**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 ensure residents were protected from abuse, including resident to resident abuse for four (4) of seven (7) sampled residents (Resident #1, Resident #2, Resident #6, and Resident #7). 1. On 09/05/2023, Resident #2 was observed by staff in Resident #1's bed (a resident of the opposite sex) with his/her hand in Resident #1's genital area. In addition, facility staff confined Resident #1 and Resident #2 to their rooms after the incident in order to allow one (1) staff member to monitor both residents at the same time. 2. On 04/16/2023, Resident #2 was observed by staff sitting on Resident #6's bed with his/her hands under a blanket covering Resident #6's lap. 3. On 09/14/2023, Resident #6 was observed by staff to hit Resident #7 in the chest area. The facility's failure to have an effective system in place to ensure residents were free from abuse, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 12/06/2023, and determined to exist on 04/16/2023, in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and (F609), both at a Scope and Severity (S/S) of J; 42 CFR 482.21 Comprehensive Resident Centered Care Plan (F656) at a S/S of a J, and 42 CFR 483.70 Administration, (F835) at a S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation. The facility was notified of the IJ on 12/06/2023. The State Survey Agency (SSA) received an acceptable IJ Removal Plan on 12/11/2023 alleging removal of the IJ on 12/10/2023. The SSA validated the removal of the IJ on 12/10/2023, prior to exit on 12/15/2023, which lowered the S/S to a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. Refer to F609 and F656 The findings include: Review of the facility's policy, titled Abuse, Neglect and Misappropriation of Property, dated 09/15/2023, revealed the facility defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It included verbal abuse, sexual abuse, physical abuse, and mental abuse. The policy stated the facility's Administrator or his/her designee would conduct a reasonable investigation of any alleged violation and the Administrator was responsible for reporting all investigation results to applicable State Agencies as required by Federal and State law. Per policy, prevention of abuse included ensuring a safe environment was established that supported a resident's safety, and identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. 1. Review of the facility's Investigation/Final Report, undated, unsigned, initiated by the Administrator, revealed Resident #2 was observed by a Certified Nursing Assistant (CNA) (the investigation did not specify which CNA) with his/her hand inside Resident #1's private parts. Residents were separated and skin assessments and interviews were performed for both residents with no concerns noted. Further review revealed both residents required redirection earlier in the day due to habitually seeking out contact with one another. (Review of the Initial Report revealed the incident occurred on 09/05/2023. However, the Investigation/Final Report did not include the date of the incident). Review of a witness statement, undated, signed by CNA #2, revealed Resident #1 and Resident #2 were outside Resident #1's room talking earlier in the shift. Continued review revealed at approximately 10:00 PM she looked in Resident #1's bed and saw Resident #1 with his/her legs spread and Resident #2 had his/her fingers inside Resident #1's private parts. Further review revealed she immediately separated the residents, and the nurse was notified. A. Review of Resident #1's Face Sheet revealed the facility admitted the resident on 11/22/2022 with diagnoses including Fracture of Left Femur, dementia with psychotic disturbance, dementia with agitation, dementia with mood disturbance, Alzheimer's disease, Attention and Concentration Deficit, Cognitive Communication Deficit, and other symptoms and signs involving cognitive functions and awareness. Review of Resident #1's Comprehensive Care Plan, dated 12/02/2022, revealed the resident had impaired cognitive skills as evidenced by decision making problems, indecision, inattention, and a Brief Interview for Mental Status (BIMS) less than thirteen (13). The goal stated the resident would improve current level of cognitive function as evidenced by completing as many Activities of Daily Living (ADLs) independently as he/she could. Interventions included providing a home like, therapeutic environment with a consistent routine and safety checks. Further review of Resident #1's Comprehensive Care Plan, dated 12/02/2022, revealed the resident had delirium as the resident had difficulty focusing attention related to dementia. The goal stated the resident would return to pre-delirium status or best potential. Interventions included orienting the resident to person, place, and time and speaking quietly, slowly, and repetitively. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 07/18/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15), indicating severe cognitive impairment. Further review revealed the facility assessed the resident as having verbal behavior symptoms directed toward others (threatening others or screaming or cursing at others). Review of Resident #1's Progress Note, dated 09/06/2023 at 12:01 AM, entered by Licensed Practical Nurse (LPN) #3, revealed the resident had been involved in a resident-to-resident altercation. Further review revealed the resident was removed and assessment including a skin assessment was completed with no complaints or injuries noted. The physician and family were made aware and the resident was in a pleasant mood. Review of Resident #1's Progress Note, dated 09/06/2023 at 12:02 AM, entered by Unit Manager (UM) #1, revealed the resident was placed on every fifteen (15) minute monitoring. Review of Resident #1's Increased Monitoring Form, dated 09/06/2023, revealed it was signed by the same staff members on day shift and night shift that signed Resident #2's continuous one-to-one (1:1) monitoring sheet, indicating both residents were being monitored by the same staff member at the same time. Further review revealed Resident #1 continued to have increased monitoring until 09/20/2023, but 09/06/2023 was the only day in which both residents were observed by the same staff member. B. Review of Resident #2's Face Sheet revealed the facility admitted the resident on 10/25/2022 with diagnoses including Psychosis, unspecified symptoms and signs involving cognitive functions and awareness, and Cognitive Communication Deficits. Review of Resident #2's Comprehensive Care Plan, dated 04/16/2023, revealed the resident exhibited inappropriate sexual behavior. The goal stated the resident's sexual behavior would not affect others. Interventions included keeping the resident away from the personal space of staff when conversing with him/her and provide personal care with a second staff member present. However, there were no care plan interventions to protect other residents related to Resident #2's inappropriate sexual behavior. (Refer to F656) Review of Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated 07/25/2023, revealed the facility assessed the resident as having a BIMS score of twelve (12) out of fifteen (15), indicating moderate cognitive impairment. No behaviors were noted per the MDS Assessment. Review of Resident #2's Progress Note, dated 09/06/2023 at 12:09 AM, entered by Licensed Practical Nurse (LPN) #3, revealed Resident #2 was involved in a resident-to-resident altercation. Further review revealed the resident was removed and assessed with no complaints or injuries noted. One-to-one (1:1) monitoring was initiated with the resident in a pleasant mood. Review of Resident #2's Increased Monitoring Form, dated 09/06/2023, revealed it was signed by the same staff members on day shift and night shift that signed Resident #1's every fifteen (15) minute monitoring sheet, indicating both residents were being monitored by the same staff member at the same time. Further review revealed Resident #2 continued to have increased monitoring until his/her discharge from the facility on 09/11/2023. Review of Resident #2's Progress Note, dated 09/09/2023 at 12:12 AM, entered by Registered Nurse (RN) #2, revealed an edited note which stated the resident remained one-on-one (1:1) with only one (1) issue; the resident had been reminded he/she had to stay inside his/her room and was not to be on the hall side of the doorway. Review of the revised note with the same date and time revealed the resident continued to be one-on-one (1:1) with no issues noted. During an interview with Resident #1, on 12/04/2023 at 3:40 PM, the resident stated he/she did not remember an altercation with another resident in September. Resident #2 was not interviewed as he/she was discharged from the facility on 09/11/2023. During an interview with LPN #3, on 12/05/2023 at 8:44 AM, he stated staff typically tried to stay near the doorway so residents could not leave their wing to travel to the other wings of the facility. He stated if a resident was not using the common area and was near the doorway leading to the other wing of the facility, staff would try to redirect the resident with television, a snack, or another activity. He stated on 09/05/2023 at approximately 10:00 PM, the CNAs reported to him they were passing ice when they witnessed Resident #2 in Resident #1's room violating [him/her] with his/her fingers. He stated while one (1) CNA came to inform him of the situation, the other CNA was getting Resident #2 out of Resident #1's room. LPN #3 stated he could not recall the CNAs involved. He further stated he checked on both residents and placed Resident #2 on one-on-one (1:1) monitoring with him and notified the Administrator of the incident. In continued interview with LPN #3 on 12/05/2023 at 8:44 AM, the nurse stated when he checked on Resident #1, the resident laughed it off. He stated Resident #1 was able to talk me through it, but now he was not sure if Resident #1 really understood what was going on at the time. LPN #3 stated he notified Resident #2's family of the incident, who had no concerns, and left a voice mail for Resident #1's family. He stated Resident #2 had been told previously he/she could not go into resident rooms of the opposite sex. He further stated he felt like it was definitely a sexual abuse incident because Resident #1 who had a BIMS score of four (4) was not competent to make the decision to be in a sexual situation. He further stated staff tried to monitor residents, but it was impossible to monitor all residents all of the time. During an interview with CNA #2, on 12/05/2023 at 9:35 AM, she stated residents often wandered into other residents' rooms and she tried to monitor them in order to know where they were and what they were doing as much as possible, at least while doing rounds every two (2) hours. She stated if residents were okay with other residents coming into their room, she allowed them to visit unless the visiting resident was of the opposite sex, in which case she removed them from the room. CNA #2 stated on 09/05/2023, she saw Resident #1 and Resident #2 sitting in the hallway outside Resident #1's room talking with each other around 9:00 PM and she told Resident #2 not to enter Resident #1's room. She stated when she went into Resident #2's room about 10:00 PM and realized the resident was not there, she immediately went to Resident #1's room looking for Resident #2. Further interview with CNA #2, on 12/05/2023, at 9:35 AM, she stated when she walked into Resident #1's room, she saw Resident #1 and Resident #2 lying in Resident #1's bed with the covers pushed back to reveal Resident #1's genital area. She stated Resident #1's legs were spread apart and Resident #2's hand was in Resident #1's genital area. CNA #2 stated she told Resident #2 he/she had to leave Resident #1's room and the resident left and went across the hall to his/her own room and slammed the door. She further stated she notified the nurse who checked Resident #1, and the Administrator was notified. CNA #2 stated since Resident #1 had a BIMS score of four (4), she would consider the incident as sexual abuse. During an interview with LPN #1, on 12/04/2023 at 4:00 PM, she stated she was not on duty at the time of the incident between Resident #1 and Resident #2, but when she came in for her next shift, she received information during report that Resident #1 allowed Resident #2 to grope him/her. She stated staff monitored the hallways for resident interactions and could tell by residents' conversations if they wanted to visit each other. She further stated if a resident did not want another resident to visit, the staff tried to distract the other resident, so they did not visit. She further stated if Resident #1 did not want Resident #2 visiting, the staff should have removed Resident #2 before the incident occurred. Additionally, she stated she was familiar with Resident #1 and Resident #2, but had not seen any sexual behaviors between them prior to the incident. She stated staff tried to monitor residents as much as they could, but if they were assisting other residents at the time then a resident could go to another resident's room undetected. During an interview with CNA #1, on 12/04/2023 at 4:17 PM, she stated staff knew who the wandering residents on their halls were and tried to monitor their locations by looking into rooms as they walked up and down the halls. She further stated there was typically one (1) to two (2) staff on each hall and it might take about fifteen (15) to twenty (20) minutes for a staff member to realize a resident was not where they were supposed to be. In further interview, she stated she was familiar with Resident #1 and Resident #2 and was unaware of any sexual behaviors between the two (2) prior to this incident. Additionally, she stated there was not enough staff to monitor residents at all times. During an interview with the Medical Director (MD), on 12/06/2023 at 2:06 PM, he stated he had been told in September there was an allegation of sexual abuse regarding Resident #1 and Resident #2, but had only received the details of the abuse on 12/05/2023. He stated Resident #2 was a special case. He further stated after Resident #2 had an alleged incident with another resident of the opposite sex in April 2023, he would have assumed staff would monitor Resident #2 closely, one-on-one (1:1) constantly to keep other residents safe. However, the MD stated staff may have been unable to monitor Resident #2 one-on-one (1:1) all the time due to being short staffed at times. He further stated, someone like [Resident #2] could not be left alone. The MD stated he felt Resident #2 had a form of mental retardation which was different from dementia and he/she may not have been placed in the correct setting, but small towns had no place for someone with mental retardation to be admitted for assistance with care. During continued interview, he stated Resident #2's behavior was unpredictable, and after this second incident, he/she should have been discharged to a specialty unit or home setting. During an interview with the Psychiatric Advanced Practice Registered Nurse (APRN), on 12/06/2023 at 2:44 PM, she stated she saw Resident #2 on 09/06/2023 and did not consider him/her to be a risk to himself/herself or other residents at that time because he/she was being monitored one-on-one (1:1) by staff, but could be a danger to others if he was not one-on-one (1:1) with a staff member. She stated she diagnosed the resident on 09/06/2023 with Paraphilia (a condition in which the person has a sexual desire or behavior that involved another person's psychological distress, injury or death, or a desire for sexual behaviors involving unwilling persons or persons unable to give legal consent) because of his/her continuous sexual behaviors. She further stated she suspected Resident #2 had intellectual delays. During an interview with CNA #7, on 12/07/2023 at 10:49 AM, she stated Resident #1 and Resident #2's rooms were directly across from each other on 09/05/2023. She stated staff were told at the time the incident occurred to provide increased monitoring for the two (2) residents, with Resident #2 being on one-on-one (1:1) monitoring and Resident #1 being on every fifteen (15) minute checks. She further stated one (1) staff member was required to sit in the hall outside the residents' rooms which were across the hallway from each other, and provide monitoring for both residents at the same time because there was not enough staff for another staff member to provide increased monitoring. Further, CNA #7 stated, if another staff member was available, they could take one (1) of the residents one-on-one (1:1) out of the room, but otherwise the residents were required to stay in their rooms so one (1) staff member could monitor them both at the same time. She was unable to say how long or how many days the residents were confined to their rooms. She stated the night shift consisted of one (1) nurse and two (2) CNAs on each hall. During further interview with CNA #7, on 12/07/2023 at 10:49 AM, she stated the CNAs were required to give baths/showers on night shift and this could take up to an hour at a time, which meant the nurse and an CNA was responsible for the entire wing during that time, and this would cause a problem when residents needed increased monitoring. CNA #7 stated the nurse was often busy giving medications, providing wound treatments, or other things, and the other CNA on the hall would be answering call lights, which left an hour or more at a time that a resident could go unsupervised if he/she wanted to wander into someone else's room. During an interview with Registered Nurse (RN) #2, on 12/08/2023 at 5:27 PM, she stated Resident #2 had a tendency to get into staff and resident personal spaces and she tried to keep an eye on the resident as much as possible. She stated one-on-one (1:1) meant one (1) staff member should only be supervising one (1) resident at a time; however, after the altercation between Resident #1 and Resident #2 on 09/05/2023, the same staff member was assigned to watch Resident #1 and Resident #2 for increased monitoring. She further stated Resident #2 liked to walk a lot and telling him/her to stay in his/her room was asking for trouble because he/she became more upset and agitated when told he/she had to stay in his/her room. RN #2 stated she was told in report, one (1) staff member was to stay in the hallway and monitor Resident #2 one-on-one (1:1) while also monitoring Resident #1 for every fifteen (15) minute checks across the hallway. She stated the only way one (1) staff member could monitor both residents was if they were confined to their rooms, which was what occurred with Resident #1 and Resident #2. RN #2 was unable to state how long the residents were confined to their rooms and was unable to find documentation the residents were confined to their rooms. During an interview with the Director of Nursing (DON), on 12/15/2023 at 4:43 PM, she stated one-on-one (1:1) meant one (1) staff member monitored one (1) resident only. She denied the nursing staff had ever been asked to monitor more than one (1) resident at a time while sitting one-on-one (1:1) with a resident. She further denied the residents were confined to their rooms. The DON stated staff followed the Abuse Policy by reporting the incident to the Administrator who was the Abuse Coordinator, who investigated the incident. Further interview revealed the alleged abuse incident involving Resident #1 and Resident #2 should not have occurred. During an interview with the Administrator, on 12/05/2023 at 1:24 PM, she stated, on 09/05/2023, LPN #3 notified her of the incident involving Resident #1 and Resident #2. She stated she informed LPN #3 to place Resident #2 on one-to-one (1:1) monitoring and perform skin assessments on both residents. She further stated Resident #2 had a prior sexual allegation and staff was aware of Resident #2's history of sexual advances and should have monitored the residents to ensure Resident #2 did not go into Resident #1's room, thus preventing the abuse from occurring. The Administrator further stated, at the time of the incident, everyone was adamant [Resident #1] invited it and when Resident #1's family was called they stated [he/she] probably asked for it and had no concerns. She further stated she felt like staff had caught them in time so no sexual assault exam was needed. However, she stated she was unable to verify by staff statements how much time had elapsed since anyone had seen Resident #1 and Resident #2 prior to the incident. The Administrator denied Resident #1 and Resident #2 being confined to their rooms while staff provided increased monitoring to both residents. 2. Review of the facility's Investigation, undated, unsigned but initiated by the Administrator , revealed Resident #2 was witnessed, by a staff member (CNA #7) passing Resident #6's room, sitting on the edge of Resident #6's bed with both Residents having their feet on the floor, and Resident #2's hands were under the blanket covering Resident #6's lap. However, the investigation did not reveal the date of the incident. The Residents were separated and skin assessments were performed on both residents with no concerns noted. Both residents were placed on one-to-one (1:1) supervision and skin assessments were performed on all residents with a BIMS of seven (7) or below with no concerns noted. All residents with a BIMS of eight (8) or above were interviewed if they felt safe in the facility and if they knew who to report to if an incident occurred with another residents or staff that made them feel uncomfortable. No concerns were noted. Further review of the facility's Investigation, revealed staff abuse education was performed with an emphasis on identifying and reporting suspected abuse per facility policy and protocol. Resident #2 received a psychiatric evaluation on 04/17/2023 with a recommendation to follow the facility monitoring protocol. The Mental Health Nurse Practitioner saw Resident #6 on 04/17/2023 with a recommendation to send referrals to inpatient psychiatric services and begin antidepressant medications. The facility determination of findings revealed there was no evidence Resident #2 touched Resident #6 when his/her hands were under Resident #6's blanket. It further stated there was no substantiated intent to harm and no signs of physical or psychological abuse revealed during the investigation and the facility did not substantiate abuse. Review of Certified Nurse Aide (CNA) #7's witness statement, dated 04/16/2023, revealed she observed Resident #2 sitting on Resident #6's bed with his/her hands under Resident #6's blanket. A. Review of Resident #6's Face Sheet revealed the facility admitted the resident on 01/10/2022 with diagnoses including Dementia without Behavioral Disturbance, Dementia with Mood Disturbance, Dementia with Agitation, and Psychotic Disorder with Delusions. Review of Resident #6's Comprehensive Care Plan, dated 02/16/2022, revealed the resident had a problem of cognitive loss/dementia; decreased memory/recall and understanding others related to his/her Brief Interview for Mental Status (BIMS) score of less than thirteen (13); and inattention and disorganized thinking. The goal stated the resident would improve memory/recall ability as evidenced by recalling staff names, stating he/she was in a nursing home, and recognizing staff faces. Interventions included providing verbal and visual reminders such as directions or pictures. Review of Resident #6's Comprehensive Care Plan, dated 04/22/2022, revealed the facility assessed the resident as having a behavior problem related to exhibiting socially inappropriate disruptive behavioral symptoms; initiating sexual behaviors with other residents of the opposite sex and entering the rooms of other residents of the opposite sex. The goal stated the resident would not perform sexual acts with other residents and not congregate in rooms of residents of the opposite sex. Interventions included assessing the resident's behavior to see if the resident's behaviors endangers the resident and/or others; intervene as necessary and observe and report socially inappropriate/disruptive behaviors when around others. Review of Resident #6's Quarterly MDS Assessment, dated 04/05/2023, revealed the facility assessed the resident to have a BIMS score of seven (7) out of fifteen (15), indicating severe cognitive impairment. The facility assessed Resident #6 to have had delusions, but did not assess him/her with any behavioral symptoms. Review of Resident #6's Progress Note, dated 04/16/2023 at 8:00 PM, entered by Licensed Practical Nurse (LPN) #7, revealed the CNA reported Resident #6 was found sitting on his/her bed with another resident of the opposite sex sitting beside him/her. Resident #6 had a blanket on his/her lap and the other resident had his/her hand under the blanket. The residents were separated, and Resident #6 was placed on one-on-one (1:1) monitoring. Skin assessments were completed on both residents, and Resident #6 was moved to a different unit in the facility. Further review revealed the Administrator, Unit Manager, Physician and Resident #6's Power of Attorney were notified. Review of the facility Safety Check Log, revealed Resident #6 was placed on one-on-on (1:1) monitoring on 04/16/2023 at 8:15 PM and continued through the twenty-four (24) hour period of 04/17/2023. B. Review of Resident #2's Face Sheet revealed the facility admitted the resident on 10/25/2022 with diagnoses including Psychosis, unspecified symptoms and signs involving cognitive functions and awareness, and Cognitive Communication Deficits. Review of Resident #2's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility assessed the resident to have a BIMS score of four (4) out of fifteen (15), indicating severe cognitive impairment. Further review revealed the facility did not assess the resident to have any behavioral symptoms. Review of Resident #2's Comprehensive Care Plan, dated 04/16/2023, revealed the resident exhibited inappropriate sexual behavior. The goal stated the resident's sexual behavior would not affect others. Interventions included keeping the resident away from the personal space of staff when conversing with him/her and provide personal care with a second staff member present. However, there were no care plan interventions to protect other residents related to Resident #2's inappropriate sexual behavior. Review of Resident #2's Progress Note, dated 04/16/2023 at 8:00 PM, recorded as a late entry by Registered Nurse (RN) #3, revealed a CNA (CNA #7) reported to the nurse while passing Resident #6's room, she witnessed Resident #6 and Resident #2 sitting on the side of the bed with their feet on the floor and Resident #6's hands under the blanket. The CNA separated the residents and reported to incident to the nurse. Further review revealed the resident was assessed to include a skin assessment. The Physician, Administrator, and Unit Manager were notified and both residents were placed on one-on-one (1:1) monitoring. Resident #2's Emergency contact was informed. Review of the facility's safety check logs revealed Resident #2 was placed on one-on-one (1:1) monitoring on 04/16/2023 at 8:05 PM through 04/19/2023 at 6:00 PM. Resident #2 was unable to be interviewed as he/she was discharged from the facility on 09/11/2023. During an interview with Resident #6, on 12/15/2023 at 4:30 PM, he/she stated he/she did not recall the incident on 04/16/2023. During an interview with CNA #7, on 12/07/2023 at 10:49 AM, she stated Resident #2 liked to go into Resident #6's room because their rooms were directly across the hall from one another. On 04/16/2023, she observed Resident #2 and Resident #6 sitting on the bed with Resident #6 having a blanket covering his/her lap. She further stated Resident #2 had his/her hands under the blanket and CNA #7 could tell Resident #2's hands were in Resident #6's crotch area. She stated she flipped out because Resident #2 knew what he/she was doing, and Resident #6 was confused. CNA #7 further stated she separated the residents and Resident #2 looked ashamed after the incident, as he/she would not look her in the eyes. CNA #7 stated staff had seen Resident #2 and Resident #6 sitting very close together during activities prior to this incident. She stated staff could tell they were hot for each other. She further stated after the incident, Resident #2 was placed on one-on-one (1:1) monitoring and confined to his/her room. CNA #7 stated Resident #2 was required to stay in his/her room until a family member became upset the resident was being held in his/her room; however, she was unable to recall how many days the resident was confined to his/her room. During an interview with LPN #7 on 12/08/2023 at 3:29 PM, she stated Resident #2 and Resident #6 were already separated when she was informed by an aide (could not remember the aide's name) about something related to these two (2) residents and a blanket. She stated she could not recall the details. LPN #7 stated, per the Abuse Policy, she immediately separated Resident #2 and Resident #6 and reported the incident, but could not remember to whom it was reported. She stated she told the aides (could not remember the aide's names) to keep an eye on both Resident #6 and Resident #2. LPN #7 further stated she thought the residents were put on every fifteen (15) minute checks. She stated staff tried to monitor the residents as closely as possible, but were not able to monitor the residents all the time. During an interview with the DON, on 12/15/2023 at 4:43 PM, she stated she was not at the facility in April 2023, but would have expected the staff to follow the Abuse policy related to the alleged abuse. During an interview with the Administrator, on 12/15/2023 at 4:54 PM, she stated she was notified of the incident involving Resident #2 and Resident#6. She further stated, when she investigated, she found there was no evidence Resident #2 was inappropriately touching Resident #6 under the blanket and thought he/she had his/her hand resting on Resident #6's leg as they were talking. During an interview with the Medical Director (MD), on 12/15/2023 at 5:25 PM, he stated, if the notes said he was notified, he was sure he had been, but he could not remember the incident. 3. Review of the facility's Investigation, undated and unsigned, initiated by the Administrator, revealed Resident #6 hit Resident #7 on 09/14/2023 in an effort to stop Resident #7 from yelling. The Residents were separated, and skin assessments and interviews were performed with both residents with no concerns noted. Review of the facility's investigation revealed the incident was witnessed; however, there were no witness statements with the investigation. The investigation further revealed the physician and residents' families were notified. A. Review of Resident #7's Face Sheet revealed the facility admitted the resident on 04/22/2013 with diagnoses including Cerebral Palsy, Blindness in Left and Right Eye, Alzheimer's,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure allegations of abuse were reported to the State Agencies and local law authorities immediately, but no later than two (2) hours, after the allegation was made for four (4) of seven (7) sampled residents (Resident #1, Resident #2, Resident #6, and Resident #7). 1. On 09/05/2023, Resident #2 was observed in Resident #1's bed (a resident of the opposite sex) with his/her hand in Resident #1's genital area. However, the facility failed to notify the appropriate State Agencies and local law authorities. 2. On 04/16/2023, Resident #2 was observed sitting on Resident #6's bed with his/her hands under a blanket covering Resident #6's lap. However, the facility failed to notify the appropriate State Agencies and local law authorities. 3. On 09/14/2023, Resident #6 was observed to hit Resident #7 in the chest area. However, the facility failed to notify the appropriate State Agencies and local law authorities. The facility's failure to have an effective system in place to ensure all alleged violations involving abuse, are reported immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 12/06/2023, and determined to exist on 04/16/2023, in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and (F609), both at a Scope and Severity (S/S) of J; 42 CFR 482.21 Comprehensive Resident Centered Care Plan (F656) at a S/S of a J, and 42 CFR 483.70 Administration, (F835) at a S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation. The facility was notified of the IJ on 12/06/2023. The State Survey Agency (SSA) received an acceptable IJ Removal Plan on 12/11/2023 alleging removal of the IJ on 12/10/2023. The SSA validated the removal of the IJ on 12/10/2023, prior to exit on 12/15/2023, which lowered the S/S to a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. Refer to F600 The findings include: Review of the facility's policy, titled Abuse, Neglect and Misappropriation of Property, dated 09/15/2023, revealed the facility defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It included verbal abuse, sexual abuse, physical abuse, and mental abuse. The policy stated the facility's Administrator or his/her designee would conduct a reasonable investigation of any alleged violation and the Administrator was responsible for reporting all investigation results to applicable State Agencies as required by Federal and State law. Per the policy, the facility defined an allegation of abuse as a report, complaint, grievance, statement, incident, or other facts that a reasonable person would understand to mean that abuse was occurring, had occurred, or plausibly might have occurred. Further review revealed all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but no later than two (2) hours after the allegation was made. Any abuse allegation must be reported to State within two (2) hours from the time the allegation was received and any reasonable suspicion of a crime with serious bodily injury must be reported to the State and Police. The policy gave an example of a crime as sexual abuse. Additionally, any allegation of neglect, exploitation, mistreatment or misappropriation of a resident's property must be reported to the State Regulatory Agency within twenty-four (24) hours. In the case of neglect, exploitation, mistreatment or misappropriation resulting in serious bodily injury it must be reported to the State Regulatory Agency and Police within two (2) hours. 1. Review of the facility's Investigation/Final Report, undated, revealed Resident #2 was observed by a Certified Nursing Assistant (CNA) with his/her hand inside Resident #1's private parts. The residents were separated and skin assessments and interviews were performed with both residents with no concerns noted. However, further review revealed there was no documented evidence the facility notified the appropriate State Agencies or the Police. Review of the witness statement, undated, signed by CNA #2, revealed Resident #1 and Resident #2 were outside Resident #1's room talking earlier in the shift. At approximately 10:00 PM she looked in Resident #1's bed and saw Resident #1 with his/her legs spread and Resident #2 had his/her fingers inside Resident #1's private parts. Additional review revealed she immediately separated the residents, and the nurse was notified. A. Resident #1's Face Sheet revealed the facility admitted the resident on 11/22/2022. The resident's diagnoses included Fracture of Left Femur, Dementia with Psychotic Disturbance, Dementia with Agitation, Dementia with Mood Disturbance, Alzheimer's disease, Attention and Concentration Deficit, Cognitive Communication Deficit, and other symptoms and signs involving cognitive functions and awareness. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 07/18/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15), which indicated severe cognitive impairment. Further review revealed the facility assessed the resident to have verbal behavior symptoms directed toward others (threatening others or screaming or cursing at others). Resident #1's Progress Note, dated 09/06/2023 at 12:01 AM, entered by Licensed Practical Nurse (LPN) #3, revealed Resident #1 was involved with a resident-to-resident altercation. Further review revealed the resident was removed and a skin assessment was completed. B. Resident #2's Face Sheet revealed the facility admitted the resident on 10/25/2022. The resident's diagnoses included Psychosis, unspecified symptoms and signs involving cognitive functions and awareness, and Cognitive Communication Deficits. Resident #2's Quarterly MDS Assessment, dated 07/25/2023, revealed the facility assessed the resident to have a BIMS score of twelve (12) out of fifteen (15), which indicated moderate cognitive impairment. Resident #2's Progress Note, dated 09/06/2023 at 12:09 AM, entered by LPN #3, revealed Resident #2 was involved with a resident-to-resident altercation. Further review revealed the resident was removed and assessed with no complaints or injuries noted. One-to-one (1:1) monitoring was initiated. Resident #2's Progress Note, dated 09/09/2023 at 12:12 AM, entered by Registered Nurse (RN) #2, revealed an edited note which stated Resident #2 remained one-on-one (1:1) with only one (1) issue; the resident had been reminded he/she had to stay inside his/her room and not be on the hall side of the doorway. The revised note stated the resident continued to be one-on-one (1:1) with no issues identified. During an interview with LPN #3, on 12/05/2023 at 8:44 AM, he stated on 09/05/2023 at approximately 10:00 PM, the CNAs reported to him they were passing ice when they witnessed Resident #2 in Resident #1's room violating [him/her] with [his/her] fingers. He stated while one (1) CNA came to report the incident to him, the other CNA was getting Resident #2 out of Resident #1's room. LPN #3 could not recall which CNAs were involved. LPN #3 further stated he checked on both residents and Resident #2 was placed on one-on-one (1:1) observation with him. Further, he notified the Administrator of the incident. LPN #3 further stated he notified Resident #2's family of the incident, who had no concerns, and left a voice mail for Resident #1's family. LPN #3 stated he felt like this was definitely a sexual abuse incident because a resident with a BIMS score of four (4) was not competent to make the decision to be in a sexual situation. LPN #3 stated he would have expected the Administrator to notify the police after he notified her of the incident. He further stated the Administrator was also to notify state agencies of an allegation of abuse. During an interview with CNA #2, on 12/05/2023 at 9:35 AM, she stated on 09/05/2023, she walked into Resident #1's room, and saw Resident #1 and Resident #2 lying in Resident #1's bed with the covers pushed back to reveal Resident #1's genital area. She stated Resident #1's legs were spread and Resident #2's hand was in Resident #1's genital area. She stated she told Resident #2 he/she had to leave Resident #1's room and he/she left and went across the hall to his/her own room and slammed the door. CNA #2 stated she informed the nurse who checked Resident #1, and the nurse notified the Administrator. She further stated since Resident #1 had a BIMS score of four (4), she would consider the incident as sexual abuse and she would have expected the Administrator, who was the Abuse Coordinator, to notify the police and whoever else was to be notified as per policy. During an interview with the Administrator, on 12/05/2023 at 1:24 PM, she stated, on 09/05/2023, LPN #3 notified her of the incident involving Residents #1 and #2, and she informed him to put Resident #2 on one-to-one (1:1) monitoring and perform skin assessments on both residents. She stated Resident #2 had a prior sexual allegation and staff was aware of Resident #2's history of sexual advances. She further stated at the time of the incident everyone was adamant Resident #1 invited it and when Resident #1's family was called they stated [he/she] probably asked for it and had no concerns which was why she did not notify the police of the incident. She further stated she felt like staff had caught them in time so no sexual assault exam was needed. However, she did state she was unable to verify by staff statements how much time had elapsed since anyone had seen Resident #1 and Resident #2 prior to the incident. Further interview revealed she thought she had notified the State Agencies of the allegation, but had sent an email to an incorrect email address. 2. Review of the facility's Investigation, undated, revealed Resident #2 was witnessed sitting on Resident #6's bed with Resident #2's hands under a blanket covering Resident #6's lap. Further, the Residents were separated, and skin assessments were performed on both residents with no concerns identified. Continued review revealed there was no documented evidence the facility notified the appropriate State Agencies or Police. Review of Certified Nurse Aide (CNA) #7's witness statement, dated 04/16/2023, revealed she observed Resident #2 sitting on Resident #6's bed with his/her hands under Resident #6's blanket. A. Resident #6's Face Sheet revealed the facility admitted the resident on 01/10/2022. The resident's diagnoses included Dementia without Behavioral Disturbance, Dementia with Mood Disturbance, Dementia with Agitation, and Psychotic Disorder with Delusions. Resident #6's Quarterly MDS Assessment, dated 04/05/2023, revealed the facility assessed the resident to have a BIMS score of seven (7) out of fifteen (15), which indicated severe cognitive impairment. Resident #6's Progress Note, dated 04/16/2023 at 8:00 PM, entered by LPN #7, revealed the CNA reported Resident #6 was found sitting on his/her bed with another resident of the opposite sex sitting beside him/her. Further review revealed Resident #6 had a blanket on his/her lap and the other resident had his/her hand under the blanket. The residents were separated, and Resident #6 was placed on one-on-one (1:1) monitoring. Skin assessments were completed on both residents, and Resident #6 was moved to a different unit within the facility. B. Resident #2's Face Sheet revealed the facility admitted the resident on 10/25/2022. The resident's diagnoses included Psychosis, unspecified symptoms and signs involving cognitive functions and awareness, and Cognitive Communication Deficits. Resident #2's Quarterly MDS Assessment, dated 03/08/2023, revealed the facility assessed the resident to have a BIMS score of four (4) out of fifteen (15), which indicated severe cognitive impairment. During interview with CNA #7, on 12/07/2023 at 10:49 AM, she stated on 04/16/2023, she observed Resident #2 and Resident #6 sitting on the bed with Resident #6 having a blanket covering his/her lap. She further stated Resident #2 had his/her hands under the blanket and CNA #7 could tell Resident #2's hands were in Resident #6's crotch area. CNA #7 further stated she separated the residents Resident #2 was placed on one-on-one (1:1) monitoring at that time. During an interview with LPN #7 on 12/08/2023 at 3:29 PM, she stated Resident #2 and Resident #6 were already separated when she was notified by an aide (couldn't remember the aide's name) about something about these two (2) residents and a blanket. LPN #7 stated she could not recall the details. LPN #7 further stated, per the Abuse Policy, she immediately separated Resident #2 and Resident #6 and reported the incident, but could not remember to whom it was reported. She further stated she told the aides (could not remember the aide's names) to keep an eye on both Resident #6 and Resident #2. LPN #7 further stated staff was educated to notify the Abuse Coordinator (the Administrator) immediately for any allegations of abuse and the Abuse Coordinator investigated and reported the incident to the proper agencies. 3. Review of the facility's Investigation, undated, revealed it was determined Resident #6 hit Resident #7 in an effort to stop Resident #7 from yelling. The residents were separated and skin assessments and interviews were performed with both residents with no concerns noted. Further review revealed the incident was witnessed; however, there was no evidence of witness statements with the investigation. Additionally, there was no documented evidence the facility reported the incident to the appropriate State Agencies or Police. A. Resident #7's Face Sheet revealed the facility admitted the resident on 04/22/2013. The resident's diagnoses included Cerebral Palsy, Blindness in Left and Right Eye, Alzheimer's, and Dementia with Mood Disturbance. Resident #7's Quarterly MDS dated [DATE], revealed the facility assessed the resident to have a BIMS score of thirteen (13) out of fifteen (15), which indicated the resident was cognitively intact. Continued review revealed the facility assessed the resident to have behavioral symptoms not directed at others (such as 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, disruptive sounds). Resident #7's Progress Notes, dated 09/14/2023, revealed no description of a resident-to-resident altercation. Resident #7's Progress Note, dated 09/14/2023 at 5:13 PM, revealed the resident was placed on every fifteen (15) minute checks related to a resident-to-resident altercation. B. Resident #6's Face Sheet revealed the facility admitted the resident on 01/10/2022 with diagnoses which included Dementia without Behavioral Disturbance, Dementia with Mood Disturbance, Dementia with Agitation, and Psychotic Disorder with Delusions. Resident #6's Quarterly MDS Assessment, dated 04/05/2023, revealed the facility assessed the resident to have a BIMS score of seven (7) out of fifteen (15), which indicated severe cognitive impairment. Resident #6's Progress Note, dated 09/14/2023 at 5:05 PM, entered by LPN #4, revealed Resident #6 walked up to another resident and smacked him/her in the chest, then attempted to smack another resident's face. The other resident (Resident #7) was immediately removed from the situation and brought to safety and Resident #6 was placed on one on-one (1:1) observation. Review of the Incident Report and Resident #6 and Resident #7's Progress Notes, revealed no documentation to indicate who witnessed the resident-to-resident altercation. The State Survey Agency (SSA) attempted to interview LPN #4 on 12/15/2023 at 2:30 PM and 4:10 PM by phone and messages were left; however, LPN #4 did not return phone calls to the SSA. During an interview with the DON, on 12/15/2023 at 4:43 PM, she stated the nursing staff followed the policy and notified the Administrator related to allegations of abuse involving Residents #1, #2, #6 and #7. She further stated the Administrator was the Abuse Coordinator and was to notify law enforcement and state agencies, as well as, investigate the allegations to determine if they were substantiated. During an interview with the Administrator, on 12/15/2023 at 4:54 PM, she stated she investigated the incident involving Residents #2 and #6, and the incident involving Resident #6 and #7 and determined none of them were substantiated as no resident(s) suffered physical or psychological harm. She further stated she thought she had notified the appropriate state agencies but she had an incorrect email address. She further stated she did not notify police because there was no harm to the residents. During an interview with the Medical Director, on 12/15/2023 at 5:25 PM, he stated he would have expected the Administrator to notify the appropriate state agencies and law enforcement regarding alleged abuse situations. The facility provided an acceptable credible Removal of Immediacy Plan on 12/11/2023 that alleged removal of the Immediate Jeopardy (IJ) on 12/10/2023. Review of the Immediacy Plan revealed the facility implemented the following: 1. On 09/11/2023, Resident #2 was discharged from the facility and had not returned as a resident since being discharged . Resident #1 still resides in the facility. Resident #6 still resides in the facility. 2. On 12/07/2023, the Social Services Director (SSD) assessed Residents #1 and #6's psychosocial status with no noted psychosocial concerns with both residents continuing to be at normal baseline. 3. On 12/07/2023, Resident #1 and Resident #6's entire comprehensive care plans were reviewed by the Unit Manager (UM) and Minimum Data Set (MDS) Coordinator to ensure their comprehensive care plans were accurate and reflected each of these residents' current problems and risks. On 12/07/2023, Resident #1 and Resident #6's comprehensive care plans were reviewed by the Director of Regulatory, Assistant Director of Nursing, and Minimum Data Set (MDS) Coordinator to ensure their behavioral care plans were accurate and reflected each of these residents' known sexual behaviors. 4. On 12/07/2023, forty-three (43) residents who had a Brief Interview for Mental Status (BIMS) of seven (7) or less, received a skin assessment by the Consultant/Regional Nurse to determine if there were any signs and symptoms of any type of abuse that may have occurred. There were no concerns with abuse identified. 5. On 12/07/2023, thirty-nine (39) residents who had a BIMS of eight (8) or higher were interviewed by the Consultant Regional Nurse with the question have you had any concerns with anyone inappropriately touching you or attempting to touch you inappropriately or any abuse concerns? This was to determine if they had any concerns with any type of abuse or anyone inappropriately touching them or attempting to inappropriately touch them. No residents voiced any concerns. 6. On 12/07/2023 through 12/08/2023, all eighty-three (83) current facility residents' care plans were reviewed by the MDS Coordinator, ADON, and Director of Regulatory to ensure each resident had a care plan developed and in place to address any resident who had current or a known history of sexual behaviors which put them and others at risk. The facility identified three (3) residents who had inappropriate sexual behaviors care plans that needed additional interventions developed and implemented due to their history of behaviors. This was completed by the ADON and MDS Coordinator. The facility identified six (6) residents who had a history of sexually inappropriate behaviors who needed a care plan developed and implemented to address having had a history of sexually inappropriate behaviors and these care plans were developed by the ADON and MDS Coordinator. 7. On 12/07/2023 through 12/09/2023, the [NAME] President of Clinical Operations, Consultant/Regional Nurse, [NAME] President of Regulatory, Staff Development Coordinator (SDC), or the Facility Administrator, reviewed all current residents' progress notes and events from 04/16/2023 through 12/07/2023 to ensure there were no instances of abuse of any kind that were not reported to the appropriate agencies if occurring. No concerns were identified. 8. On 12/07/2023, the Director of Regulatory provided education to the facility Administrator on the entire facility Abuse Policy, the entire Care Plan Policy, and the entire federal regulation at F600, F609, F656, and F835 from Appendix PP of the State Operations Manual. A posttest was given to the facility Administrator after the education was provided and a score of one hundred (100%) percent was obtained on the posttest by the Administrator. All new Administrators would be required to have all education on federal regulations at F600, F609, F656, F835 from Appendix PP of the State Operations Manual, the facility Abuse Policy, and the facility Care Plan Policy, with a posttest given during orientation by nurse management prior to their working. 9. On 12/07/2023, the Consultant/Regional Nurse educated the acting Director of Nursing (DON)/Assistant Director of Nursing (ADON), Unit Manager (UM), Staff Development Coordinator (SDC), Social Service Director (SSD), Plant Ops, and Activities Director on the entire facility Abuse Policy and the entire federal regulation at F600 and F609 from Appendix PP of the State Operations Manual with a posttest given to these staff members after the education was provided. A score of one hundred (100%) percent was required and anyone who did not receive a one hundred (100%) percent score was reeducated and then provided another posttest. This process continued until a one hundred (100%) percent score was obtained by all staff. 10. Beginning on 12/07/2023 and ending on 12/09/2023, the Consultant/Regional Nurse educated the DON/ADON, UM, SDC, SSD, MDS, Therapy Director, Dietary Manager, Activities Director, and Licensed Nurses on the entire Care Plan Policy regarding the development and implementation of the care plan and on the entire federal regulation from Appendix PP on F656 with a posttest given to these staff members after the education was provided. A score of one hundred (100%) percent was required and anyone who did not receive a one hundred (100%) percent score was reeducated and then provided another posttest. This process continued until a one hundred (100%) percent score was obtained by all staff. If those disciplines did not receive the education during those dates, they would be required to receive the education prior to their next shift. All new staff and all new agency staff would be required to have all education during orientation by nurse management prior to their working with a posttest. 11. On 12/07/2023, the Consultant/Regional Nurse, DON/ADON, UM, SDC, SSD, Plant Ops, Activity Director, Administrator, or Regulatory Director provided education to current facility staff which included Certified Nurse Aides, Kentucky Medication Aides, Licensed Nurses, Therapy Staff, Environmental Staff, Dietary Staff, Activity Staff, Maintenance Staff, and Business Office Staff on the entire facility Abuse Policy and the entire federal regulation at F600 and F609 from Appendix PP of the state operations manual with a posttest given to these staff members after the education was provided. A score of one hundred (100%) percent was required and anyone who did not receive a one hundred (100%) percent score was reeducated and then provided another posttest. This process continued until a one hundred (100%) percent score was obtained by all staff. Any staff not receiving this education and posttest by 12/07/2023 would receive this education and posttest prior to being able to work their next shift. A score of one hundred (100%) percent was required and anyone not receiving a one hundred (100%) percent score would be reeducated and then provided another posttest. This process will continue until one hundred (100%) percent score was obtained by all staff. All new staff and all new agency staff would be required to have all education during orientation by nurse management prior to their working with posttest. 12. On 12/07/2023, an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Medical Director, the Facility Administrator, the Assistant Director of Nursing acting as Interim Director of Nursing, the Staff Development Coordinator, and Consultant/Regional Nurse regarding Immediate Jeopardy (IJ) removal plans that were formulated and implemented at that time. The facility Administrator presented the plan and information at the QAPI meeting. The Facility Medical Director was onsite at the facility and was notified by the facility Administrator of the Immediate Jeopardies and the rationale for being cited with the Immediate Jeopardies. The Medical Director reviewed the entirety of the plan and made no further suggestions. The Medical Director stated the plan was appropriate and would be effective. Starting on 12/08/2023, A Quality Assurance meeting would be held daily for seven (7) days, then would decrease to monthly for recommendations and further follow up regarding the above stated plan. Moving forward the facility Administrator would continue to be the person who presented the information and audits at the QAPI Meetings, and the following members were expected to be present unless unable to attend: Facility Administrator, Medical Director, Director of Nursing, Assistant Director of Nursing, Staff development Coordinator, Plant Ops Director, Social Services Director, Activity Director, Therapy Director, and MDS Coordinator. The QAPI Committee would determine at what frequency any ongoing audits would need to continue. The Administrator was responsible for the implementation of this plan. 13. Beginning 12/08/2023, the DON, ADON, UM, SDC, MDS, or Consultant/Regional Nurse would audit progress notes and events for all current residents for any documented or noted abuse concerns and to ensure if any abuse allegations, they were reported timely to the appropriate agencies per the state and federal regulations. This would be for all residents daily for seven (7) days, then decrease to all residents daily Monday through Friday for two (2) weeks, then decrease to all residents three (3) times a week for six (6) weeks, then decrease to all residents weekly for four (4) weeks. 14. Beginning 12/08/2023, the DON, ADON, UM, SDC, MDS, SCC, VP of Clinical Operations, or VP of Regulatory would audit ten (10) random residents' care plans weekly for four (4) weeks to ensure the care plans were accurate, had been revised as applicable, and reflected the residents' inappropriate sexual behaviors if at risk for such, then this would decrease to five (5) random residents' care plans weekly for four (4) weeks, then to three (3) random residents' care plans weekly for four (4) weeks. 15. Beginning 12/08/2023, the DON, ADON, UM, SDC, MDS, Administrator, [NAME] President of Regulatory, [NAME] President of Clinical Operations, Director of Regulatory, or Consultant/Regional Nurse would observe five (5) random staff members daily for seven (7) days to ensure staff were following the residents' care plans when providing assistance or care to the residents, then decrease to three (3) random staff members three (3) times a week for two (2) weeks, then decrease to two (2) random staff members two (2) times a week for two (2) weeks. 16. Beginning 12/08/2023, the Consultant/Regional Nurse, VP of Clinical Operations, the VP of Operations, or the VP of Regulatory would review each new self-reported facility incidents daily to ensure all agencies had been notified per state and federal guidelines, timely, and appropriately per the guidance. This would be completed daily for two (2) weeks, then daily Monday through Friday for two (2) weeks, then on Monday, Wednesday, and Friday for two (2) weeks, then weekly for four (4) weeks. 17. New sexually inappropriate behaviors would be addressed by the following actions: physician notification would be completed by a licensed nurse; Psychosocial monitoring would be completed for seventy-two (72) hours for all residents who were involved in any sexually inappropriate behaviors by the SSD or a licensed nurse; the Interdisciplinary Team (IDT) (which included the Administrator, DON, ADON, UM, Consultant/Regional Nurse, SDC, and MDS Coordinator) would meet the next business day after the sexual inappropriate behaviors were identified so the IDT could discuss the behaviors and ensure appropriate interventions had been put in place along with appropriate notifications had been completed to the physician, responsible party, and local state agencies per state and federal guidelines. Care plan reviews with revision would be completed by the MDS Coordinator, DON, ADON, UM, SSD, or a licensed nurse; one-to-one (1:1) observation monitoring might need to be implemented and would be completed by a member of the nursing department such as a Certified Nursing Assistant (CNA) or licensed nurse; modifications to care plans were discussed for reevaluations as needed by the IDT and modifications would be completed by a member of the IDT as needed. The State Survey Agency validated the implementation of the facility's Immediate Jeopardy (IJ) Removal Plan as follows: 1. Review of Resident #2's census information revealed the resident was discharged on 09/11/2023 with no return to the facility as a resident. Review of the facility census revealed Resident #1 still resided in the facility. Review of the facility census revealed Resident #6 still resided in the facility. 2. Review of the 12/07/2023 Progress Note, entered by the Social Services Director (SSD), revealed Resident #1 had no noted adverse reaction or changes and remained at baseline with no noted concerns from the incident. Review of the 12/07/2023 Progress Note, entered by the SSD revealed Resident #6 had no adverse reaction or changes and remained at baseline with no concerns from the incident. During an Interview with the SSD, on 12/15/2023 at 2:37 PM, she stated she had interviewed Resident #1 and Resident #6, on 12/07/2023, with no concerns noted. 3. Review of Resident #1 and Resident #6's entire comprehensive care plan revealed accuracy and reflected each of the residents' current problems and risks and the residents' known sexual behaviors. During an interview with the Unit Manager (UM), (who was also the ADON and acting DON), on 12/15/2023 at 4:10 PM, she stated she had reviewed Resident #1 and Resident #6's entire comprehensive care plan on 12/07/2023 to ensure their comprehensive care plans were accurate and reflected each of these residents' current problems and risks and to ensure their behavioral care plans were accurate and reflected each of these residents' known sexual behaviors. During an interview with the Minimum Data Set (MDS) Coordinator, on 12/15/2023 at 3:19 PM, she stated she had reviewed Resident #1 and Resident #6's entire comprehensive care plan on 12/07/2023 to ensure their comprehensive care plans were accurate and reflected each of these residents' current problems and risks and to ensure their behavioral care plans were accurate and reflected each of these residents' known sexual behaviors. During an interview with Director of Regulatory (DOR) #2, on 12/15/2023 at 5:07 PM, she stated she assisted in reviewing Resident [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the facility's policies, review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, and review of the Minimum Data Set (MDS) Coordinator Job Description, it was determined the facility failed to ensure a comprehensive person-centered care plan was developed and implemented to meet a resident's medical, nursing, and mental and psychosocial needs for four (4) of seven (7) sampled residents (Resident #1, Resident #2, Resident #6, and Resident #7). 1. On 09/05/2023, Resident #2 was observed in Resident #1's bed (a resident of the opposite sex) with his/her hand in Resident #2's genital area. There was no documented evidence Resident #1's Comprehensive Care Plan (CCP) was implemented related to safety checks on 09/05/2023 prior to the incident with Resident #2, even though both residents required redirection earlier in the day due to habitually seeking out contact with one another. Additionally, Resident #2's CCP was not developed with interventions to protect other residents related to his/her history of inappropriate sexual behavior prior to the incident with Resident #1. 2. On 04/16/2023, Resident #2 was observed sitting on Resident #6's bed with his/her hands under a blanket covering Resident #6's lap. There was no documented evidence Resident #6's CCP was implemented related to staff intervening prior to the incident involving Resident #6 and Resident #2 on 04/16/2023. Additionally, Resident #2's CCP was not developed with interventions to protect other residents related to his/her history of inappropriate sexual behavior prior to the incident with Resident #6. 3. On 09/14/2023, Resident #6 was observed to hit Resident #7 in the chest area. There was no documented evidence Resident #7's care plan intervention was implemented related to assisting the resident away from other residents prior to Resident #7 being hit by Resident #6, even though the facility Investigation revealed Resident #6 hit Resident #7 in an effort to stop Resident #7 from yelling. Additionally, there was no documented evidence Resident #6's CCP was implemented related to assessing the resident's behavior to see if behavior endangers the resident and/or others; and intervening as necessary on 09/14/2023 prior to Resident #6 smacking Resident #7 in his/her in the chest. The facility's failure to have an effective system in place to ensure a comprehensive person-centered care plan was developed and implemented for each resident to meet a resident's medical, nursing, and mental and psychosocial needs has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 12/06/2023, and determined to exist on 04/16/2023, in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and (F609), both at a Scope and Severity (S/S) of J; 42 CFR 482.21 Comprehensive Resident Centered Care Plan (F656) at a S/S of a J, and 42 CFR 483.70 Administration, (F835) at a S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation. The facility was notified of the IJ on 12/06/2023. The State Survey Agency (SSA) received an acceptable IJ Removal Plan on 12/11/2023 alleging removal of the IJ on 12/10/2023. The SSA validated the removal of the IJ on 12/10/2023, prior to exit on 12/15/2023, which lowered the S/S to a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. Refer to F600 The findings include: Review of the facility's policy, titled Comprehensive Care Plan, dated 09/15/2023, revealed each resident's Comprehensive Care Plan would be designed to incorporate identified problem areas and incorporate risk factors associated with identified problems. Further review revealed care plan interventions were implemented after consideration of the resident's problem areas and their causes. Interventions addressed the underlying source(s) of the problem area(s) rather than addressing only symptoms or triggers. The interventions would reflect action, treatment, or procedure to meet the objectives toward achieving the residents' goals. Continued review revealed care plans were ongoing and revised as information about the resident and the resident's condition changed. Review of the facility's policy, titled Abuse, Neglect and Misappropriation of Property, dated 09/15/2023, revealed the facility defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It included verbal abuse, sexual abuse, physical abuse, and mental abuse. Per the policy, prevention of abuse included a safe environment was established that supported a resident's safety, and identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. Review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, dated October 2023, revealed the Comprehensive Care Plan was an interdisciplinary communication tool and must include measurable objectives and timeframe's and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental,and psychosocial wellbeing. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Review of the Minimum Data Set (MDS) Coordinator Job Description, dated 03/2021, revealed the MDS Coordinator was responsible for reviewing the Plan of Care at least quarterly and with each Comprehensive Assessment to assure changes during the quarter were included and updated. During an interview with MDS Coordinator #1, on 12/06/2023 at 3:10 PM, she stated one of the MDS Coordinators updated care plans as needed at the daily white board meeting based upon Physician's orders and Nurse's Notes from the previous day. She stated if a resident had an immediate situation, such as a fall or a resident-to-resident altercation, the nurse on duty should put in an immediate intervention on the care plan, and then it was reviewed by the Interdisciplinary Team (IDT) at the next daily white board meeting to see if it was an appropriate intervention. She stated a member of the IDT team changed the intervention if it was found not to be appropriate. 1. Review of the facility's Investigation/Final Report, undated and unsigned, initiated by the Administrator, revealed Resident #2 was observed by a Certified Nursing Assistant (CNA) with his/her hand inside Resident #1's private parts, and residents were immediately separated. Skin assessments and interviews were completed with both residents with no concerns noted. Additional review revealed both residents required redirection earlier in the day due to habitually seeking out contact with one another. CNA #2's witness statement, undated, revealed Resident #1 and Resident #2 were outside Resident #1's room talking earlier in the shift. At approximately 10:00 PM she looked in Resident #1's bed and saw Resident #1 with his/her legs spread and Resident #2 had his/her fingers inside Resident #1's private parts. The Investigation was unsigned. (The facility's Initial Report revealed the date of the incident was 09/05/2023. However, the Final Report did not include the date of the incident.) A. Review of Resident #1's Face Sheet revealed the facility admitted the resident on 11/22/2022 with diagnoses which included including Fracture of Left Femur, Dementia with Psychotic Disturbance, Dementia with Agitation, Dementia with Mood Disturbance, Alzheimer's disease, Attention and Concentration Deficit, Cognitive Communication Deficit, and other symptoms and signs involving cognitive functions and awareness. Review of Resident #1's Comprehensive Care Plan (CCP), dated 12/02/2022, revealed the facility assessed the resident to have impaired cognitive skills as evidenced by decision making problems, indecision, inattention, and a Brief Interview for Mental Status (BIMS) less than thirteen (13). The goal stated the resident would improve current level of cognitive function as evidenced by completing as many Activities of Daily Living (ADLs) independently as possible. Interventions included: provide a home like, therapeutic environment with a consistent routine and safety checks. Review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15), indicating severe cognitive impairment. Further review revealed the facility assessed the resident as having verbal behavior symptoms directed toward others (threatening others or screaming or cursing at others). Review of Resident #1's Progress Note, dated 09/06/2023 at 12:01 AM, completed by Licensed Practical Nurse (LPN) #3, revealed Resident #1 was involved with a resident-to-resident altercation. Further review revealed the resident was removed and assessment with a skin assessment completed. There was no documented evidence Resident #1's CCP was implemented related to safety checks on 09/05/2023 prior to the incident with Resident #2, even though both residents required redirection earlier in the day due to habitually seeking out contact with one another as per the facility Investigation. During an interview with LPN #3, on 12/05/2023 at 8:44 AM, he stated staff would try to redirect the residents with television, a snack, or another activity if there was a problem or change in behavior. He further stated he came on shift on 09/05/2023 around 7:00 PM and was not aware of any behaviors earlier in the day which required Resident #1 and Resident #2 being redirected or monitored closely. He stated he had seen Resident #1 and Resident #2 talking in the hallway earlier in the shift, but did not realize there was a problem until he was notified at approximately 10:00 PM of the incident. During an interview with CNA #2, on 12/05/2023 at 9:35 AM, she stated residents often wandered into other residents' rooms and she tried to monitor them in order to know where they were and what they were doing as much as possible, at least while doing rounds every two (2) hours. She stated she allowed them to visit unless the visiting resident was of the opposite sex, in which case she removed them from the room. CNA #2 stated on 09/05/2023, she saw Resident #1 and Resident #2 sitting in the hallway outside Resident #1's room talking with each other around 9:00 PM and she told Resident #2 not to enter Resident #1's room. However, she did not redirect the residents or closely monitor them prior to the incident. B. Review of Resident #2's Face Sheet revealed the facility admitted the resident on 10/25/2022 with diagnoses which included Psychosis, unspecified symptoms and signs involving cognitive functions and awareness, and Cognitive Communication Deficits. Review of Resident #2's Comprehensive Care Plan (CCP), dated 04/16/2023, revealed the resident exhibited inappropriate sexual behavior with a goal stating the resident's sexual behavior would not affect others. Interventions included: keep the resident away from the personal space of staff when conversing with him/her and provide personal care with a second staff member present. However, there were no care plan interventions developed to protect other residents related to Resident #2's inappropriate sexual behavior. Review of Resident #2's Quarterly MDS Assessment, dated 07/25/2023, revealed the facility assessed the resident to have a BIMS score of twelve (12) out of fifteen (15), which indicated moderate cognitive impairment. Review of Resident #2's Progress Note, dated 09/06/2023 at 12:09 AM, completed by LPN #3, revealed Resident #2 was involved with a resident-to-resident altercation. Further review revealed the resident was removed and assessed with no complaints or injuries noted. During an interview with MDS Coordinator #1, on 12/06/2023 at 3:10 PM, she stated Resident #2's Comprehensive Care Plan should have been developed with care plan interventions for increased monitoring to keep other residents safe and to prevent inappropriate sexual behavior toward other residents. Further, she stated the CCP should have been developed with these interventions due to his/her previous resident-to-resident altercation on 04/16/2023. During an interview with the Director of Nursing (DON), on 12/15/2023 at 4:44 PM, she stated she was not sure why Resident #2's CCP was not developed with appropriate interventions due to the resident's history of sexual behavior. During an interview with the Administrator, on 12/05/2023 at 1:24 PM, she stated, on 09/05/2023, LPN #3 notified her of the incident involving Resident #1 and #2. She further stated Resident #2 had a prior sexual allegation, and the staff were aware of Resident #2's history of sexual advances. She stated staff should have been checking the care plans every shift and re-directing residents if needed for a change in behavior. She stated she was unsure why Resident #2 had not been care planned with interventions to prevent inappropriate sexual behaviors toward residents. The Administrator further stated all residents should be redirected when attempting to go into the room of a resident of the opposite sex and some residents required frequent redirection as they were confused to which room was theirs or attempted to visit with other residents to talk. 2. Review of the facility's Investigation, undated and unsigned, initiated by the Administrator, revealed Resident #2 was witnessed by staff sitting on Resident #6's bed and Resident #2's hands were under a blanket covering Resident #6's lap. Further, the residents were then separated and skin assessments were performed with both residents with no concerns noted. However, the facility investigation did not state the date of the incident. CNA #7's witness statement, dated 04/16/2023, revealed she observed Resident #2 sitting on Resident #6's bed with his/her hands under Resident #6's blanket. A. Review of Resident #6's Face Sheet revealed the facility admitted the resident on 01/10/2022 with diagnoses which included Dementia without Behavioral Disturbance, Dementia with Mood Disturbance, Dementia with Agitation, and Psychotic Disorder with Delusions. Review of Resident #6's Comprehensive Care Plan, dated 02/16/2022, revealed the facility assessed the resident to have cognitive loss/dementia; a BIMS score less than thirteen (13), and inattention and disorganized thinking. The goal stated the resident would improve memory/recall ability as evidenced by recalling staff names, stating he/she was in a nursing home, and recognizing staff faces. Interventions included to provide verbal and visual reminders. Review of Resident #6's Comprehensive Care Plan, dated 04/22/2022, revealed the facility assessed the resident with a behavior problem related to exhibiting socially inappropriate disruptive behavioral symptoms by initiating sexual behaviors with other residents of the opposite sex and entering the rooms of other residents of the opposite sex. The goal stated the resident would not perform sexual acts with other residents and not congregate in rooms of residents of the opposite sex. Interventions included assessing the resident's behavior to see if endangers the resident and/or others and intervene as necessary and observe and report socially inappropriate/disruptive behaviors when around others. Review of Resident #6's Quarterly MDS Assessment, dated 04/05/2023, revealed the facility assessed the resident to have a BIMS score of seven (7) out of fifteen (15), indicating severe cognitive impairment. Further, the facility assessed Resident #6 with delusions, but did not assess him/her as having any behavioral symptoms. Review of Resident #6's Progress Note, dated 04/16/2023 at 8:00 PM, completed by LPN #7, revealed the CNA reported Resident #6 was found sitting on his/her bed with another resident of the opposite sex sitting beside him/her. Resident #6 had a blanket on his/her lap and the other resident had his/her hand under the blanket. The residents were separated, and Resident #6 was placed on one-on-one (1:1) monitoring. Skin assessments were completed on both residents and Resident #6 was moved to a different unit in the facility. There was no documented evidence Resident #6's Comprehensive Care Plan was implemented related to staff intervening as necessary prior to the incident involving Resident #6 and Resident #2 on 04/16/2023. During an interview with CNA #7, on 12/07/2023 at 10:49 AM, she stated on 04/16/2023, she observed Resident #2 and Resident #6 sitting on the bed with Resident #6 having a blanket covering his/her lap. Resident #2 had his/her hands under the blanket and CNA #7 could tell Resident #2's hands were in Resident #6's crotch area. CNA #7 stated staff had seen Resident #2 and Resident #6 sitting very close together during activities prior to this incident and staff could tell they were hot for each other. However, she stated she had not intervened to monitor the residents closely prior to the incident as per Resident #6's CCP. B. Review of Resident #2's Face Sheet revealed the facility admitted the resident on 10/25/2022 with diagnoses which included Psychosis, unspecified symptoms and signs involving cognitive functions and awareness, and Cognitive Communication Deficits. Review of Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated 03/08/2023, revealed the facility assessed the resident to have a BIMS score of four (4) out of fifteen (15), which indicated the resident had severe cognitive impairment. Review of Resident #2's Comprehensive Care Plan, dated 04/16/2023, revealed the resident exhibited inappropriate sexual behavior with a goal stating the resident's sexual behavior would not affect others. Interventions included: keep the resident away from the personal space of staff when conversing with him/her and provide personal care with a second staff member present. During an interview with CNA #7, on 12/07/2023 at 10:49 AM, she stated Resident #2 liked to go into Resident #6's room because their rooms were directly across the hall from one another. Further, on 04/16/2023, she observed Resident #2 and Resident #6 sitting on the bed with Resident #6 having a blanket covering his/her lap. She stated Resident #2 had his/her hands under the blanket and CNA #7 could tell Resident #2's hands were in Resident #6's crotch area. She stated staff had seen Resident #2 and Resident #6 sitting very close together during activities and on the unit together prior to this incident. She further stated staff could tell they were hot for each other. There was no documented evidence Resident #2's CCP was developed with interventions related to preventing inappropriate sexual behavior toward other residents. (Refer to MDS Coordinator #1's interview on 12/06/2023 at 3:10 PM). 3. Review of the facility's Investigation, undated and unsigned, initiated by the Administrator, revealed Resident #6 hit Resident #7 in an effort to stop Resident #7 from yelling. The residents were separated and skin assessments and interviews were performed with both residents with no concerns noted. (Review of the Initial Report, revealed the date of the incident was 09/14/2023; however, the final investigation did not state a date for the incident). A. Review of Resident #7's Face Sheet revealed the facility admitted the resident on 04/22/2013 with diagnoses which included Cerebral Palsy, Blindness in left and right eye, Alzheimer's, and Dementia with mood disturbance. Review of Resident #7's Comprehensive Care Plan, dated 01/03/2023, revealed the resident demonstrated inappropriate behaviors and sexual comments to staff with a goal the resident's behavior would not result in disruption of others' environment. Interventions included assist resident away from other residents as needed and observe for triggers of inappropriate behaviors and alter environment as needed. Review of Resident #7's Comprehensive Care Plan, dated 04/28/2023, revealed the resident was noted to have behaviors of hitting staff and yelling out during care with a goal the resident would not hit staff during care. Interventions included: encourage the resident not to hit during care. Review of Resident #7's Quarterly MDS Assessment, dated 07/24/2023, revealed the facility assessed the resident to have a BIMS score of thirteen (13) out of fifteen (15), which indicated the resident was cognitively intact. Further review revealed the facility assessed the resident to have behavioral symptoms not directed at others (such as 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, disruptive sounds). Review of Resident #7's Progress Notes, dated 09/14/2023, revealed no description of the resident-to-resident altercation with Resident #6. Review of Resident #7's Progress Note, dated 09/14/2023 at 5:13 PM, revealed the resident was placed on every fifteen (15) minute checks related to a resident-to-resident altercation. There was no documented evidence Resident #7's care plan intervention was implemented related to assisting the resident away from other residents prior to the resident to resident altercation involving Resident #7 being hit by Resident #6 on 09/14/2023, even though the facility Investigation revealed Resident #6 hit Resident #7 in an effort to stop Resident #7 from yelling. B. Review of Resident #6's Face Sheet revealed the facility admitted the resident on 01/10/2022 with diagnoses which included Dementia without behavioral disturbance, Dementia with mood disturbance, Dementia with agitation, and Psychotic disorder with delusions. Review of Resident #6's Comprehensive Care Plan, dated 02/16/2022, revealed the facility assessed the resident as having cognitive loss/dementia; memory/recall problem; difficulty understanding others related to his/her BIMS score less than thirteen (13), and inattention and disorganized thinking. The goal stated the resident would improve memory/recall ability as evidenced by recalling staff names, stating he/she was in a nursing home, and recognizing staff faces. Interventions included providing verbal and visual reminders such as directions or pictures. Review of Resident #6's Quarterly MDS Assessment, dated 04/05/2023, revealed the facility assessed the resident as having a BIMS score of seven (7) out of fifteen (15), which indicated severe cognitive impairment. Further review revealed the facility assessed the resident as having delusions and wandering behaviors that occurred one (1) to three (3) times during the look back period. Review of Resident #6's Comprehensive Care Plan, dated 04/22/2022, revealed the resident exhibited socially inappropriate disruptive behavioral symptoms by initiating sexual behaviors with other residents of the opposite sex and entering the rooms of residents of the opposite sex. The goal stated the resident would not perform sexual acts with other residents and would not congregate in rooms of residents of the opposite sex. Interventions included assessing the resident's behavior to see if behavior endangers the resident and/or others; intervene as necessary and observe and report socially inappropriate/disruptive behaviors when around others. Review of Resident #6's Progress Note, dated 09/14/2023 at 5:05 PM, completed by LPN #4, revealed Resident #6 walked up to another resident (Resident #7) and smacked him/her in the chest, then attempted to smack another (unknown) resident's face. The other resident (Resident #7) was immediately removed from the situation and brought to safety and Resident #6 was placed on one-on-one observation. Review of the facility investigation, dated 09/14/2023, and Resident #6 and Resident #7's Progress Notes revealed no evidence of who witnessed the resident-to-resident altercation. There was no documented evidence Resident #6's CCP was implemented related to assessing the resident's behavior to see if behavior endangers the resident and/or others; and intervening as necessary on 09/14/2023 prior to Resident #6 smacking Resident #7 in his/her in the chest. The State Survey Agency (SSA) attempted to interview LPN #4 by telephone on 12/15/2023 at 2:30 PM and 4:10 PM as this nurse was assigned to Resident #6 and Resident #7 at the time of the incident. However, LPN #4 did not return the phone calls. During an interview with the DON, on 12/15/2023 at 4:44 PM, she stated she expected staff (nurses and CNAs) to review resident care plans each shift prior to caring for the residents and follow the care plans. She stated CNAs had access to specific care plans and should follow the interventions specified. She further stated she expected staff to develop/update the care plans with changes in residents' condition, physician's orders or after any incidents such as resident to resident altercations. Per interview, the MDS Nurse developed/updated care plans, but any nurse could ensure appropriate interventions were added on the care plans. She further stated the Interdisciplinary Team (IDT) discussed any incidents and care plan interventions during the next morning meeting and someone from the IDT was to ensure appropriate interventions were in place on the care plan. During interview with the Administrator, on 12/05/2023 at 1:24 PM, she stated staff should be checking the care plans every shift and following the care plan interventions. Further, it was her expectation the care plans were developed with appropriate interventions to provide safety for the residents and prevent abuse from occurring. During an interview with the Medical Director, on 12/15/2023 at 5:25 PM, he stated he expected there to be appropriate care plan interventions and for staff to be aware of the residents' care plan interventions and to follow them. The facility provided an acceptable credible Removal of Immediacy Plan on 12/11/2023 that alleged removal of the Immediate Jeopardy (IJ) on 12/10/2023. Review of the Immediacy Plan revealed the facility implemented the following: 1. On 09/11/2023, Resident #2 was discharged from the facility and had not returned as a resident since being discharged . Resident #1 still resides in the facility. Resident #6 still resides in the facility. 2. On 12/07/2023, the Social Services Director (SSD) assessed Residents #1 and #6's psychosocial status with no noted psychosocial concerns with both residents continuing to be at normal baseline. 3. On 12/07/2023, Resident #1 and Resident #6's entire comprehensive care plans were reviewed by the Unit Manager (UM) and Minimum Data Set (MDS) Coordinator to ensure their comprehensive care plans were accurate and reflected each of these residents' current problems and risks. On 12/07/2023, Resident #1 and Resident #6's comprehensive care plans were reviewed by the Director of Regulatory, Assistant Director of Nursing, and Minimum Data Set (MDS) Coordinator to ensure their behavioral care plans were accurate and reflected each of these residents' known sexual behaviors. 4. On 12/07/2023, forty-three (43) residents who had a Brief Interview for Mental Status (BIMS) of seven (7) or less, received a skin assessment by the Consultant/Regional Nurse to determine if there were any signs and symptoms of any type of abuse that may have occurred. There were no concerns with abuse identified. 5. On 12/07/2023, thirty-nine (39) residents who had a BIMS of eight (8) or higher were interviewed by the Consultant Regional Nurse with the question have you had any concerns with anyone inappropriately touching you or attempting to touch you inappropriately or any abuse concerns? This was to determine if they had any concerns with any type of abuse or anyone inappropriately touching them or attempting to inappropriately touch them. No residents voiced any concerns. 6. On 12/07/2023 through 12/08/2023, all eighty-three (83) current facility residents' care plans were reviewed by the MDS Coordinator, ADON, and Director of Regulatory to ensure each resident had a care plan developed and in place to address any resident who had current or a known history of sexual behaviors which put them and others at risk. The facility identified three (3) residents who had inappropriate sexual behaviors care plans that needed additional interventions developed and implemented due to their history of behaviors. This was completed by the ADON and MDS Coordinator. The facility identified six (6) residents who had a history of sexually inappropriate behaviors who needed a care plan developed and implemented to address having had a history of sexually inappropriate behaviors and these care plans were developed by the ADON and MDS Coordinator. 7. On 12/07/2023 through 12/09/2023, the [NAME] President of Clinical Operations, Consultant/Regional Nurse, [NAME] President of Regulatory, Staff Development Coordinator (SDC), or the Facility Administrator, reviewed all current residents' progress notes and events from 04/16/2023 through 12/07/2023 to ensure there were no instances of abuse of any kind that were not reported to the appropriate agencies if occurring. No concerns were identified. 8. On 12/07/2023, the Director of Regulatory provided education to the facility Administrator on the entire facility Abuse Policy, the entire Care Plan Policy, and the entire federal regulation at F600, F609, F656, and F835 from Appendix PP of the State Operations Manual. A posttest was given to the facility Administrator after the education was provided and a score of one hundred (100%) percent was obtained on the posttest by the Administrator. All new Administrators would be required to have all education on federal regulations at F600, F609, F656, F835 from Appendix PP of the State Operations Manual, the facility Abuse Policy, and the facility Care Plan Policy, with a posttest given during orientation by nurse management prior to their working. 9. On 12/07/2023, the Consultant/Regional Nurse educated the acting Director of Nursing (DON)/Assistant Director of Nursing (ADON), Unit Manager (UM), Staff Development Coordinator (SDC), Social Service Director (SSD), Plant Ops, and Activities Director on the entire facility Abuse Policy and the entire federal regulation at F600 and F609 from Appendix PP of the State Operations Manual with a posttest given to these staff members after the education was provided. A score of one hundred (100%) percent was required and anyone who did not receive a one hundred (100%) percent score was reeducated and then provided another posttest. This process continued until a one hundred (100%) percent score was obtained by all staff. 10. Beginning on 12/07/2023 and ending on 12/09/2023, the Consultant/Regional Nurse educated the DON/ADON, UM, SDC, SSD, MDS, Therapy Director, Dietary Manager, Activities Director, and Licensed Nurses on the entire Care Plan Policy regarding the development and implementation of the care plan and on the entire federal regulation from Appendix PP on F656 with a posttest given to these staff members after the education was provided. A score of one hundred (100%) percent was required and anyone who did not receive a one hundred (100%) percent score was reeducated and then provided another posttest. This process continued until a one hundred (100%) percent score was obtained by all staff. If those disciplines did not receive the education during those dates, they would be required to receive the education prior to their next shift. All new staff and all new agency staff would be required to have all education during orientation by nurse management prior to their w[TRUNCATED]

Based on interview, record review, review of the Director of Nursing and Administrator's Job Description, and review of the facility's policies, it was determined the facility failed to ensure it was administered in a manner to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of each resident and to ensure prevention of abuse. Staff interviews and record review revealed the facility failed to provide adequate supervision to residents to prevent abuse, failed to ensure the Comprehensive Care Plans (CCPs) were developed and implemented to prevent abuse, and failed to notify the appropriate State Agencies and local law authorities of allegations of abuse. The facility's failure to have an effective system in place to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 12/06/2023, and determined to exist on 04/16/2023, in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and (F609), both at a Scope and Severity (S/S) of J; 42 CFR 482.21 Comprehensive Resident Centered Care Plan (F656) at a S/S of a J, and 42 CFR 483.70 Administration, (F835) at a S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation. The facility was notified of the IJ on 12/06/2023. The State Survey Agency (SSA) received an acceptable IJ Removal Plan on 12/11/2023 alleging removal of the IJ on 12/10/2023. The SSA validated the removal of the IJ on 12/10/2023, prior to exit on 12/15/2023, which lowered the S/S to a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. Refer to F600 The findings include: Review of the Administrator's Job Description, dated 03/2021, revealed the Administrator would lead and direct the overall operations of the facility in accordance with customer needs, government regulations and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. Further review revealed the Administrator would maintain a working knowledge of and confirm compliance with all governmental regulations. Review of the Director of Nursing's (DON) Job Description, dated 03/2021, revealed the DON would manage the overall operations of the Nursing Department in accordance with Company Policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all residents' needs. Review of the facility's policy, titled Abuse, Neglect and Misappropriation of Property, dated 09/15/2023, revealed the facility defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It included verbal abuse, sexual abuse, physical abuse, and mental abuse. The policy stated the facility's Administrator or his/her designee would conduct a reasonable investigation of any alleged violation and the Administrator was responsible for reporting all investigation results to applicable State Agencies as required by Federal and State law. Per the policy, prevention of abuse included a safe environment was established that supported a resident's safety, and identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. Further review revealed any abuse allegation must be reported to State within two (2) hours from the time the allegation was received and any reasonable suspicion of a crime with serious bodily injury must be reported to the State and Police. 1. The facility failed to provide adequate supervision to ensure Resident #1 was protected from abuse by Resident #2. On 09/05/2023, Resident #2 was observed in Resident #1's bed (a resident of the opposite sex) with his/her hand in Resident #2's genital area. In addition, staff interviews revealed the facility confined Resident #1 and Resident #2 to their rooms after the incident due to not enough staff to have a separate staff members to closely monitor both residents. Resident #1's Comprehensive Care Plan (CCP) was not implemented related to safety checks on 09/05/2023 prior to the incident with Resident #2, even though both residents required redirection earlier in the day due to habitually seeking out contact with one another. Also, Resident #2's CCP was not developed with interventions to protect other residents related to his/her history of inappropriate sexual behavior prior to the incident with Resident #1. Moreover, the facility failed to notify the appropriate State Agencies and local law authorities of the alleged abuse. 2. The facility failed to provide adequate supervision to ensure Resident #6 was protected from abuse by Resident #2. On 04/16/2023, Resident #2 was observed sitting on Resident #6's bed with his/her hands under a blanket covering Resident #6's lap. Resident #6's CCP was not implemented related to staff intervening prior to the incident involving Resident #6 and Resident #2 on 04/16/2023. Additionally, Resident #2's CCP was not developed with interventions to protect other residents related to his/her history of inappropriate sexual behavior prior to the incident with Resident #6. Furthermore, the facility failed to notify the appropriate State Agencies and local law authorities of the alleged abuse. 3. The facility failed to provide adequate supervision to ensure Resident #7 was protected from abuse by Resident #6. On 09/14/2023, Resident #6 was observed to hit Resident #7 in the chest area. Resident #7's care plan intervention was not implemented related to assisting the resident away from other residents prior to the incident on 09/14/2023, even though the facility Investigation revealed Resident #6 hit Resident #7 in an effort to stop Resident #7 from yelling. Additionally, Resident #6's CCP was not implemented related to assessing the president's behavior to see if behavior endangers the resident and/or others; and intervening as necessary prior to Resident #6 smacking Resident #7 in his/her in the chest. Moreover, the facility failed to notify the appropriate State Agencies and local law authorities of the alleged abuse. During an Interview with the DON, on 12/15/2023 at 4:43 PM, she stated she expected all staff to follow the Abuse Policy to ensure residents were protected and safe. Further, she stated it was her expectation staff monitor residents and be aware of any behaviors which may lead to possible abuse. In continued interview, she stated it was her expectation care plan interventions be developed and followed to keep residents free from abuse. Additionally, she stated it was her expectation for the Administrator, as the Abuse Coordinator, to investigate all allegations of abuse and report to the appropriate state agencies and law enforcement. During an interview with the Administrator, on 12/05/2023 at 1:24 PM, she stated she was responsible for making sure the proper notifications were made to the appropriate state agencies and law enforcement with any suspicion of abuse. She further stated she should have notified the proper agencies and law enforcement of the incident between Resident #1 and Resident #2 on 09/05/2023, the incident between Resident #2 and Resident #6 on 04/16/2023, and the incident between Resident #6 and Resident #7 on 09/14/2023. She continued to state it was her expectation that the care plans were developed with appropriate interventions and staff had knowledge of the care plans and followed the interventions for resident safety. Further interview revealed it was her expectation that all staff monitor and supervise residents to prevent abuse and follow the facility Abuse policy. During an Interview with the Medical Director (MD), on 12/15/2023 at 5:25 PM, he stated he expected all staff to be aware of the residents' care plans and follow the interventions. He further stated he was notified on a general basis of any allegations of abuse during the monthly Quality Assurance Performance Improvement (QAPI) meetings, but did not always get the specific details. During further interview, he stated it was his expectation that staff would have followed the Abuse Policy related to protecting residents from abuse, and reporting abuse to the proper agencies and law enforcement. During an Interview with Consultant #1/Regional Nurse, on 12/15/2023 at 5:13 PM, she stated the Administrator was responsible for investigating and reporting all suspicions of abuse and should have reported all abuse allegations to the proper agencies and law enforcement timely. Additionally, she stated it was the facility's responsibility to ensure residents were properly supervised to ensure safety and prevent abuse from occurring. The facility provided an acceptable credible Removal of Immediacy Plan on 12/11/2023 that alleged removal of the Immediate Jeopardy (IJ) on 12/10/2023. Review of the Immediacy Plan revealed the facility implemented the following: 1. On 09/11/2023, Resident #2 was discharged from the facility and had not returned as a resident since being discharged . Resident #1 still resides in the facility. Resident #6 still resides in the facility. 2. On 12/07/2023, the Social Services Director (SSD) assessed Residents #1 and #6's psychosocial status with no noted psychosocial concerns with both residents continuing to be at normal baseline. 3. On 12/07/2023, Resident #1 and Resident #6's entire comprehensive care plans were reviewed by the Unit Manager (UM) and Minimum Data Set (MDS) Coordinator to ensure their comprehensive care plans were accurate and reflected each of these residents' current problems and risks. On 12/07/2023, Resident #1 and Resident #6's comprehensive care plans were reviewed by the Director of Regulatory, Assistant Director of Nursing, and Minimum Data Set (MDS) Coordinator to ensure their behavioral care plans were accurate and reflected each of these residents' known sexual behaviors. 4. On 12/07/2023, forty-three (43) residents who had a Brief Interview for Mental Status (BIMS) of seven (7) or less, received a skin assessment by the Consultant/Regional Nurse to determine if there were any signs and symptoms of any type of abuse that may have occurred. There were no concerns with abuse identified. 5. On 12/07/2023, thirty-nine (39) residents who had a BIMS of eight (8) or higher were interviewed by the Consultant Regional Nurse with the question have you had any concerns with anyone inappropriately touching you or attempting to touch you inappropriately or any abuse concerns? This was to determine if they had any concerns with any type of abuse or anyone inappropriately touching them or attempting to inappropriately touch them. No residents voiced any concerns. 6. On 12/07/2023 through 12/08/2023, all eighty-three (83) current facility residents' care plans were reviewed by the MDS Coordinator, ADON, and Director of Regulatory to ensure each resident had a care plan developed and in place to address any resident who had current or a known history of sexual behaviors which put them and others at risk. The facility identified three (3) residents who had inappropriate sexual behaviors care plans that needed additional interventions developed and implemented due to their history of behaviors. This was completed by the ADON and MDS Coordinator. The facility identified six (6) residents who had a history of sexually inappropriate behaviors who needed a care plan developed and implemented to address having had a history of sexually inappropriate behaviors and these care plans were developed by the ADON and MDS Coordinator. 7. On 12/07/2023 through 12/09/2023, the [NAME] President of Clinical Operations, Consultant/Regional Nurse, [NAME] President of Regulatory, Staff Development Coordinator (SDC), or the Facility Administrator, reviewed all current residents' progress notes and events from 04/16/2023 through 12/07/2023 to ensure there were no instances of abuse of any kind that were not reported to the appropriate agencies if occurring. No concerns were identified. 8. On 12/07/2023, the Director of Regulatory provided education to the facility Administrator on the entire facility Abuse Policy, the entire Care Plan Policy, and the entire federal regulation at F600, F609, F656, and F835 from Appendix PP of the State Operations Manual. A posttest was given to the facility Administrator after the education was provided and a score of one hundred (100%) percent was obtained on the posttest by the Administrator. All new Administrators would be required to have all education on federal regulations at F600, F609, F656, F835 from Appendix PP of the State Operations Manual, the facility Abuse Policy, and the facility Care Plan Policy, with a posttest given during orientation by nurse management prior to their working. 9. On 12/07/2023, the Consultant/Regional Nurse educated the acting Director of Nursing (DON)/Assistant Director of Nursing (ADON), Unit Manager (UM), Staff Development Coordinator (SDC), Social Service Director (SSD), Plant Ops, and Activities Director on the entire facility Abuse Policy and the entire federal regulation at F600 and F609 from Appendix PP of the State Operations Manual with a posttest given to these staff members after the education was provided. A score of one hundred (100%) percent was required and anyone who did not receive a one hundred (100%) percent score was reeducated and then provided another posttest. This process continued until a one hundred (100%) percent score was obtained by all staff. 10. Beginning on 12/07/2023 and ending on 12/09/2023, the Consultant/Regional Nurse educated the DON/ADON, UM, SDC, SSD, MDS, Therapy Director, Dietary Manager, Activities Director, and Licensed Nurses on the entire Care Plan Policy regarding the development and implementation of the care plan and on the entire federal regulation from Appendix PP on F656 with a posttest given to these staff members after the education was provided. A score of one hundred (100%) percent was required and anyone who did not receive a one hundred (100%) percent score was reeducated and then provided another posttest. This process continued until a one hundred (100%) percent score was obtained by all staff. If those disciplines did not receive the education during those dates, they would be required to receive the education prior to their next shift. All new staff and all new agency staff would be required to have all education during orientation by nurse management prior to their working with a posttest. 11. On 12/07/2023, the Consultant/Regional Nurse, DON/ADON, UM, SDC, SSD, Plant Ops, Activity Director, Administrator, or Regulatory Director provided education to current facility staff which included Certified Nurse Aides, Kentucky Medication Aides, Licensed Nurses, Therapy Staff, Environmental Staff, Dietary Staff, Activity Staff, Maintenance Staff, and Business Office Staff on the entire facility Abuse Policy and the entire federal regulation at F600 and F609 from Appendix PP of the state operations manual with a posttest given to these staff members after the education was provided. A score of one hundred (100%) percent was required and anyone who did not receive a one hundred (100%) percent score was reeducated and then provided another posttest. This process continued until a one hundred (100%) percent score was obtained by all staff. Any staff not receiving this education and posttest by 12/07/2023 would receive this education and posttest prior to being able to work their next shift. A score of one hundred (100%) percent was required and anyone not receiving a one hundred (100%) percent score would be reeducated and then provided another posttest. This process will continue until one hundred (100%) percent score was obtained by all staff. All new staff and all new agency staff would be required to have all education during orientation by nurse management prior to their working with posttest. 12. On 12/07/2023, an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Medical Director, the Facility Administrator, the Assistant Director of Nursing acting as Interim Director of Nursing, the Staff Development Coordinator, and Consultant/Regional Nurse regarding Immediate Jeopardy (IJ) removal plans that were formulated and implemented at that time. The facility Administrator presented the plan and information at the QAPI meeting. The Facility Medical Director was onsite at the facility and was notified by the facility Administrator of the Immediate Jeopardies and the rationale for being cited with the Immediate Jeopardies. The Medical Director reviewed the entirety of the plan and made no further suggestions. The Medical Director stated the plan was appropriate and would be effective. Starting on 12/08/2023, A Quality Assurance meeting would be held daily for seven (7) days, then would decrease to monthly for recommendations and further follow up regarding the above stated plan. Moving forward the facility Administrator would continue to be the person who presented the information and audits at the QAPI Meetings, and the following members were expected to be present unless unable to attend: Facility Administrator, Medical Director, Director of Nursing, Assistant Director of Nursing, Staff development Coordinator, Plant Ops Director, Social Services Director, Activity Director, Therapy Director, and MDS Coordinator. The QAPI Committee would determine at what frequency any ongoing audits would need to continue. The Administrator was responsible for the implementation of this plan. 13. Beginning 12/08/2023, the DON, ADON, UM, SDC, MDS, or Consultant/Regional Nurse would audit progress notes and events for all current residents for any documented or noted abuse concerns and to ensure if any abuse allegations, they were reported timely to the appropriate agencies per the state and federal regulations. This would be for all residents daily for seven (7) days, then decrease to all residents daily Monday through Friday for two (2) weeks, then decrease to all residents three (3) times a week for six (6) weeks, then decrease to all residents weekly for four (4) weeks. 14. Beginning 12/08/2023, the DON, ADON, UM, SDC, MDS, SCC, VP of Clinical Operations, or VP of Regulatory would audit ten (10) random residents' care plans weekly for four (4) weeks to ensure the care plans were accurate, had been revised as applicable, and reflected the residents' inappropriate sexual behaviors if at risk for such, then this would decrease to five (5) random residents' care plans weekly for four (4) weeks, then to three (3) random residents' care plans weekly for four (4) weeks. 15. Beginning 12/08/2023, the DON, ADON, UM, SDC, MDS, Administrator, [NAME] President of Regulatory, [NAME] President of Clinical Operations, Director of Regulatory, or Consultant/Regional Nurse would observe five (5) random staff members daily for seven (7) days to ensure staff were following the residents' care plans when providing assistance or care to the residents, then decrease to three (3) random staff members three (3) times a week for two (2) weeks, then decrease to two (2) random staff members two (2) times a week for two (2) weeks. 16. Beginning 12/08/2023, the Consultant/Regional Nurse, VP of Clinical Operations, the VP of Operations, or the VP of Regulatory would review each new self-reported facility incidents daily to ensure all agencies had been notified per state and federal guidelines, timely, and appropriately per the guidance. This would be completed daily for two (2) weeks, then daily Monday through Friday for two (2) weeks, then on Monday, Wednesday, and Friday for two (2) weeks, then weekly for four (4) weeks. 17. New sexually inappropriate behaviors would be addressed by the following actions: physician notification would be completed by a licensed nurse; Psychosocial monitoring would be completed for seventy-two (72) hours for all residents who were involved in any sexually inappropriate behaviors by the SSD or a licensed nurse; the Interdisciplinary Team (IDT) (which included the Administrator, DON, ADON, UM, Consultant/Regional Nurse, SDC, and MDS Coordinator) would meet the next business day after the sexual inappropriate behaviors were identified so the IDT could discuss the behaviors and ensure appropriate interventions had been put in place along with appropriate notifications had been completed to the physician, responsible party, and local state agencies per state and federal guidelines. Care plan reviews with revision would be completed by the MDS Coordinator, DON, ADON, UM, SSD, or a licensed nurse; one-to-one (1:1) observation monitoring might need to be implemented and would be completed by a member of the nursing department such as a Certified Nursing Assistant (CNA) or licensed nurse; modifications to care plans were discussed for reevaluations as needed by the IDT and modifications would be completed by a member of the IDT as needed. The State Survey Agency validated the implementation of the facility's Immediate Jeopardy (IJ) Removal Plan as follows: 1. Review of Resident #2's census information revealed the resident was discharged on 09/11/2023 with no return to the facility as a resident. Review of the facility census revealed Resident #1 still resided in the facility. Review of the facility census revealed Resident #6 still resided in the facility. 2. Review of the 12/07/2023 Progress Note, entered by the Social Services Director (SSD), revealed Resident #1 had no noted adverse reaction or changes and remained at baseline with no noted concerns from the incident. Review of the 12/07/2023 Progress Note, entered by the SSD revealed Resident #6 had no adverse reaction or changes and remained at baseline with no concerns from the incident. During an Interview with the SSD, on 12/15/2023 at 2:37 PM, she stated she had interviewed Resident #1 and Resident #6, on 12/07/2023, with no concerns noted. 3. Review of Resident #1 and Resident #6's entire comprehensive care plan revealed accuracy and reflected each of the residents' current problems and risks and the residents' known sexual behaviors. During an interview with the Unit Manager (UM), (who was also the ADON and acting DON), on 12/15/2023 at 4:10 PM, she stated she had reviewed Resident #1 and Resident #6's entire comprehensive care plan on 12/07/2023 to ensure their comprehensive care plans were accurate and reflected each of these residents' current problems and risks and to ensure their behavioral care plans were accurate and reflected each of these residents' known sexual behaviors. During an interview with the Minimum Data Set (MDS) Coordinator, on 12/15/2023 at 3:19 PM, she stated she had reviewed Resident #1 and Resident #6's entire comprehensive care plan on 12/07/2023 to ensure their comprehensive care plans were accurate and reflected each of these residents' current problems and risks and to ensure their behavioral care plans were accurate and reflected each of these residents' known sexual behaviors. During an interview with Director of Regulatory (DOR) #2, on 12/15/2023 at 5:07 PM, she stated she assisted in reviewing Resident #1 and Resident #6's comprehensive care plans to ensure their behavioral care plans were accurate and reflected each of these residents' known sexual behaviors. 4. Review of the facility census sheet and the facility's assessment of Brief Interview for Mental Status (BIMS) for the residents, revealed on 12/07/2023, forty-three (43) residents were assessed to have a BIMS score of seven (7) or less. Review of the skin assessments revealed on 12/07/2023 these forty-three (43) residents had skin assessments completed by the Consultant/Regional Nurse with no concerns of abuse identified. During an interview with Consultant/Regional Nurse #1, on 12/15/2023 at 5:13 PM, she stated she conducted skin assessments on forty-three (43) residents who had a BIMS of seven (7) or less to determine if there were any signs and symptoms of any type of abuse and no concerns with abuse were identified. 5. Review of the facility census sheet and the facility's assessment of BIMS for the residents, revealed thirty-nine (39) residents were assessed to have a BIMS score of eight (8) or higher on 12/07/2023. Review of the questionnaires revealed they were completed by the Consultant Regional Nurse for these thirty-nine (39) with no concerns of abuse identified. The Questionnaire had a question, have you had any concerns with anyone inappropriately touching you or attempting to touch you inappropriately or any abuse concerns? During an interview with Consultant/Regional Nurse#1, on 12/15/2023 at 5:13 PM, she stated she completed assessments for thirty-nine (39) residents with a BIMS of eight (8) or higher on 12/07/2023 with no concerns identified. 6. Review of the facility census revealed the facility had eighty-three (83) residents in the facility on 12/07/2023. Review of the facility's audits revealed the facility identified three (3) residents who had inappropriate sexual behaviors care plans that needed additional interventions developed and implemented due to their history of behaviors. Further review of the facility's audits revealed six (6) residents who had a history of sexually inappropriate behaviors needed a care plan developed and implemented to address having had a history of sexually inappropriate behaviors. During interviews with the MDS Coordinator, on 12/15/2023 at 3:19 PM; the ADON, on 12/15/2023 at 4:10 PM; and the Director of Regulatory #2, on 12/15/2023 at 5:07 PM, they verbalized assisting in reviewing residents' care plans to ensure each resident had a care plan developed and in place to address any resident who had current or a known history of sexual behaviors which put them and others at risk. Further, they verbalized developing Care plans as needed for some residents and adding additional interventions to some Care plans related to sexual behaviors. 7. Review of a written statement, signed by the [NAME] President (VP) of Regulatory and Consultant/Regional Nurse #2 on 12/09/2023, revealed they reviewed all current residents' progress notes and events from 04/16/2023 through 12/07/2023 to ensure there was no noted instances of abuse of any kind that were not reported to the appropriate agencies. During an interview with the VP of Regulatory, on 12/15/2023 at 10:42 AM, and Consultant/Regional Nurse #2, on 12/15/2023 at 11:01 AM, they verbalized assisting in reviewing all current residents' progress notes and events from 04/16/2023 through 12/07/2023 to ensure there were no noted instances of abuse of any kind that were not reported to the appropriate agencies with no concerns noted. 8. Review of the education and sign in sheet signed by the Administrator on 12/07/2023, revealed the Administrator had been educated on federal regulations at F600, F609, F656, F835 from Appendix PP of the State Operations Manual, the facility Abuse Policy, and the facility Care Plan Policy, by the Director of Regulatory #1. Further review revealed the Administrator had taken a posttest with a score of one hundred percent (100%). During an interview with the Director of Regulatory #1, on 12/15/2023 at 9:51 AM, he stated he had educated the Administrator, on 12/07/2023, on the entire facility Abuse Policy, the entire Care Plan Policy, and the entire federal regulation at F600, F609, F656, and F835 from Appendix PP of the state operations manual. During an interview with the Administrator, on 12/15/2023 at 4:52 PM, she stated she had been educated by the Director of Regulatory #1, on 12/07/2023, on the entire facility Abuse Policy, the entire Care Plan Policy, and the entire federal regulation at F600, F609, F656, and F835 from Appendix PP of the state operations manual. Review of a statement completed by Director of Regulatory #2, undated, revealed all new Administrators would be required to have all education on federal regulations at F600, F609, F656, F835 from Appendix PP of the State Operations Manual, the facility Abuse Policy, and the facility Care Plan Policy, during orientation by nurse management prior to their working with a posttest. During an interview with Director of Regulatory #2, on 12/15/2023 at 5:07 PM, she stated all new Administrators would be required to have all education on federal regulations at F600, F609, F656, F835 from Appendix PP of the State Operations Manual, the facility Abuse Policy, and the facility Care Plan Policy, during orientation by nurse management prior to their working with a posttest. 9. Review of the education and sign in sheet for 12/07/2023, revealed the DON/ADON, UM, SDC, SSD, Plant Operations Manager, and Activities Director were educated by Consultant/Regional Nurse #3 on the entire facility Abuse Policy and the entire federal regulation at F600 and F609 from Appendix PP of the State Operations Manual and had posttests with scores of one hundred percent (100%). During an interview with Consultant/Regional Nurse #3, on 12/15/2023 at 3:59 PM, she stated she had educated the DON/ADON, UM, SDC, SSD, Plant Operations Manager, and Activities Director on the facility Abuse Policy and the entire federal regulation at F600 and F609 from Appendix PP of the state operations manual and each had posttests with scores of one hundred percent (100%). She further stated a score of one hundred (100%) percent was required and anyone who did not receive a one hundred (100%) percent score was reeducated and then provided another posttest. This process continued until a one hundred (100%) percent score was obtained by all staff. 10. Review of the education and sign in sheets revealed Consultant/Regional Nurse #1 educated the DON/ADON, UM, SDC, SSD, MDS, Therapy Director, Dietary Manager, Activities Director, and Licensed Nurses on F656 from Appendix PP of the state operations manual and the facility Care Plan Policy, and posttests were given with a score of one hundred percent (100%). During an interview with the Consultant Regional Nurse #1, on 12/15/2023 at 2:56 PM, she stated she educated the DON/ADON, UM, SSD, MDS, Therapy Director, Dietary Manager, Activities Director, and Licensed Nurses on the entire Care Plan Policy regarding the development and implementation of the care plan and on the entire federal regulation from Appendix PP on F656 with a posttest given to these staff members after the education was provided. A score of one hundred (100%) percent was required and anyone who did not receive a one hundred (100%) percent score was reeducated and then provided another posttest. She stated the process continued until a one hundred (100%) percent score was obtained by all staff and if any of these staff members did not receive the education, they were required to receive the education prior to their next shift. Further, all new staff and all new agency staff would be required to have all education during orientation by nurse management prior to their working with a posttest. 11. Review of the education and sign in sheets revealed starting 12/07/2023, the SCC, DON/ADON, UM, SDC, SSD, Plant Operations Manager, Activities Director, Administrator, or Regulatory Director provided education related to the Abuse Policy and the entire federal regulation at F600 and F609 from Appendix PP of the State Operations Manual to current facility staff which included Certified Nurse Aides, Kentucky Medication Aides, Licensed Nurses, Therapy Staff, Environmental Staff, Dietary Staff, Activity Staff, Maintenance Staff, and Business Office Staff. A posttest was given to