a J; 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR §483.40, Behavioral Health Services (F744) at the highest S/S of a K; 42 CFR §483.70 Administration (F835 and F838) at the highest scope and severity (S/S) of a J; and 42 CFR §483.75, Quality Assurance and Performance Improvement (F865), at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610); 42 CFR §483.25, Free of Accident/Hazards/Supervision/ Devices (F689); and 42 CFR §483.40 Behavioral Health Services (F744). The facility was notified of the Immediate Jeopardy on [DATE] and is Ongoing. Findings include: Review of the Facility's policy, titled Accidents and Supervision, Revised [DATE], revealed the residents' environment should remain as free of accident hazards as possible and each resident should receive adequate supervision and assistive devices to prevent accidents including, identification, evaluation, and implementation of interventions, and monitor to minimize hazards and risks. Interview with the Administrator on [DATE] at 2:43 PM revealed the facility did not have a policy to address the mechanical lift; however, revealed there should have been. Review of the Facility's State Registered Nursing Assistant (SRNA) job description, undated, revealed SRNA's were responsible for performing tasks in accordance with the Facility's policy and procedures and the individual residents' Plan of Care, which included resident transfer assistance. Per the job description, it was the responsibility of the SRNA to ensure safe work practices and to ensure the facility's rules and procedures were followed. Review of the facility's Mental and Physical Profile for SRNA's, undated, revealed the SRNA's had the ability to follow the facility's safety policy to prevent injury to self or others and had the ability to work as a team with other staff members. Review of the Battery-Operated Mechanical Lift's Manufacturer's Owner's Manual, Safety Instructions, undated, revealed special care would be taken with residents unable to aid while being lifted. Continued review revealed the Manufacturer's six (6) point slings were specifically designed for use for the manufacturer's mechanical lift only. Further review of the Manufacturer's recommendation revealed that utilizing the non-manufacturer's brand lift slings were unsafe and would result in injury to the resident or caregiver. Further review of the Manual's Maintenance Schedule included instructions to check the entire sling inventory for fraying, tearing, or excessive wear of any kind and replace any worn or damaged slings with new Manufacturer's slings. Continued review revealed that per the warnings in the owner's manual, the lift should not be utilized unless all maintenance points passed inspection. 1. Closed Record Review revealed the facility admitted Resident #1 on [DATE] with diagnoses that included, Diabetes Mellitus, Chronic Diastolic Heart Failure, Morbid (Severe) Obesity, and acquired Absence of Right Leg above the knee. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed, the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact. Review of Resident #1's Comprehensive Care Plan, revised [DATE], revealed the resident was care planned for mobility with interventions to include assistance with his/her Geri chair utilizing the mechanical lift. Additionally, the resident was care planned for two (2) staff assistants for all transfers. Review of Resident #1's Progress Note, dated [DATE], documented by the Director of Nursing (DON), revealed Resident #1 was transferred utilizing the mechanical lift by one (1) staff when the lift sling broke, and the resident fell. Per the progress note, the resident complained of pain in his/her head, shoulder, and back and was sent to the Emergency Department (ED) due to his/her injuries. Review of Resident #1's Progress Note, dated [DATE] at 2:23 PM, documented by Registered Nurse (RN) #1, revealed the RN was called to Resident #1's room, by a State Registered Nursing Assistant (SRNA unknown). Further review revealed Resident #1 was found lying on his/her back on the floor. Continued review of the progress note revealed the lift sling was frayed and broke while in use with the resident in the lift. Per the progress note, the resident complained of head, back, and shoulder pain. According to the progress note, the nurse notified Emergency Medical Services (EMS) and the resident was transferred to the hospital for evaluation. Review of the facility's Fall Review Assessment, dated [DATE], documented by the Director of Nursing (DON), revealed Resident #1 sustained injuries related to Vertebral Fractures at the levels of Cervical Seven (C7) and Thoracic One (T1), hematoma to his/her posterior head, and a right Humerus Fracture. Continued review of the record revealed the cause of the fall was two- fold, the lift sling strap broke and there was a failure to have two (2) SRNA's in the resident's room to assist with the lift. Review of the Hospital Medical Record, dated [DATE], revealed Resident #1 presented to the Emergency Department (ED) for evaluation of a traumatic injury sustained in a fall from a lift . Per the ED report, the resident was in a lift at his/her long term care facility, when he/she fell approximately four (4) feet onto a concrete floor. Continued review revealed the resident was on Eliquis (a blood thinner) for Atrial Fibrillation. Further review revealed a left scalp hematoma, and Computed Axial Tomography (CAT) scan imaging revealed an acute spinous process at Cervical seven (C7) a compression fracture of Thoracic one (T1), and a right fractured humerus. Resident #1 had been admitted to the hospital on [DATE] and expired on [DATE] as a result of his/her injuries. Review of the Coroner's Report, dated [DATE], revealed Resident #1's cause of death was a blunt trauma injuries of the spine and extremity. Further review revealed the manner of death was due to being moved by a Hoyer lift, when a strap broke, dropping the resident approximately four (4) feet to the floor, landing on his/her head. Review of Resident #1's Death Certificate, dated [DATE], revealed the identified cause or Resident #1's death was related to blunt trauma injuries of the spine and extremity. Observation on [DATE] at 4:45 PM revealed eight (8) slings were removed from service after Resident #1's incident, on [DATE]. Continued observation revealed the labels were faded so that the laundry instructions and sling size was not legible. Additionally, the sling loops were observed to be brittle and easily broken. Observation on [DATE] at 4:45 PM, of the Multi-Brand Compatible Slings, revealed the sling utilized on [DATE], the day of Resident #1's incident, revealed the sling originated from a different manufacturer, which was unsafe, per the manufacturer's recommendation. Interview on [DATE] at 11:41 AM, with Family Member #1, revealed Registered Nurse (RN) #1 reported to her, on [DATE], that while raised in the mechanical lift, the sling that held Resident #1 broke and the resident fell to the ground, hitting his/her head. Further interview revealed the lift sling fabric was frayed and contributed to the accident. Family Member #1 stated Resident #1 informed her there was only one (1) staff member that operated the lift when he/she fell. Family Member #1 revealed Resident #1 was transferred by ambulance to a local hospital and fractures were identified at C7 and T1 vertebrae and a complete break of the resident's right humerus bone. Per the interview, she stated Resident #1 was transferred from the Emergency Department (ED) at the first hospital to a larger hospital to better address the resident's care needs. Further interview revealed it was difficult to watch her parent in pain and the resident required medication to maintain blood pressure and a unit of blood following the accident. Family Member #1 revealed she thought it was the facility's policy to have two (2) staff when operating the mechanical lift. Interview on [DATE] at 2:50 PM with State Registered Nursing Assistant (SRNA) #1 revealed, on [DATE], she transferred Resident #1 to bed from the Geri chair, utilizing the mechanical lift. Continued interview revealed that while the resident was suspended in the air, the right side of the sling, near the resident's head, broke and the resident fell to the floor. Further interview revealed the resident hit the ground, headfirst. SRNA #1 revealed she attempted to grab the resident but heard a loud thud. She stated part of the resident's body landed on the metal legs of the mechanical lift. SRNA #1 revealed she grabbed one (1) of the resident's arms and legs and pulled the resident off the lift. Further, the SRNA revealed she then went to the resident's door to yell for help. Per the interview, she revealed she should not have transferred the resident alone. Interview on [DATE] at 3:35 PM, with SRNA #2 revealed, on [DATE], she was documenting at the nurse's station when she heard a thud and a shriek. Per the interview, Resident #1 could not move his/her right arm. SRNA #2 revealed she was aware SRNA #1 transferred the resident independently and knew the resident required an assist of two (2) staff for all transfers. SRNA #2 revealed she offered to assist with the transfer; however, SRNA #1 refused her help. SRNA #2 revealed she should have reported SRNA #1's refusal to accept assistance with the resident's transfer to management, to prevent injury. Interview with Registered Nurse (RN #1), on [DATE] at 12:11 PM, revealed it was the standard to utilize two (2) staff members when operating a mechanical lift and common sense to check the lift sling before using it on a resident. Continued interview revealed, on [DATE], she was at the nurse's station when SRNA #2 informed her Resident #1 fell out of the sling. Further interview revealed she went to the room and immediately thought Resident #1's shoulder was fractured because of the position of his/her arm. RN #1 stated that after assessing the resident, she knew the facility was in deep trouble and should have been. Continued interview revealed no part of Resident #1's body was on the lift sling. She stated she observed pillows placed under the residents' arms and legs. Further interview revealed that no part of the resident's body should have been moved until the resident was fully assessed after his/her fall with injury. RN #1 revealed the resident sustained a hematoma towards the back of her head and was surprisingly calm. RN #1 revealed this caused concern and she wondered if the resident had a head injury. She revealed she called the Emergency Medical Service (EMS) immediately. Review of the facility's policy titled, Fall Prevention and Management Policy, revised [DATE], revealed the purpose of the policy was to provide a process for fall reviews and fall prevention practices. Further review revealed it was the policy to minimize the risk of serious injury, recognize risks/causes of falls, and implement all prevention management interventions. Continued review of the policy revealed a fall was defined as the unintentional change in position, coming to rest on the ground, floor or on to the next lower surface. Continued review revealed that when a fall occurred, staff would note any statements made regarding the fall, assess the environment for factors that may have contributed to the fall, and document any non-compliance with prevention measures. Further review revealed staff would add necessary interventions to prevent the reoccurrence of the fall. Review of the facility's policy titled, Fall Prevention and Management, revised [DATE], revealed the nursing staff would complete an incident report under risk management, after any occurrence of a fall. Further review revealed the [resident's] care plan would be updated as needed. Interviews with staff revealed Resident #15 fell out of bed on [DATE] and [DATE]; however, there was no evidence to support that the resident's falls were investigated. Further interviews with staff revealed Resident #15 was pulled out of bed by Resident #4; however, the facility failed to implement Resident #4's care plan to prevent accidents and incidents. 2. Closed record review of Resident #4 revealed no evidence to support the facility documented the incidents identified on [DATE] and [DATE]. Review of Resident #4's Progress Note, dated [DATE], documented by Licensed Practical Nurse (LPN) #4 revealed the resident was wandering the halls and became agitated and combative, the entire shift. The LPN documented the resident was wandering in and out of rooms and threatened multiple other residents. Further review revealed the resident was aggressive towards staff, asking for his/her purse and grandbaby. LPN #4 Noted the resident was throwing items from rooms into the hallway and screaming out. Per the note, the resident was placed on fifteen (15)-minute checks after speaking with the Administrator and Medical Director. Review of Resident #4's admission record revealed the facility admitted the resident on [DATE] with diagnoses to include Insomnia, Unspecified Dementia with Behavioral Disturbance, Alzheimer's Disease, and Unspecified Psychosis. Review of Resident #4's admission MDS dated [DATE], revealed the facility assessed the resident to have a BIMS score of three (3), which indicated the resident was severely cognitively impaired. Further review of the MDS, under Section E for behaviors, revealed the resident was assessed to have behaviors daily. These behaviors included hitting, kicking, pushing, scratching, grabbing, threatening, and screaming at others. Additionally, the resident was assessed to have behavior symptoms not directed toward others, four (4) to five (5) days a week. These behaviors included physical symptoms such as hitting or scratching self, pacing and rummaging. Further, the resident was assessed for wandering, including intruding on the privacy or activities of others. He/She exhibited these behaviors four (4) to six (6) days, but less than daily. Review of Resident #4's Comprehensive Care Plan, initiated on [DATE], revealed the resident was care planned to be at risk for falls/injury related to a history of wandering. Further review revealed interventions included monitoring the resident for safety needs and the resident was placed on hourly rounds. Continued review of the care plan revealed the resident was care planned for mood/behaviors related to Depression, new diagnoses of Disturbance, Sundowners, and being verbally and physically abusive towards staff and rejecting care. The goal of the care plan was to stabilize the resident's mood for the next ninety (90) days. Interventions included assessing, monitoring, and documenting any displayed mood/behaviors (sad affect, tearfulness, and wandering). Interview with the Licensed Practical Nurse (LPN) #4, on [DATE] at 6:00 AM, revealed he was familiar with the incidents that occurred on [DATE] and [DATE]. Per the interview, LPN #4 revealed he thought Resident #15's fall should have been investigated. Further, he stated that after each incident, Resident #4 reported he/she dropped his/her baby both times. 3. Review of Resident #15's Progress Note, dated [DATE] at 9:25 AM, documented by Registered Nurse (RN) #1, revealed she was called to Resident #15's room, by a resident [Resident #20]. Per the progress note, Resident #15 was found face down on the floor and had a hematoma to the forehead, a reddened area to his/her back, knees, and elbows. Further review of the progress note revealed the resident was sent to the Emergency Department (ED) for further examination. Review of the Emergency Department (ED) Discharge summary, dated [DATE], revealed Resident #15 presented to the ED for a possible fall with an unspecified head injury. Continued review revealed the nursing facility reported the resident was non-ambulatory, nonverbal, legally blind, had a history of congenital birth trauma and had a feeding tube. Further review revealed the nursing home reported the resident had a bruise on his/her forehead and scratches on his/her back. A physical exam revealed bruising to the left knee and right frontal forehead. Due to the resident's injuries and physical exam findings, a Cat Scan (CT) of the head, chest. abdomen and left knee were performed, and no acute injuries were found. Continued review revealed the resident was discharged back to the facility on [DATE]. Review of the facility's Fall Review Assessment, dated [DATE] at 9:15 AM, revealed Resident #15 was found lying face down on the floor beside the bed with a hematoma and bruise on the forehead, redness to the midback, bilateral elbow scratches and bruising to the chin. Continued review revealed the resident had been sent to the ED for evaluation. Review of the Progress Note, dated [DATE] at 1:35 PM, documented by Licensed Practical Nurse (LPN #7), revealed Resident #15 returned to the facility at 1:06 PM. Continued review revealed a skin observation revealed a knot and bruise were noted to the resident's forehead, bilateral elbows were scratched and bruised, scratches and bruises to the gastric tube site, and bruising to his/her chin. Review of the Progress Note, dated [DATE] at 7:30 PM, documented by LPN #4, revealed Resident #15 was discovered on the floor on his/her back on top of the chuck and draw sheet next to the bed facing the doorway with no injures noted. Per the progress note, a wandering resident [Resident #4] had been seen going in and out of Resident #15's room and surrounding rooms minutes prior to finding Resident #15 on the floor. Review of the facility's Fall Review Assessment, dated [DATE] at 7:30 PM, revealed Resident #15 had an unwitnessed fall and was found on the floor, on his/her back, on top of a chuck, with the drawsheet facing the doorway with no injuries noted. Review of Resident #15's Skin assessment dated [DATE] at 1:52 PM, revealed the resident had a knot and bruise noted to the forehead, bilateral elbows were scratched and bruised, scratches and redness to gastric tube site, and bruising to the chin. Review of Resident #15's admission Record revealed the facility had admitted Resident #15 on [DATE], with diagnoses to include Blindness, Congenital malformation of the nervous system, Severe intellectual disabilities, Hearing loss, and Cerebral hemorrhage due to birth injury. Review of Resident #15's Quarterly MDS dated [DATE], revealed the facility had assessed the resident as being highly hearing impaired, indicating absence of useful hearing, and severely vision impaired, indicating no vision or sees only sees light, color, or shapes, and eyes did not appear to follow objects. Continued review revealed the facility had assessed the resident as having a Cognitive Skills for Daily Decision Making score of three (3), indicating severely impaired, never/rarely made decisions. Further review revealed the resident had been assessed as total dependence for care, meaning full staff performance every time, with two plus (2+) person physical assistance for Bed Mobility and Transfers. Review of Resident #15's Care Plan initiated on [DATE] and revised on [DATE], revealed the resident required twenty-four (24)-hour care related to Congenital Neurological Condition, nonverbal, legally blind and deaf, and was dependent on staff for all Activities of Daily Living care, with a Goal to include the resident would maintain status within a safe environment. Interventions initiated on [DATE] included approach in a calm manner, and a new intervention initiated on [DATE] to place a stop sign across the doorway to deter other residents from entering the room without invitation. Interview with Registered Nurse (RN) #1, on [DATE] at 4:36 PM, revealed that on [DATE], she was walking down the hall when Resident #20 came to her and stated very calmly, this child has come out of the bed and [his/her parent] needed to take him/her home. RN #1 stated she went to Resident #15's room and observed the resident face down on the floor. She stated the resident was unconscious. Per the interview, she shook the resident's head and the resident took a deep breath. The RN stated Resident #4 was standing over the resident's lifeless body. RN #1 revealed she called for help as she could not pick the resident up or move him/her. Continued interview revealed she did not document Resident #4 standing over Resident #15's body. Further, she stated she thought Resident #4 pulled Resident #15 out of his/her bed. Interview with Licensed Practical Nurse (LPN) #4, [DATE] at 6:00 AM, revealed Resident #15 was contracted and had a gastrostomy tube (G-tube, a tube inserted through the belly that brings nutrition directly to the stomach). Per the interview, LPN #4 revealed he was aware the resident has had two (2) falls. The first fall, RN #1 was involved, and the resident was sent to the ED. LPN #4 revealed the resident had a big knot on his/her head. LPN #4 revealed he worked the next night, on [DATE], when Resident #15 was found on the floor. The LPN revealed that while passing medications, Resident #15 was discovered on the floor with his/her chux off the bed with Resident #15 on it. LPN #4 revealed Resident #4 was observed leaving the resident's room. LPN #4 stated he contacted the Administrator. He stated Resident #15 was moved to a different room and a laser alarm was added to alert staff when Resident #4 wandered into the resident's room. LPN #4 revealed Resident #4 was on increased supervision; however, that was not enough. LPN #4 stated the resident needed one-on-one (1:1) supervision and the facility did not have enough staff to provide the increased supervision. Interview with the Resident Care Coordinator (RCC) #18, on [DATE] at 1:11 PM, revealed she did not know much about the incidents that occurred on [DATE] and [DATE], between Resident #4 and Resident #15, but knew Resident #15 was found on the floor, twice. She stated Resident #15 was vulnerable and while she did not see the incident, the position Resident #15 was positioned in did not seem as though Resident #15 could have placed himself/herself in that position. Interview with the Medical Director (MD), on [DATE] at 9:19 AM, revealed the resident was functionally a quadriplegic and questioned at the time of both accidents, how the incidents could possibly have occurred. Per the interview, the MD stated the facility advised her they suspected Resident #4 had pulled Resident #15 from his/her bed on both occasions. Interview with the Director of Nursing (DON), on [DATE] at 9:20 PM, revealed she could not remember the incidents between Resident #4 and Resident #15; however, recalled the charge nurse informing her Resident #15 was found on the floor, for the incident that occurred on [DATE], and was sent out to the Emergency Department (ED) for an evaluation. She further revealed LPN #4 notified her of Resident #15's fall, on [DATE]. Per the interview, LPN #4 was noticeably upset and reported Resident #15 was found on the floor and Resident #4 was observed coming out of Resident #15's room. The DON stated LPN #4 reported he thought Resident #4 pulled Resident #15 out of his/her bed. Continued interview revealed the facility should have completed a falls investigation and should have placed Resident #4 on one-to-one (1:1) observations, to ensure the safety of the resident. Interview with the Administrator, on [DATE] at 3:10 PM, revealed Resident #15 had a lot of developmental issues. Further, she stated the resident could not perform functions with his/her limbs. Per the interview, the Administrator stated staff informed her the resident fell out of bed. She stated that had she known about the additional information related to Resident #4 wandering in and out of residents' rooms, she would have expected Resident #15's fall to be investigated. Further, she stated there were no witnesses to the fall, as the facility did not have proof, and could not make assumptions. Review of the Manufacturer's Owner's Manual Safety Instructions, for the battery-operated mechanical lift, not dated, revealed special care must be taken with residents unable to aid while being lifted and included severely handicapped residents. Continued review revealed the Manufacturer's six (6) point slings were specifically designed for use with their lifts and use of non-manufacturer's brand lift slings were unsafe and may result in injury to the resident or caregiver. 3. Review of Resident #22's Medical Record revealed the facility admitted the resident on [DATE] with diagnoses to include Non-Alzheimer's Dementia, Anxiety, and Depression. Review of Resident #22's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was severely impaired. Review of Resident #22's State Registered Nursing Assistant (SRNA) [NAME] (a tool used to give a brief overview of each residents care needs) revealed the resident required the use of a mechanical lift with two (2) staff assist for transfers. Observation on [DATE] at 1:50 PM, revealed State Registered Nursing Assistant (SRNA) #3 and SRNA #7 used the mechanical lift to transfer Resident #22 from the Geri chair to the bed; however, observation revealed the SRNA's utilized a lift sling that was not recommended by the manufacturer's recommendations. Interview on [DATE] at 1:20 PM, with SRNA #3 revealed she had worked at the facility for a year. Continued interview revealed that the utilization of the mechanical lift required the use of two (2) staff if the resident was not good with standing. Per interview, she had received training when hshe was hired. Interview with the Maintenance Director, on [DATE] at 11:32 AM, revealed it was his responsibility to check machinery and equipment once per month; however, he did not include the mechanical lift slings. Interview with the Director of Nursing (DON), on [DATE] at 4:09 PM, revealed the facility did not follow the manufacturer's instructions prior to the incident that occurred on [DATE]. Interview, on [DATE] at 2:43 PM with the Administrator revealed the facility did not follow the mechanical lift manufacturer's instructions regarding the type of sling to use with the lifts. Per the interview, she stated there was no process in place to routinely inspect the condition of the slings used with the mechanical lifts to prevent serious accident and injury. Per interview, there were no policies in place to address the mechanical lift and there should have been The Administrator stated resident safety was her responsibility.

Based on interview, record review, and review of the facility's Administrator's Job Description and policies, it was determined the facility failed to ensure it was administered in a manner that used its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for three (3) of twenty-one (21) sampled residents (Resident #16, Resident #18, and Resident #20) with Dementia. On 06/23/2022, staff observed Resident #16 in the hallway across from the nurse's station, kissing and groping Resident #18's breasts. However, there was no documented evidence the facility reported the incident to the State Survey Agency (SSA) or Law Enforcement as sexual abuse, or thoroughly investigated the sexual abuse as per the facility's policy. On 12/08/2022, staff found Resident #16 on top of Resident #18 in a recliner chair in Resident #16's room, kissing and humping Resident #18. However, there was no documented evidence the Administrator ensured the allegation of sexual abuse was reported to the SSA or Law Enforcement, or thoroughly investigated the sexual abuse as per the facility's policy. The facility's administration failed to follow its policy related to discharge planning, transfers and discharges, and failed to ensure Social Services was provided in order to maintain the highest practicable, physical, mental, and psychosocial well-being of each resident. The facility's failure to ensure it was administered in a manner that used its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of its residents has caused or is likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy (IJ) was identified on 01/27/2023 at 42 CFR §483.21, Comprehensive Care Plans (F656), at the highest scope and severity (S/S) of a J; 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR §483.70, Facility assessment (838), at the highest S/S of a K; and 42 CFR §483.90, Maintain all mechanical, electrical, and resident care equipment in safe operating condition (F908), at the highest scope and severity S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689). The Immediate Jeopardy was determined to exist on 01/22/2023. The facility was notified of the Immediate Jeopardy on 01/27/2023. Additionally, Immediate Jeopardy was identified on 02/22/2023 and was determined to exist on 01/16/2022 in the areas of 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, F610) at the highest S/S of a J; 42 CFR §483.21, Comprehensive Care Plans (F656) at the highest S/S of a J; 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR §483.40, Behavioral Health Services (F744) at the highest S/S of a K; 42 CFR §483.70 Administration (F835 and F838) at the highest scope and severity (S/S) of a J; and 42 CFR §483.75, Quality Assurance and Performance Improvement (F865), at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610); 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689); and 42 CFR §483.40 Behavioral Health Services (F744). The facility was notified of the Immediate Jeopardy on 02/22/2023 and is ongoing. The findings include: Review of the facility's Administrator Position Description, undated, revealed the major duties included: operating the facility in accordance with established policies and procedures of the Governing Body; prepare and forward on time to the proper authorities all reports required by management; and write definite policies regarding the activities and duties of facility staff and explain the policies to staff to ensure the health care and safety of residents. Further review of the Description revealed additional major duties of the Administrator included: writing personnel policies and individual duties of staff to ensure they were known by all employees; and to supervise all Department Heads by performing regular rounds and conferences. Review of the facility's Abuse Prevention Policy, revised 01/25/2018 and last reviewed 09/09/2022, revealed sexual abuse was defined as non-consensual sexual contact of any type with a resident. Per policy review, all alleged violations involving abuse were to be reported immediately in accordance with State law through established procedures, to include the State Survey Agency (SSA/ licensure and certification agency) and other officials. Continued review of the Policy revealed an in-house investigation was to be performed by the Administrator and/or his/her designee and all appropriate agencies, such as the SSA and Ombudsman, were to be notified immediately after the suspected abuse was reported. Further review of the policy revealed the investigative results of the in-house investigation was to be reported to the outside entities within five (5) working days. Review of Resident #16's medical record revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of ten (10) which indicated he/she was moderately cognitively impaired. Continued review revealed the facility assessed Resident #16 as having no behaviors directed towards others to include sexually abusing others. However, on 06/23/2022, Resident #16 was observed by Licensed Practical Nurse (LPN) #2 in the hallway across from the nurse's station, kissing Resident #20, and groping Resident #18's breasts. Further review revealed there was no documented evidence the facility reported the incident to the State Survey Agency (SSA) or Law Enforcement as sexual abuse as required, or thoroughly investigated the sexual abuse as per the facility's policy. Interview, on 02/14/2023 at 6:35 AM, with Licensed Practical Nurse (LPN) #2 revealed he had been in the medication room on 06/23/2022, and observed Resident #16, through the window, kissing Resident #18 and groping his/her breasts. Per LPN #2, when he exited the medication room Resident #16 and Resident #18 had returned to their rooms. LPN #2 stated he had not immediately reported the incident even though he believed the incident was sexual abuse. He stated for three (3) years he had observed Resident #16 displaying behaviors towards residents with Dementia, such as he observed during the incident involving Resident #18. Per LPN #2, Resident #18 really needed to be on one on one (1:1) supervision. Continued interview revealed he later reported the sexual abuse incident involving Resident #18 to the Director of Nursing (DON). LPN #2 stated he discussed the sexual incident involving Resident #18 kissing Resident #16 with the DON, who told him the incident was not reportable to the State since the incident did not appear to be unwanted. Interview with LPN #4 on 02/13/2023 at 8:00 AM, revealed he had received information from another staff member (State Registered Nursing Assistant [SRNA] #15) on 12/18/2022, about seeing Resident #16 on top of Resident #18, kissing and humping Resident #18. LPN #4 stated he reported the incident to the Social Services Director (SSD) on 12/18/2022. Interview, with SRNA #15 on 02/14/2023 at approximately 12:30 PM, revealed she had observed Resident #16 on top of Resident #18 fondling and kissing Resident #18. SRNA #15 stated Resident #18 was not capable of making the decision to participate in a sexual act with Resident #16. Further interview revealed she reported the incident to the nurse (LPN #4) immediately, and additionally stated Resident #18's spouse, who was also the resident's Power of Attorney (POA) was not notified or aware of the incident. Interview with Registered Nurse (RN) on 02/15/2023 at 4:36 PM, revealed Resident #16's sexually inappropriate behaviors were common knowledge at the facility. Further interview revealed the facility's Abuse Coordinator was well aware of Resident #16's inappropriate sexual behavior. However, the facility's Administration again failed to address the sexual abuse of Resident #18 by Resident #16 on 12/18/2022, when Resident #16 was observed by staff on top of Resident #18 in a recliner chair in Resident #16's room, kissing and humping Resident #18. The facility's Administration also failed to thoroughly investigate the sexual abuse of Resident #18 by Resident #16, as per facility policy. In addition, the facility's Administration failed to provide documented evidence allegations of sexual abuse were reported to the SSA or Law Enforcement. Interview on 02/14/2023 at 6:00 AM, with LPN #4 revealed he believed Resident #16 was abusing residents sexually, and the Resident Care Coordinator (RCC) told him it was for the good of the facility not to report. Continued interview revealed the LPN was very upset, about Resident #16's sexual incidents not having been reported after he told the Administrator and Medical Director about the incidents. LPN #4 stated I think it is a cover up. Further interview revealed about three (3) months ago there was an incident where Resident #16 molested and touched SRNA #10, and molested a resident. LPN #4 further stated that information should have been reported. Interview, with LPN #2 on 02/14/2023 at approximately 6:35 AM, revealed he witnessed Resident #16 kissing a resident who had dementia and groping another resident, with his/her hands on the other resident's breasts. Per interview, LPN #2 stated he put a note in about the incident. Continued interview revealed he did not report the incident at that time; however, he talked to the DON about it later. He stated the DON told him in order for it to be abuse there had to be unwanted contact by the victim. He stated the DON told him she put a note in stating there was no distress in the residents. According to LPN #2, that incident had not been the first time, he stated he had witnessed Resident #16, who had displayed that behavior ever since he first started working at the facility. Further interview revealed he had seen Resident #16 kissing other residents and some of those residents had dementia. The LPN further stated Resident #16's sexual behaviors had been happening for three (3) years, the resident should have had increased supervision, really needed one on one (1:1) supervision. He further stated they (administrative staff) gave staff the reason for not reporting Resident #16's sexual incidents was because the other residents had not been in distress; however, the incidents were abuse. Interview, with the DON on 02/16/2023 at 9:20 AM, and on 02/21/2023 at 3:05 PM, revealed the facility did not have oversight of its reporting and investigating processes, and had no one designated to ensure the reporting and investigations of sexual abuse allegations occurred. Continued interview revealed the facility had an in person training in November on abuse related to the new regulations which had gone into effect. Per the DON, the training consisted of printouts which were gone over with staff and the updated changes reviewed. She stated the printouts referred to a resident's capacity to consent in sexual interactions. She stated it could not be relied on whether the resident understood or what their Brief Interview for Mental Score (BIMS) scores were. Interview revealed residents were to be interviewed and a psychiatric (psych) consult performed for the resident. The DON stated however, the facility had no one who could come perform the psych evaluations of residents. She stated she had been notified by staff of residents being sexually inappropriate before and the facility usually tried to get to the bottom of it. According to the DON, the sexual allegations had been discussed in the facility's morning meetings; however, the facility did not report the allegations because there had not been any harm and we did not think it was abuse. Further interview revealed there needed to be more training and investigations performed. She further stated other residents deserved to be protected from sexual abuse; and if they did not have the ability to consent that was sexual abuse. Interview with the Administrator, on 02/16/2023 at 3:10 PM, and on 02/21/2023 at 3:30 PM, revealed in the facility's morning meetings changes in residents' condition were discussed, and the sexual allegations by Resident #18 would have been or should have been discussed. Per the Administrator, it was her expectation for the sexual allegations to have been discussed, and the residents' care plans updated with interventions to protect the resident and/or other residents. However, the Administrator stated she did not recall if the sexual allegations were discussed. The Administrator revealed the facility's Abuse Coordinator should direct staff on whether to report an incident or not, and if there was an injury the Abuse Coordinator would tell staff to start an investigation. According to the Administrator, the facility was reevaluating the entire (incident) process, and the would be more likely to extend the evaluation period of an incident, and report it if we were unable to determine if what occurred was abuse. The Administrator stated she thought if there had been an investigation it would have shown abuse. Continued interview revealed the Administrator stated the sexual incidents should have been reported. The Administrator stated the Medical Director was updated during the facility's Quarterly Quality Assurance Performance Improvement (QAPI) meetings. `

Based on interview, record review, and review of the facility's policy, investigations, and documentation, it was determined the facility failed to implement its Quality Assurance Performance Improvement (QAPI) program to identify opportunities for improvement in the care and services provided to residents. The facility's QAPI process failed to identify quality of care deficiencies; failed to develop and implement plans of action to correct identified quality of care deficiencies; and failed to ensure standards of quality of care regarding performance improvement measures were sustained. As a result, the facility's QAPI program failed to develop, implement, and monitor to ensure its effectiveness in addressing sexual abuse in the facility. (Refer to F600, F609, F610, and F835) Interview and record review revealed facility staff were aware of sexual abuse allegations; however, they failed to report the allegations to the State Survey Agency (SSA) and other State agencies and failed to conduct thorough investigations of the allegations. Therefore, the facility's QAPI program failed to develop and implement plans to prevent sexual abuse in the facility. The facility's failure to ensure it developed, implemented, and maintained an effective, comprehensive, data-driven QAPI program that focused on indicators regarding outcomes of care and quality of life for its residents has caused or is likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy (IJ) was identified on 01/27/2023 at 42 CFR §483.21, Comprehensive Care Plans (F656), at the highest scope and severity (S/S) of a J; 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR §483.70, Facility assessment (838), at the highest S/S of a K; and 42 CFR §483.90, Maintain all mechanical, electrical, and resident care equipment in safe operating condition (F908), at the highest scope and severity S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR §483.25, Free of Accident Hazards/ Supervision/Devices (F689). The Immediate Jeopardy was determined to exist on 01/22/2023. The facility was notified of the Immediate Jeopardy on 01/27/2023. Additionally, Immediate Jeopardy was identified on 02/22/2023 and was determined to exist on 01/16/2022 in the areas of 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, F610) at the highest S/S of a J; 42 CFR §483.21, Comprehensive Care Plans (F656) at the highest S/S of a J; 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR §483.40, Behavioral Health Services (F744) at the highest S/S of a K; 42 CFR §483.70 Administration (F835 and F838) at the highest scope and severity (S/S) of a J; and 42 CFR §483.75, Quality Assurance and Performance Improvement (F865), at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610); 42 CFR §483.25, Free of Accident Hazards/Supervision/ Devices (F689); and 42 CFR §483.40 Behavioral Health Services (F744). The facility was notified of the Immediate Jeopardy on 02/22/2023 and is ongoing. The findings include: Review of the facility's Administrator Position Description, undated, revealed the Administrator's major duties included: ensuring operation of the facility in accordance with the Governing Body's established policies and procedures; writing definitive policies in relation to the duties and activities of staff and explaining the policies to staff to ensure the safety and healthcare of facility residents. Review of the Description further revealed the Administrator's major duties also included the writing of individual duties of staff and personnel policies to ensure staff knew the policies and duties. In addition, the Administrator was to supervise all Department Heads by performing regular rounds and conferences. Review of the facility's Abuse Prevention Policy, revised 01/25/2018 and last reviewed 09/09/2022, revealed the definition of sexual abuse was the non-consensual sexual contact of any type with a resident. Continued policy review revealed all alleged violations involving abuse were to be reported immediately in accordance with State law through the facility's established procedures. Per review of the policy, reporting was to include alleged violations being sent to the State Survey Agency (SSA) and other officials, and all appropriate agencies, such as the SSA and Ombudsman, were to be notified immediately after the suspected abuse was reported. Further review of the policy revealed the Administrator and/or his/her designee was to perform an in-house investigation, and the results of the investigation were to be reported to the outside entities within five (5) working days. Interview, on 02/15/2023 at approximately 12:30 PM, and on 02/21/2023 at 2:23 PM, with the Minimum Data Set (MDS) Coordinator revealed she was part of the facility's QAPI team. She stated behaviors and allegations of abuse should be discussed in the QAPI meetings, to include sexual abuse allegations. Continued interview revealed she did not recall Resident #16's sexual incidents on 06/23/2022 and 12/18/2022 having been discussed in any Interdisciplinary Team (IDT) meeting she had attended, which included QAPI meetings. She stated she attended the facility's morning meetings and QAPI meetings. Per interview, the morning meetings were held Monday through Friday, and residents' behaviors, to include sexual incidents, were part of what was discussed in the meetings. The MDS Coordinator further stated she did not recall sexual behaviors of Resident #16 being discussed in the facility's QAPI meetings. Interview, with the Director of Nursing (DON) on 02/16/2023 at 9:20 AM, revealed the facility had no one designated to ensure the reporting and investigations of sexual abuse allegations. The DON stated the facility did not have oversight of its reporting and investigating process. Per interview, the DON stated in November the facility performed an in person training on abuse. Continued interview revealed the printouts talked about a resident's capacity to consent in sexual interactions, a resident's Brief Interview for Mental Score (BIMS) and whether the resident understood could not be relied on. The DON stated residents needed to be interviewed and there would need to be a psychiatric (psych) consult for the resident; however, the facility did not have anyone who could come perform psych evaluations. She revealed staff had notified her of residents being sexually inappropriate before they usually tried to get to the bottom of it. The DON stated other residents deserved to be protected from sexual abuse; and if they did not have capacity to consent that was sexual abuse. Interview revealed the facility had not reported Resident #16's sexual incidents because there is not any harm - we didn't think it was abuse. Per the DON, there needed to be more training and investigations performed. She stated in the morning meetings falls, allegations, including sexual allegations were discussed and what was to go to the monthly Performance Improvement Plan (PIP) meetings (monthly) was decided. Further interview revealed everything that went to PIP went to the facility's QAPI. The DON further stated the Medical Director attended the QAPI meetings, by phone or in-person. Interview, on 02/16/2023 at 3:10 PM, and on 02/21/2023 at 3:30 PM, with the Administrator revealed the facility needed to reevaluate its entire process for reporting and investigating allegations of abuse to improve its processes. Continued interview revealed the facility's current process had failed and she had not been aware of the extent of sexual abuse allegations which had occurred in the facility on 06/23/2022 and 12/18/2022. The Administrator stated the facility had morning meeting with all supervisors, and the report sheet, which noted residents' condition changes, was gone over. Further interview revealed the sexual allegations involving Resident #16 would have or should have been discussed; however, the Administrator did not recall if the allegations had been discussed. She further stated it was her expectation for allegations, including sexual allegations, to be discussed in the meetings, and for the MDS Coordinator to update the resident's care plan with interventions to protect the resident and other residents. In addition, the Administrator stated in the morning meetings it might be decided something should go to the PIP, then to the facility's quarterly QAPI meeting to be reviewed and the Medical Director updated. The Administrator further stated the facility did not have a system in place to audit or monitor for its effectiveness of its processes. Interview, on 02/21/2023 at 5:35 PM, with the Medical Director revealed QAPI meetings were held quarterly, and the facility had been religious with having those meetings. The Medical Director stated in the QAPI meetings they looked at falls, infections, etc. and decided what was to be done. Per the Medical Director, she was the facility's oversight person and would think they should notify me regardless. Continued interview revealed there had been a lot of research with elderly people having relations in nursing homes and there were sometimes when people had sexual relations in facilities. According to the Medical Director, residents were adults and it was difficult to say if they were consenting, and they should have had a psychiatric (psych) evaluation. Further interview revealed she attended the facility's QAPI meetings and allegations were discussed; however, she did not recall if the sexual abuse was discussed in the QAPI meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to ensure residents with a dementia diagnosis were provided individualized care needs to ensure care and services were maintained at their highest practicable mental, physical, and psychosocial well-being, for seven (7) of twenty-one (21) sampled residents (Resident #16, Resident #18, Resident #20, Resident #4, Resident #13, Resident #17, and Resident #14) 1. On 06/23/2022, staff observed Resident #16 kissing Resident #20 while groping Resident #18's breast. Record review revealed the resident had a Dementia diagnosis and was care planned for staff to assess/monitor and document the resident's behaviors. Review of the resident's care plan; however, was not updated to include the resident's sexual behaviors to prevent further behaviors. Additionally, on 12/18/2022, staff observed the resident humping and kissing Resident #18 in his/her room. The facility failed to ensure the resident's care plan was implemented to ensure the resident's stop sign was at his/her doorway to prevent others from entering his/her room uninvited. 2. On 06/23/2022, Resident #18 was observed by staff in the hallway, across from the nurse's station, with Resident #16, as he/she kissed Resident #20, and groped Resident #18's breast. The resident was care planned for wandering behaviors which required staff to access and monitor for these behaviors. The facility failed to ensure the care plan was implemented to determine its effectiveness and failed to revise the resident's care plan to address the resident's sexual behaviors, to ensure the safety of the resident. Subsequently, on 12/18/2022, the resident was observed in Resident #16's room, seated in his/her recliner as Resident #16 humped and kissed Resident #18. 3. On 06/23/2022, Resident #20 was observed in the hallway, with Resident #16 kissing him/her. However, there was no evidence to support the facility implemented the resident's care plan to assess/monitor the resident's behavior, related to wandering, to determine the effectiveness of the interventions. Additionally, the facility failed to revise the resident's care plan when the resident exhibited inappropriate sexual behaviors. 4. Resident #4 exhibited behaviors to include wandering, threatening residents and staff, being combative, and increased agitation. The resident was care planned for wandering; however, the facility failed to implement the resident's care plan to assess/monitor and document the effectiveness of its interventions. Additionally, the Medical Director (MD) recommended for the resident to have a sitter to prevent his/her behaviors. The facility; however, failed to ensure the resident's care plan was revised to provide increased supervision. 5. Resident #13 was observed on 01/30/2022 to wander on his/her floor the entire shift, with Resident #4. Record review revealed staff attempted to separate the residents, however, was unsuccessful. The facility failed to implement the resident's care plan to determine the root cause of the unsuccessful attempt to separate the residents. Additionally, the facility failed to provide 1:1 supervision as needed, as per the resident's care plan. 6. On 09/02/2022, Resident #17 was observed by staff kissing his/her roommate. The resident was care planned for staff to assess/monitor and document the resident's behaviors and to refer to his/her physician. However, the facility failed to ensure the resident's care plan was implemented to refer to behavior services and the facility failed to revise the resident's care plan to address the resident's inappropriate sexual behavior. 7. Record review revealed on 09/02/2022, Resident #14 was observed kissing his/her roommate, Resident #17. The facility failed to implement the resident's plan of care to assess and monitor the resident to prevent the resident from getting into bed with other residents, prevent his/her wandering, and/or revise the plan of care to include sexually inappropriate behaviors with interventions to determine its effectiveness. The facility's failure to ensure residents with Dementia and individualized care needs received the necessary services and care to maintain their highest practicable mental, physical, and psychosocial well-being, has caused or is likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy (IJ) was identified on 01/27/2023 at 42 CFR §483.21, Comprehensive Care Plans (F656), at the highest scope and severity (S/S) of a J; 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR §483.70, Facility assessment (838), at the highest S/S of a K; and 42 CFR §483.90, Maintain all mechanical, electrical, and resident care equipment in safe operating condition (F908), at the highest scope and severity S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689). The Immediate Jeopardy was determined to exist on 01/22/2023. The facility was notified of the Immediate Jeopardy on 01/27/2023. Additionally, Immediate Jeopardy was identified on 02/22/2023 and was determined to exist on 01/16/2022 in the areas of 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, F610) at the highest S/S of a J; 42 CFR §483.21, Comprehensive Care Plans (F656) at the highest S/S of a J; 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR §483.40, Behavioral Health Services (F744) at the highest S/S of a K; 42 CFR §483.70 Administration (F835 and F838) at the highest scope and severity (S/S) of a J; and 42 CFR §483.75, Quality Assurance and Performance Improvement (F865), at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610); 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689); and 42 CFR §483.40 Behavioral Health Services (F744). The facility was notified of the Immediate Jeopardy on 02/22/2023 and is Ongoing. The findings include: Review of the facility's policy titled, ADL Care of Dementia Residents, revised 02/15/2022, revealed the care plan interventions for residents with dementia, were to be monitored on an ongoing basis for its effectiveness. The care plans were to be reviewed/revised as necessary. Additional policy review revealed that appropriate referrals were to be made if the current interventions were ineffective. 1. Review of the admission Record for Resident #16 revealed the facility admitted the resident on 02/05/2015, with diagnoses which included Generalized Anxiety Disorder and Unspecified Dementia. Review of Resident #16's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had been assessed to have a Brief Interview for Mental Status (BIMS) score of ten (10), indicating moderate cognitive impairment. Continued review revealed the facility had assessed the resident as having Zero (0) physical behavioral symptoms directed toward others such as hitting, kicking, pushing, scratching, grabbing, or abusing others sexually. Further review revealed the facility had assessed the resident as having Zero (0) other behavioral symptoms not directed toward others such as physical symptoms of hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming or disruptive sounds. Review of Resident #16's Care Plan initiated on 12/14/2021, revealed the resident had been care planned for 24-hour supervised/assisted care related to diagnosis of Depression and Anxiety, with an intervention to administer medications as ordered, monitor for effectiveness and adverse reactions, and notify the physician as needed. Continued review revealed a new intervention had been initiated on 12/14/2021 to include a stop sign in his/her doorway to deter other residents from entering his/her room uninvited. Further review revealed the resident had been care planned for being at risk for Altered Mood related to Depression and Anxiety, with interventions to include, administer medications as ordered, monitor for effectiveness and adverse reactions, and notify the physician as needed; assess, monitor, and document mood/behaviors such as sad affect, tearfulness, restlessness; and notify the physician of abnormal reactions; provide reassurance as needed; psych evaluation as needed. There, however, was no evidence to support the facility implemented Resident #16's care plan to monitor the effectiveness of the resident's care. Additionally, the facility failed to revise the resident's care plan when he/she exhibited sexually inappropriate behaviors, for the safety of the resident and other vulnerable residents. Review of Resident #16's Progress Note, dated 06/23/2022 at 11:13 PM, entered by LPN #2, revealed he came out of the South medication room and saw Resident #16 standing in the center of South Hall with his/her tongue down a male/female's (Resident #20) throat while at the same time groping another male/female resident's (Resident #18) breast. When Resident #16 saw LPN#2, he/she stopped and acted nonchalant like nothing had happened. Review of Resident #16's Progress Note, dated 12/18/2022 at 9:07 PM, documented by LPN #4, revealed he was informed by State Registered Nurse Aide (SRNA), [SRNA #10], in report of an interaction on dayshift between Resident #16 and another resident (Resident #18) in his/her room. Continued review revealed LPN #4 notified the SSD of the incident and was told to place Resident #16 on every fifteen (15) minute checks. However, the Care Plan was not revised to reflect Resident #16 had been placed on fifteen (15) minute checks after the incident occurred on 12/18/2022. 2. Record Review of Resident #18 revealed the facility admitted the resident on 09/10/2021, with diagnoses which included Unspecified Dementia with Unspecified Severity, Insomnia, Major Depressive Disorder, and Anxiety disorder. Review of Resident #18's admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of five (5), indicating severe cognitive impairment. a. Review of Resident #18's Comprehensive Care Plan dated 10/28/2021, revealed the facility care planned the resident for twenty four (24) hour supervision/assisted care related to Dementia with Behavioral Disturbance, anxiety, depression and wandering in hallways with exit-seeking behaviors, and wandering in and out of other residents' rooms, with interventions to include monitor placement of Wander Guard every shift; monitor front door alarm every day with monitoring device to ensure functioning correctly; no butter knives on meal tray to aid in the prevention of removal of Wander Guard; Wander Guard Bracelet on at all times related to exit seeking/wandering behaviors. Continued review revealed Resident #18 had been care planned for Altered Mood/Behaviors related to diagnosis of Dementia with behavioral disturbance, anxiety, and depression, with episodes of wandering in the facility with exit seeking behavior, and frequent wandering in and out of other resident's rooms, with new interventions to include, monitor the resident related to his/her habit of wandering in and out of other resident's rooms and to redirect him/her out of rooms, explain inappropriate behavior to him/her and remind him/her to refrain from going into other residents' rooms without invitation. The facility, however, failed to implement the resident's care plan to prevent the resident from wandering and going into other residents' rooms, to ensure the safety of the resident. Review of Resident #18's Progress Note, dated 12/18/2022 at 9:14 PM, revealed the Licensed Practical Nurse (LPN) #4 was informed by State Registered Nursing Assistant (SRNA), [SRNA #10], that she was told in report from a previous shift about an incident between Resident #18 and Resident #16. Continued review of the progress note revealed LPN #4 notified the SSD of the incident and the resident was placed on fifteen (15) minute checks. Interview on 02/16/2023 at 12:34 PM, with Resident #18's, Family Member #3, revealed he had not been made aware of the sexual interactions involving Resident #16 and Resident #18. Family Member #3 stated had Resident #18 been in his/her right mind, no one would have touched him/her in a sexual way. Interview on 02/14/2023 at approximately 12:30 PM, with SRNA #15, revealed Resident #18 was not capable of making the decision to participate in a sexual act with Resident #16. She stated she had reported the incident to the nurse on 12/18/2022 when she observed Resident #16 on top of Resident #18 in the recliner fondling and kissing Resident #18. 3. Review of Resident #20's medical record revealed the facility admitted the resident on 06/11/2021, with diagnoses to include Major Depressive Disorder, Unspecified Dementia, and Anxiety Disorder. Review of Resident #20's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of nine (9), indicating moderate cognitive impairment. Review of Resident #20's Comprehensive Care Plan, dated 06/18/2021, revealed the facility care planned the resident for Altered Mood/Behavior related to anxiety and dementia with episodes of wandering with exit seeking behaviors, with interventions to include, administering medications as ordered by the physician, monitor for effectiveness of medications, as well as adverse reactions, notify physician as needed; assess, monitor and document mood/behaviors such as sad affect, restlessness, agitation, and wandering, and provide reassurance/redirection as needed, notify the physician of abnormal reactions. There was no evidence to support the facility implemented the resident's care plan to assess/monitor the resident's behavior related to wandering, to determine the effectiveness of the interventions. Additionally, the facility failed to revise the resident's care plan when the resident exhibited inappropriate sexual behaviors. Review of Resident #20's Progress Note, dated 06/25/2022 as a late entry, documented by Licensed Practical Nurse (LPN) #2, revealed he came out of the South Hall medication room and saw a male/female resident (Resident #16) kissing Resident #20 while at the same time groping another male/female resident's (Resident #18's) breast. 4. Closed record review revealed the facility admitted , Resident #4 on 01/11/2022, with diagnoses which included Unspecified Alzheimer's disease, Unspecified Dementia with behavioral disturbance, Major Depressive Disorder, age-related cognitive decline, and Unspecified Psychosis,. Review of the admission Minimum Data Set (MDS) Assessment for Resident #4, dated 01/17/2022, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (3), which indicated severe cognitive impairment. Continued review of the MDS, under Section E for Behaviors, revealed the resident exhibited behaviors to include physical behavioral symptoms directed toward others such as hitting, kicking, pushing, scratching, grabbing, or abusing others sexually, daily. Further review revealed the resident had verbal behavioral systems that was directed toward others. These behaviors included threatening others, screaming at others, and cursing at others. Additional review revealed the resident had a diagnosis of non-Alzheimer's Dementia. Review of Resident #4's Comprehensive Care Plan, initiated on 01/12/2022, revealed Resident #4 was at risk for Altered Mood/Behaviors related to Dementia with Behavioral Disturbance, history of wandering, episodes of being verbally and physically abusive towards staff, rejection of care and Depression. Review of the care plan revealed the interventions for Resident #4 included: administering medications as ordered by Physician and monitoring for adverse reactions to the medications; monitoring and documenting any displayed mood/behaviors (such as sad affect, tearfulness, wandering); and report/notify abnormal reactions to the Physician. Per review of the care plan, additional interventions included: providing reassurance and redirection as possible; attempting to redirect the resident when displaying altered behaviors (such as wandering, cursing) by offering snack, reminiscing about family and his/her former career of factory supervisor, and toileting. Further review revealed the resident had Sundowners Syndrome with episodes of being physically abusive towards staff and rejecting care. Review of Resident #4's Progress Note, dated 01/14/2022, at 3:22 AM, documented by Licensed Practical Nurse (LPN) #4, revealed the resident had been up wandering, had increased agitation, and was combative and had hit staff with a water pitcher. Continued review revealed Resident #4 had hidden forks and butter knives in his/her drawer and stated to staff he/she would stab them if they kept bothering him/her. Per review, staff had been called to the room by Resident #4's roommate multiple times related to the resident throwing the roommate's objects at him/her. Additional review revealed Resident #4 had been observed going in and out of six (6) other residents' rooms and flipping the other residents' televisions onto the floor. Further review of the Progress Note revealed staff would continue to observe Resident #4's behavior. Review of the Progress Note for Resident #4, dated 01/14/2022 at 9:00 PM, documented by LPN #4, revealed the resident rummaged through other residents' rooms and became increasingly agitated and combative with staff and other residents around the nurse's station. Continued review revealed Resident #4 had taken a fork from another resident's meal tray and attempted to stab another resident and staff with the fork. Record review revealed the facility contacted the Medical Director and received a new order for a one (1) time dose of intramuscular (IM) Ativan (a medication used to treat anxiety) one (1) milligram (mg). Further review revealed the Medical Director told staff Resident #4 could not continue those behaviors and the resident might need a sitter, or a psychiatric (psych) evaluation. Review of the Progress Note for Resident #4, dated 01/18/2022 at 2:19 AM, revealed the resident had been wandering in the hallways and in and out of other residents' rooms, and became very agitated and combative. Continued review revealed Resident #4 had threatened multiple other residents and was aggressive towards other residents and staff. Per review of the Note, Resident #4 flipped chairs at the desk and a wheelchair in the lounge and attempted to hit staff with a wet floor sign. Further review revealed Resident #4 threw other residents' items into the hallway and screamed at the other residents. Review of the Note revealed per instructions from the Administrator and Medical Director, Resident #4 was placed on every fifteen (15) minute checks. However, additional review revealed no documented evidence the resident's care plan was revised with the increased need for supervision, to include a sitter. Review of the Progress Note for Resident #4, dated 01/27/2022 at 11:57 PM, revealed the resident had wandered into other residents' rooms, and became agitated at staff when they attempted to remove him/her from the other residents' rooms. Continued review revealed Resident #4 took other residents' personal items and threw them in the floor and hallway and threatened another resident who asked Resident #4 to leave his/her room. Review of the Behavioral Note for Resident #4, dated 01/30/2022 at 1:30 AM, revealed the resident wandered the hallways and into other residents' rooms and was short tempered with the staff. Continued review revealed Resident #4 was combative with staff and followed another resident around for most of the shift. Per review, when staff attempted to separate Resident #4 from the other resident, Resident #4 would go into other residents' rooms looking for the other resident he/she had been following. Record review revealed when the other resident attempted to get away from Resident #4, Resident #4 grabbed the other resident's shirt and punched him/her in the back. Further review revealed the staff separated Resident #4 from the other resident. However, Resident #4 continued to try to follow the other resident. Review of the Note further revealed Resident #4 was placed on every fifteen (15) minute checks per the Social Services Director (SSD) and the Administrator. Additional review revealed the facility failed to revise the resident's care plan to address the resident's behaviors. Interview on 02/15/2023 at 7:20 PM with LPN #4, revealed staff were unable to continuously monitor Resident #4 for the entire shift because of the staffing. LPN #4 stated staffing consisted of only two (2) nurses and two (2) State Registered Nursing Assistants (SRNA's) for the entire facility during the 7:00 PM to 7:00 AM shift for all four (4) halls. Interview on 02/08/2023 at 5:59 AM, with LPN #2 revealed the facility did not have the staff to provide one-on-one (1:1) supervision/care when residents needed increased supervision. He stated he had called Resident #4's family to sit with the resident; however, they were unable to come. Interview, on 02/15/2023 at 7:20 PM, with LPN #4 revealed staff did not report Resident #4's behaviors when they occurred because the resident's behaviors were normal. Continued interview revealed Resident #4 was admitted to the facility with dementia and behaviors that included wandering and going in and out of other residents' rooms. 5. Review of the admission Record for Resident #13 revealed the facility admitted the resident on 01/11/2022, with diagnoses that included Unspecified Dementia without behavioral disturbance. Review of Resident #13's admission MDS Assessment, dated 01/17/2022, revealed the facility assessed the resident to have a BIMS score of zero (0) indicating severe cognitive impairment. Review of Resident #13's Care Plan, initiated on 01/12/2022, revealed the facility care planned the resident as at risk for Altered Mood/Behaviors related to Dementia. Continued review revealed the interventions included administer medications as ordered by the Physician; assess, monitor and document any displayed mood/behaviors (such as sad affect, tearfulness, wandering, restlessness); provide reassurance/redirection as needed, and notify doctor of abnormal findings. Further review revealed the interventions additionally included: a psychiatric evaluation as needed initiated on 01/27/2022; and Social Services intervention for 1:1 supervision as needed, initiated on 03/31/2022. Additional review revealed no documented evidence to support the facility had implemented the resident's care plan to include 1:1 supervision as needed and no evidence to support the facility documented and monitored the effectiveness of the resident's care plan. Review of Resident #13's Progress Note, dated 01/30/2022 at 1:30 AM, revealed the resident had wandered the entire shift accompanied by another resident (later identified as Resident #4). Continued review revealed Resident #13 attempted to get away from the other resident and staff attempted to separate the two (2) residents without success. Per review of the Note, Resident #13 attempted to walk away from the other resident (Resident #4), the other resident grabbed the back of Resident #13's shirt and punched him/her in the back. Further review revealed staff separated the residents, Resident #13 wanted to sit down, and the other resident continued to attempt to follow Resident #13. Resident #13 was placed on every fifteen (15) minute checks per instructions from the SSD and the Administrator. However, the facility failed to document the unsuccessful attempt to separate the residents and provide 1:1 as needed, as per the resident's care plan. 6. Review of the admission Record for Resident #17 revealed the facility admitted the resident on 05/31/2022, with diagnoses which included Unspecified Dementia with other Behavioral Disturbance and Altered Mental Status. Review of Resident #17's admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of five (5), indicating severe cognitive impairment. Review of Resident #17's Care Plan initiated on 06/06/2022, revealed the facility had care planned the resident to be at risk for Altered Mood/Behavior related to Dementia with Behavioral Disturbance, and a history of wandering. Continued review of the Care Plan revealed the interventions included: administering medication as ordered by the doctor; monitor for the effectiveness of the medication, as well as adverse reactions to medication, and report adverse reactions to the doctor. Review of the Care Plan revealed the interventions also included: assessing, monitoring and documenting the resident's mood/behaviors (examples include wandering episodes, tearfulness, restlessness, sad affect) and report abnormal findings to the doctor; provide reassurance/redirection as needed; pharmacy to review psychotropic medication use quarterly and as needed; psychiatric evaluation as needed; and Wander Guard bracelet on as ordered by the doctor. However, further review revealed no documented evidence to support the facility had implemented the resident's care plan, to assess/monitor and document the resident's behaviors to refer concerns to his/her psychiatrist/physician and failed to revise the resident's care plan to address the inappropriate sexual contact. Review of Resident #14's Progress Note, dated 09/02/2022 at 6:29 AM, documented by Licensed Practical Nurse (LPN) #1, revealed Resident #14 had been found kissing Resident #17, who was his/her roommate. Further record review revealed no evidence to support the facility documented the incident in Resident #17's medical record. Review of Resident #17's Therapy Note, dated 09/08/2022 at 2:36 PM, revealed the Psychiatrist #1 saw the resident for a follow-up psychiatric therapy via telehealth. Continued review revealed the resident was anxious and was not sure where he/she was during the visit. Interview on 02/14/2023 at 1:03 PM, with SRNA #1, revealed Resident #14 and Resident #17 were found disrobing each other on an unknown date. SRNA #1 stated she had reported this information to two (2) different charge nurses, the DON, and the Resident Care Coordinator (RCC) and suggested the residents should no longer be roommates. 7. Review of the admission Record for Resident #14 revealed the facility admitted the resident on 08/15/2022, with diagnoses that included Agitation, Restlessness, Unspecified Dementia, Unspecified Severity, with other behavioral disturbance, Unspecified Depression, and Unspecified Anxiety disorder. Review of the admission MDS Assessment for Resident #14, dated 08/22/2022, revealed the facility assessed the resident to have a BIMS score of five (5), indicating severe cognitive impairment. Review of the Care Plan for Resident #14 initiated on 08/16/2022, revealed the facility care planned the resident as at risk for Altered Mood/Behaviors related to Dementia with behavioral disturbance and Anxiety. Continued review revealed the interventions included: administering medications as ordered by the Physician and monitoring for the effectiveness of the medications as well as adverse reactions; notify the Physician as needed if abnormalities were observed. The care plan stated: assess, monitor and document mood/behaviors (such as sad affect, tearfulness, restlessness); notify the Physician of abnormal reactions; provide reassurance and redirection as needed; pharmacy to review the resident's psychotropic medication use quarterly and, as needed. Additional review revealed the interventions also included: provide redirection; assist the resident to his/her own room/bed when getting into other residents' beds in their rooms; and psychiatric evaluation as needed. However, there was no documented evidence to support the facility implemented the resident's care plan to assess and monitor the resident to prevent the resident from getting into bed with other residents, prevent his/her wandering, or revised to include sexually inappropriate behaviors with interventions to determine its effectiveness. Review of Resident #14's Progress Note, dated 09/02/2022 at 6:29 AM, documented by LPN #1, revealed Resident #14 had been found kissing Resident #17, who was his/her roommate. Observation on 02/14/2023 at 6:10 AM, revealed Resident #14 was lying on the couch in the common room, then pacing up and down the hallways, and in and out of other residents' rooms, without staff's oversight. Interview with LPN #4, on 02/14/2023 at 6:10 AM, revealed he was not aware Resident #14 was out of his/her bed and in the common room. Interview on 02/14/2023 at 1:03 PM, with State Registered Nursing Assistant (SRNA) #1 revealed Resident #14 and Resident #17 were found disrobing each other on an unknown date. SRNA #1 stated she had reported this information to two (2) different charge nurses, the DON, and the Resident Care Coordinator (RCC) and suggested the residents should no longer be roommates. However, review of multiple progress and psychiatric notes for Resident #14, dated 02/14/2023, revealed no documented evidence Resident #14 had any behaviors. Interview on 02/15/2023 at 7:20 PM with LPN #4, revealed the facility had multiple residents who wandered, and staff could not maintain visualization of all the residents throughout the 7:00 PM to 7:00 AM shift. LPN #4 stated he believed if appropriate interventions had been implemented for Resident #4 that his/her future behaviors might have been prevented. Interview on 02/07/2023 at 11:55 AM, with Registered Nurse (RN) #2, revealed if she witnessed a resident abuse another resident, she would separate the residents, notify her supervisor (the DON), and notify the families and doctors of the residents. She further stated there were many wandering residents in the facility and not all of their behaviors were documented. She stated that she receives annual dementia training. Interview on 02/08/2023 at 5:50 AM, with LPN #3 revealed the facility had two (2) nurses and two (2) or three (3) SRNA's on a typical 7:00 PM to 7:00 AM shift to cover all four (4) halls. LPN #3 stated there was no time to document all the residents' behaviors. Interview on 02/08/2023 at 5:59 AM, with Licensed Practical Nurse (LPN) #2 revealed the facility did not have the staff to provide one-on-one (1:1) supervision/care when residents needed increased supervision. He further stated the residents' behaviors were normal and there were multiple residents who wandered in the facility. Interview on 02/10/2023 at 11:41 AM, with the Minimum Data Set (MDS) Coordinator, revealed she was responsible for all care plan updates to the comprehensive care plan. She stated she followed the Resident Assessment Instrument (RAI) and care planned the problems triggered by the MDS. She stated behaviors, falls, and condition changes were discussed in the daily morning meeting. She further stated that she should have put additional interventions on the resident's care plan. Interview with the Director of Nursing (DON), on 02/16/2023 at 3:16 PM, revealed the MDS Coordinator completed the Comprehensive Care Plan based on the items triggered by the MDS. She further stated the MDS Coordinator was responsible for updating the care plan. Continued review revealed she it was her expectation care plans would have been revised to reflect the care needs of the residents. Interview on 02/21/2023 at 4:44 PM, with the [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to conduct and document a facility-wide assessment to evaluate what resources were required to provide the necessary care and services for residents who required the use of a mechanical lift. On [DATE], staff transferred Resident #1 from a Geri chair to his/her bed utilizing the mechanical lift when the lift sling strap broke, and the resident fell to the concrete floor. Resident #1 fell approximately four (4) feet and sustained serious injuries which included fractures identified at C7 and T1 vertebrae and a complete break of the right humerus (upper arm bone). Resident #1 died related to his/her injuries from the fall. Review of the Facility Assessment revealed the facility failed to ensure there was a system in place to inspect the mechanical lift slings for safety. The Assessment also failed to specify an inspection schedule and failed to designate staff responsible for inspection of the mechanical lift slings to prevent accidents and serious injury. The facility's failure to ensure residents with Dementia, had their individualized care needs and the necessary services and care to maintain their highest practicable mental, physical, and psychosocial well-being were provided, has caused or is likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy (IJ) was identified on [DATE] at 42 CFR §483.21, Comprehensive Care Plans (F656), at the highest scope and severity (S/S) of a J; 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR §483.70, Facility assessment (838), at the highest S/S of a K; and 42 CFR §483.90, Maintain all mechanical, electrical, and resident care equipment in safe operating condition (F908), at the highest scope and severity S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689). The Immediate Jeopardy was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. Additionally, Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, F610) at the highest S/S of a J; 42 CFR §483.21, Comprehensive Care Plans (F656) at the highest S/S of a J; 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR §483.40, Behavioral Health Services (F744) at the highest S/S of a K; 42 CFR §483.70 Administration (F835 and F838) at the highest scope and severity (S/S) of a J; and 42 CFR §483.75, Quality Assurance and Performance Improvement (F865), at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610); 42 CFR §483.25, Free of Accident Hazards/Supervision/ Devices (F689); and 42 CFR §483.40 Behavioral Health Services (F744). The facility was notified of the Immediate Jeopardy on [DATE] and is ongoing. The findings include: Review of Resident #1 electronic health record (EHR), dated [DATE], revealed the facility admitted him/her with diagnoses that included, Diabetes Mellitus, Chronic Diastolic Heart Failure, Thoracic Aortic Aneurysm, Morbid (severe) Obesity, and acquired Absence of Right Leg Above Knee. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) examination score of fourteen (14) of fifteen (15). This score indicated the resident was cognitively intact. Review of Resident #1's Comprehensive Care Plan, revealed the facility-initiated mobility interventions, revised on [DATE]. The interventions included assistance to the Geri chair via a mechanical lift and two (2) staff assist for all transfers. Interview, on [DATE] at 11:41 AM, with Family Member #1, revealed Registered Nurse (RN) #1 reported to her, that on [DATE], while raised in the mechanical lift, the sling that held him/her broke, and Resident #1 fell to the floor and hit his/her head. Family Member #1 stated, Resident #1 told her there was only one staff member that operated the lift when the resident fell. Interview, on [DATE] at 2:50 PM with State Registered Nurse Aide (SRNA) #1 revealed on [DATE], she was alone while operating the mechanical lift with Resident #1. She stated she was positioned near the handles of the lift when the strap of the sling on the right side broke and the resident hit the floor head - first. Continued interview revealed SRNA #1 attempted to grab the resident. However, he/she slipped through her hands and his/her head hit the floor with a loud thud. Review of the facility's, Facility Assessment Tool, reviewed on [DATE], and updated on [DATE], revealed the facility assessed seventeen (17) residents to be dependent on staff for transfers. Per the Facility Assessment Tool, care and services were offered based on the resident's needs which included providing person centered/directed care with specific care or practices that included identifying hazards and risks for residents. Continued review of the Facility Assessment Tool revealed the facility developed policies to outline the purpose and procedures for staff to follow for care areas and practices. Further review revealed the facility would complete time - specified inspections of physical resources which included lift slings. However, the facility provided no documented evidence of specified inspection of lift slings. Interview, on [DATE] at 11:32 AM, with the Maintenance Director, revealed it was his responsibility to check machinery and equipment once per month. However, that did not include the mechanical lift slings. Further interview revealed all department heads had worked together on the Facility Assessment and provided input, but he definitely did not include the lift slings in time specified equipment inspections. Interview, on [DATE] at 9:00 AM with the Director of Nursing (DON), revealed the facility did not utilize slings from the mechanical lift's manufacturer. Per interview, it was her responsibility to remove slings from service that were damaged or worn. However, she stated surveillance had not occurred prior to the accident on [DATE], when Resident #1 fell to the floor from the lift sling. During interview, on [DATE] at 12:40 PM, the DON stated she participated in the facility's assessment; however, there were no policies in place to address the mechanical lift and safe patient (resident) handling at the time the accident occurred on [DATE]. Interview, with the Administrator, on [DATE] at 2:43 PM, revealed she was ultimately responsible for the Facility Assessment. She stated maintenance and surveillance of the mechanical lift slings had not been included in the facility's Assessment Tool, but it should have been. Further interview revealed there should have been a designated person(s) to assess the slings and a time specified schedule and process to ensure the slings remained in safe condition. Further interview revealed the facility did not have a policy in place for safe resident handling with mechanical lifts. Continued interview revealed that the slings were not adequately addressed in the Facility Assessment, but they should have been. Interview, on [DATE] at 2:20 PM, the Administrator stated there was no Facility Assessment Policy in place at the time of the accident on [DATE]. Interview, on [DATE] at 3:39 PM, with the Medical Director revealed it was her expectation the facility would have a policy or procedure in place to inspect the facility's equipment and slings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the lift's Manufacturer's Owner's Manual Safety Instructions and the Slings Manufacturer's Owner's Manual it was determined the facility failed to maintain all mechanical, electrical, and resident care equipment in safe operating condition regarding the mechanical lift equipment, specifically, the required lift slings for one (1) of twenty-one (21) sampled residents (Resident #1). The facility failed to follow the manufacturer's recommendations and utilized slings that were not recommended by the manufacturer. In addition, the facility failed to follow the manufacturer's maintenance recommendations for laundering and inspecting the lift slings. The facility assessed twelve (12) residents that required the use of a mechanical lift. On [DATE], during transfer from a Geri chair to his/her bed, Resident #1 was dropped from the mechanical lift when the lift sling strap broke. The resident fell approximately four (4) feet to the floor. Resident #1 hit his/her head on the concrete floor, causing substantial injuries. Emergency Medical Services (EMS) were called to the scene. Resident #1 was transferred to the local hospital for evaluation. Resident #1 was discharged from the local hospital with diagnoses from the fall that included: displaced comminuted supracondylar fracture of the right humerus; fracture of the seventh cervical vertebra; fracture of the first thoracic vertebra; and contusion of the scalp. Resident #1 was transferred to another hospital emergency department equipped to manage his/her injuries. On [DATE], Resident #1 was pronounced dead from injuries sustained in the accident on [DATE]. The facility's failure to maintain all mechanical, electrical, and resident care equipment in safe operating condition has caused or is likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy (IJ) was identified on [DATE] at 42 CFR §483.21, Comprehensive Care Plans (F656), at the highest scope and severity (S/S) of a J; 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR §483.70, Facility assessment (838), at the highest S/S of a K; and 42 CFR §483.90, Maintain all mechanical, electrical, and resident care equipment in safe operating condition (F908), at the highest scope and severity S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689). The Immediate Jeopardy was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. Additionally, Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, F610) at the highest S/S of a J; 42 CFR §483.21, Comprehensive Care Plans (F656) at the highest S/S of a J; 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR §483.40, Behavioral Health Services (F744) at the highest S/S of a K; 42 CFR §483.70 Administration (F835 and F838) at the highest scope and severity (S/S) of a J; and 42 CFR §483.75, Quality Assurance and Performance Improvement (F865), at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610); 42 CFR §483.25, Free of Accident Hazards/Supervision/ Devices (F689); and 42 CFR §483.40 Behavioral Health Services (F744). The facility was notified of the Immediate Jeopardy on [DATE] and is ongoing. The findings include: Review of the Manufacturer's Owner's Manual Safety Instructions, for the battery-operated mechanical lift, not dated, revealed special care must be taken with residents unable to aid while being lifted and included severely handicapped residents. Continued review revealed the Manufacturer's six (6) point slings were specifically designed for use with their lifts and use of non-manufacturer's brand lift slings were unsafe and may result in injury to the resident or caregiver. Further review of the Manual's Maintenance Schedule included instructions to check the entire sling inventory for fraying, tearing, or excessive wear of any kind and replace worn or damaged slings with new Manufacturer's recommended slings. Per the warnings in the Owner's Manual, lifts should not be in operation unless all maintenance points passed inspection, which included a warning not to use slings unless recommended for use with the lift and never use frayed or damaged slings. Review of the Slings Manufacturer's Owner's Manual, not dated, revealed warnings to carefully inspect the sling before each use for wear and damage to the seams, fabric, straps, and strap loops. Per the manual's warnings, torn, cut, frayed, or broken slings could fail, resulting in serious personal injury. Continued review revealed only slings in good condition should be used and old, unusable slings should be destroyed and discarded. Further review of the manual specified washing instructions which included that bleached slings were unsafe and may result in serious injury. Review of the facility's Maintenance Records, dated [DATE] to [DATE], for the Mechanical Lifts that were in use when the accident occurred, on [DATE], revealed no documentation that the lift slings were inspected for damage or wear. Review of Resident #1's electronic health record (EHR) revealed the facility admitted him/her, on [DATE]. The resident's diagnoses include; Diabetes Mellitus, Chronic Diastolic Heart Failure, Thoracic Aortic Aneurysm, Morbid (Severe) Obesity, and acquired Absence of Right Leg Above Knee. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated, [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact. Review of Resident #1's Comprehensive Care Plan, revealed the facility-initiated mobility interventions, revised on [DATE], which included assistance to Geri chair via mechanical lift and two (2) staff assist for all transfers. Review of Resident #1's Nurse's Progress Notes, dated [DATE], signed by Registered Nurse (RN) #1, revealed RN #1 was called to Resident #1's room, by a State Registered Nursing Assistant (SRNA) and found Resident #1 lying on his/her back on the floor. Continued review of the Progress Note revealed the lift sling was frayed and broke during Resident #1's transfer with the mechanical lift. Resident #1 fell to floor and sustained serious injuries. Observation, on [DATE] at 4:45 PM, revealed a non-manufacturer recommended sling had been used for Resident #1 at the time of the accident. Continued observation revealed the sling had brittle straps and multiple broken loops. Per observation, a total of eight (8) non-manufacturer recommended slings, were in operation on [DATE]. The sling loops were brittle, and the labels were faded so that washing instructions and sling size were not legible. Interview, on [DATE] at 11:41 AM, with Family Member #1, revealed RN #1 reported to her, on [DATE], that while Resident #1 was raised in the mechanical lift, the sling that held him/her broke and the resident fell to the ground and hit his/her head. Further interview revealed the lift sling fabric was frayed and contributed to the accident. Continued interview revealed Resident #1 was transferred by ambulance to a local hospital. Fractures were identified at C7 and T1 vertebrae and a complete break of the right humerus (upper arm bone). Per interview Resident #1 was transferred from the ED at the first hospital to a larger hospital to address the injuries sustained during the fall from the mechanical lift sling. Resident #1 expired from his/her injuries. Interview, on [DATE] at 2:50 PM with SRNA #1 revealed, on [DATE], she was alone while operating the mechanical lift with Resident #1. Per interview, she was positioned near the handles of the lift when the sling's strap's loop broke and the resident hit the floor, 'head - first. Continued interview revealed SRNA #1 attempted to grab the resident. However, the resident slipped through SRNA #1's hands and his/her head hit the floor with a loud thud. Interview, on [DATE] at 12:50 PM with Laundry Staff #1 revealed she washed the mechanical lift slings in the big washer most often. However, there were no posted laundry instructions prior to the accident that occurred on [DATE]. Per interview, she did not receive training or instruction regarding assessment of slings for dry, brittle, or damaged slings prior to the accident. Continued interview revealed she had not been given sling laundering instruction. She stated that the laundering instructions on the label were faded and not legible. Interview with Laundry Staff #1 revealed other staff often 'fill in' in the laundry department and they would not know how to wash the slings if the label was faded and no laundering instructions were posted. Interview, on [DATE] at 11:32 AM, with the Maintenance Director, revealed it was his responsibility to check the machinery and equipment once per month. However, that did not include the mechanical lift slings. Per interview, he was never asked to assess the slings and checking for frays and tears would be a nursing responsibility. Continued interview revealed the Maintenance Department included the Laundry Department and the staff knew how to wash the slings according to manufacturer's instructions by reading the labels on the slings. Per interview, he was not aware of special laundering instructions for the slings other than not to use fabric softener because it damaged the sling fabric. Further interview revealed the staff did not receive training regarding removing slings from service for damage, fray, or laundering. Interview, on [DATE] at 4:09 PM, with the DON revealed the facility did not follow the manufacturer's instructions for laundering the mechanical lift slings prior to the accident that occurred on [DATE], when the mechanical lift sling holding Resident #1 snapped, and the resident fell to the floor. Per interview there were a total of eight (8) slings removed from the nursing floors because the tags were faded and not legible. Continued interview revealed she examined the sling in use when Resident #1 was seriously injured and later discovered several of the sling loops broke easily and indicated the worn slings resulted from not following the manufacturer's instructions for laundering the slings. Interview, on [DATE] at 2:43 PM with the Administrator revealed the facility did not follow the mechanical lift manufacturer's instructions regarding the type of sling to use with the lifts, nor did the facility follow the sling manufacturer's instructions for laundering the slings. In addition, there was no process in place to routinely inspect the condition of the slings used with the mechanical lifts to prevent serious accident and injury. Per interview, there were no policies in place to address the mechanical lift and there should have been The Administrator stated resident safety was her responsibility. Interview, on [DATE] at 3:39 PM, with the Medical Director revealed it was her expectation the facility would have a policy or procedure in place to inspect the facility's equipment and slings.