**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 its policy was implemented related to completing a thorough investigation, ensuring staff reported without fear of retaliation, and failed to have an effective Quality Assurance and Performance Improvement (QAPI) program to ensure measures were taken, to protect the residents from abuse for one (1) of thirty-nine (39) sampled residents, Resident #7. Review of the facility's Alleged Abuse Incident Nursing Description Note, dated 07/20/2023, revealed an anonymous call was received by the Executive Director (ED) during which the caller reported a relationship involving texting and sending inappropriate pictures via text messages to a resident (Resident #7) by a facility staff Certified Nurse Aide (CNA #24). Interview with Resident #7 and with facility staff revealed they were afraid to report allegations of abuse, out of fear of retaliation. Therefore, the allegation of sexual abuse was not reported timely. Review of the Quality Assurance (QA) Meeting Sign-In Sheet dated 07/20/2023, revealed the QA Committee met to discuss the Investigation Process to include reportable events, resident information needed, and the process of investigating. However, review of the facility's documentation revealed no documented evidence to support the facility thoroughly investigated the allegations reported on 07/20/2023, by the anonymous caller, and implemented corrective actions. The facility's failure to ensure its policies were implemented related to abuse has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 07/29/2023 at 483.12 Freedom from Abuse, Neglect, and Exploitation (F600), at the highest Scope and Severity (S/S) of a K; 483.12 Freedom from Abuse, Neglect, and Exploitation (F607 & F609), at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR §483.12, Free from Abuse, Neglect, and Exploitation (F600). The Immediate Jeopardy was determined to exist on 07/20/2023. The facility was notified of the Immediate Jeopardy on 07/29/2023. IJ is ongoing. The findings include: Review of the facility's, Compliance and Ethics - Communication Policy dated December 2020, revealed the Compliance and Ethics Committee was responsible for establishing, implementing and overseeing the methods by which information associated with the Compliance and Ethics Program was communicated. Continued review revealed employees were encouraged to report suspected civil, criminal or administrative violations to the Compliance and Ethics Committee and were protected from retaliation and retribution. Review of the facility's, Freedom from Abuse and Neglect Policy, undated, revealed all residents were to be protected from harm. Review revealed the Executive Director (ED) was responsible for oversight of abuse prohibition standards, and all allegations involving staff necessitated suspension pending investigation. Per facility policy, the definition of abuse was the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain or mental anguish. Review of the policy revealed types of abuse included verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Continued review revealed staff members were to identify and assess suspected or alleged reports of abuse and neglect. Review revealed types of abuse might include: mental abuse; humiliation, harassment, threats; taking unauthorized resident photos or video recordings; posting of any resident photos, video recordings or other resident information on social media networks. Review revealed additional types of abuse included sexual harassment, sexual coercion, and verbal abuse. Further review revealed training included procedures for reporting incidents of abuse, and assurance that any individual who made a report or was in the process of making a report was not retaliated against. Review further revealed the training was to include prohibition of staff taking, keeping, or using photographs or recordings in any manner that would demean or humiliate a resident(s) such as any type of equipment (ex. cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and recordings on social media. Further review of the policy; however, revealed the facility had not addressed the coordination of QAPI to identify, monitor, or implement corrective actions related to allegations of abuse. Review of Resident #7's admission Record revealed the facility admitted the resident on 05/29/2023, with diagnoses including Osteomyelitis, Anxiety, Opioid Abuse, and other Stimulant Abuse. Review of Resident #7's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Review of the facility's Alleged Abuse Investigation Nursing Incident Description note dated 07/26/2023 at 6:26 PM, entered by the Director of Nursing (DON), revealed on 07/20/2023 the ED received an anonymous call that Resident #7 was involved in a relationship with a staff member,with only first name given. Continued review revealed the caller was unable to give a last name or description of the employee. Per review, the caller stated the employee and resident had been texting and sending inappropriate pictures via text messages. Review revealed Resident #7 was interviewed at that time and denied any inappropriate relationship with a staff member or receiving any inappropriate pictures via text messages. Review of the note revealed the Human Services Director (HSD) and Director of Nursing (DON) interviewed all employees with the first name provided and all denied any inappropriate relationship with a resident or sending inappropriate pictures to a resident. Review of the Facility Resident Description section review revealed on 07/20/2023, Resident #7 was interviewed and gave a signed statement noting he/she had never received any pictures from any staff members and he/she felt completely safe at the facility. Continued review revealed on 07/26/2023 Resident #7 spoke with a Peer Support Specialist (PSS) and stated that he/she had not been honest when first interviewed. Per review, Resident #7 told the PSS he/she had had a friendship with CNA #24, an agency CNA, and attempted to cut the relationship off. Further review revealed Resident #7 reported CNA #24 would come to his/her room and shower room which made him/her feel uncomfortable. Review further revealed Resident #7 stated he/she realized he/she was in a vulnerable state due to his/her sobriety, but thought he/she could handle the situation on his/her own. Additional review of the facility's Alleged Abuse Investigation of the Immediate Action Taken Description section dated 07/26/2023 at 6:26 PM, revealed CNA #24 was removed from the schedule and the CNA's agency was notified of the allegations and that the CNA would no longer be able to work at the facility. Continued review revealed on 07/26/2023, Resident #7 received a psychiatric (psych) telehealth visit to ensure the resident was not having any psychosocial distress. Review further revealed Resident #7's care plan was reviewed and updated, and an intervention added to monitor for signs and symptoms (s/s) of psychosocial distress. In addition, review revealed the Medical Director and Police were notified and a full investigation was initiated. Review of agency CNA #24's Clock In and Out Sheet revealed she worked on Saturday 07/22/2023 from 7:00 AM to 7:00 PM and on Sunday 07/23/2023 from 7:00 AM to 11:00 PM (After the ED received the anonymous caller's report on 07/20/2023). Observation revealed the facility had one (1) small five (5) by seven (7) framed posting hanging on the wall in the middle of the hall on the [NAME] Hall noting staff would be free from retaliation when reporting abuse. Interviews with staff revealed they were not aware of the posting displayed on the [NAME] Hall wall and had not observed any such posting throughout the facility. Observation on 07/27/2023 at 9:00 AM, revealed Resident #7 lying on his/her bed, awake, dressed and well-groomed. In interview, at the time of observation, Resident #7 stated at first, he and CNA #24 were just talking a lot and their relationship was as friends, because it was nice having someone close to talk to as he/she did not have any family or friends. Resident #7 stated CNA#24 then started sending him/her nude photos of herself on snapchat on his/her phone, and the relationship progressed and the CNA kissed him/her which made him/her uncomfortable. The resident stated he/she told CNA#24 he/she did not feel comfortable having that kind of relationship because of being in treatment for his/her addiction. Resident #7 stated he/she told CNA #24 he/she needed to continue to work his/her program to recovery before having an intimate relationship with anyone. According to Resident #7, CNA#24 continued to send nude photos however, even after being told to stop. The resident stated CNA #24 would wake him/her up at all hours of the night coming into his/her room when she was working at the facility. Resident #7 stated he/she confided in two (2) other residents on the Lotus Unit about his/her concerns with CNA #24, and those residents asked to see the photos, so he/she showed them the photos. Resident #7 stated he/she told the two (2) other residents he/she told CNA#24 to stop, and it was making him/her uncomfortable because she kept coming into his/her room at night and entering the bathroom when he/she was showering. The resident stated CNA #24 entered the shower multiple times when he/she was showering even though he/she kept telling her to stay out of the shower room. In continued interview on 07/27/2023 at 9:00 AM, Resident #7 stated a rumor had gotten out all over the facility about what was going on. The resident stated the DON and the Human Resources (HR) person called him/her into their offices to talk about the incidents. Resident #7 stated he/she only admitted to the shower incidents because he/she was embarrassed and ashamed about the photos and did not want to get CNA# 24 in trouble. The resident stated, I was afraid if I told the truth about the texting and the photos, they would move me out of the facility, and I really like it here and I want to finish out my program. Resident #7 stated the photos of CNA #24 topless and showing her bare breasts were sent through a social media app called Snapchat, and the photos deleted after twenty-four (24) hours. The resident stated he/she was now feeling harassed by CNA#24 because of her continuing to come to his/her room late at night and by her entering the shower room when he/she was unclothed and showering. Resident #7 stated CNA #24 entered his/her room the other night on the 7:00 PM to 7:00 AM shift when she was not assigned to work on his/her unit, the Lotus Unit. According to Resident #7, on 07/27/2023 at 9:00 AM, Licensed Practical Nurse (LPN) #1 saw CNA #24 coming in and out of his/her room, and asked the CNA why she was on the Lotus Unit when she was supposed to be working another unit. Resident #7 stated after that incident, LPN #1 and LPN #11 came in and talked with him/her about why CNA#24 was in his/her room, and he/she told them CNA#24 would not leave him/her alone. The resident stated he/she told the LPN's about the shower incidents and that he/she was feeling harassed, shamed, and embarrassed by CNA #24, and by the managers at the facility who kept asking him/her about the relationship. Resident #7 further stated he/she felt bad about saying anything to anyone because he/she did not want to get CNA#24 in trouble or cause her to get fired; however, he/she just wanted her to leave him/her alone. During a phone interview on 07/27/2023 at 8:00 PM, LPN #1 stated she had been working on the Lotus Unit since February 2023. LPN#1 stated prior to working at the facility she had worked for fifteen (15) years at the jail and had a lot of experience working with substance abuse clients. She stated on 07/24/2023, she heard staff members talking on the unit about something going on between CNA #24 and Resident #7. LPN #1 stated LPN #11 agreed what she had heard should be reported and made a call to the DON that night to report CNA #24 and Resident #7 being in a relationship. She stated after they (the LPNs) heard about the relationship, they went to talk with Resident #7. According to LPN #11, they were talking to Resident #7 and the resident told them he/she decided to cut it off with CNA #24; however, she started harassing him/her and invading his/her space. She stated she had Resident #7 sign a statement which she handed to the Assistant Director of Nursing (ADON) at the end of her shift that morning. Continued phone interview on 07/27/2023 at 8:00 PM, with LPN #1 revealed she stated two (2) other residents, Resident #9 and Resident #13, told her CNA #24 had been harassing Resident #7 and told her there were pictures exchanged by phone of CNA #24. LPN #1 stated Resident #7 said he/she ended the relationship because he/she needed to work on his/her sobriety, and CNA #24 had not accepted it well. She stated Resident #7 told her he/she was embarrassed and uncomfortable talking about the relationship with CNA #24. LPN #1 stated she saw CNA #24 enter Resident #7's room and was on the Lotus Unit in the middle of the night when she was not assigned to work on the unit. The LPN stated the DON knew about all of this, but the DON did not interview Resident #7 because she told the ADON to do it. She stated she reported everything to the Unit Manager/Infection Prevention (UM/IP) Nurse #1 and Registered Nurse (RN) #2 who both defended CNA #24 and stated Resident # 7 was manipulating and taking advantage of the CNA. The LPN further stated they made Resident #7 the perpetrator in the situation and revised his/her care plan to make him/her care in pairs and care planned him/her for seeking relationships with staff. During an interview, on 07/27/2023 at 8:50 PM, with RN #3 she stated she primarily worked the Lotus Unit and had been at the facility almost two (2) years. RN #3 stated there was an inappropriate physical relationship between CNA #24 and Resident #7. She stated CNA #24 had been pursuing Resident #7 and always going to his/her unit and into his/her room. The RN stated CNA #24 would constantly be wherever Resident #7 was and was always in his/her space. She stated Resident #9 reported CNA #24 had sent Resident #7 naked photos, which he/she had seen and had also seen the text messages from the CNA. RN #3 stated she heard about the inappropriate relationship about two (2) weeks ago and told the DON, who said she would take care of it. She stated she could not see where anything happened after she reported the incident to the DON. RN #3 stated after she reported the inappropriate relationship to the DON she started receiving a lot of backlash from the DON, ADON, and the Unit Manager. She stated they gave her a lot a papers to redo and said she was not doing her job. In a continued interview, on 07/27/2023 at 8:50 PM, the RN #3 stated after a week went by she then heard about the photos; however, after the backlash, she stated she was too scared to say anything to the DON about the photos. She stated she told her brother about the relationship between CNA #24 and Resident #7 and he reported it anonymously to the ED. RN #3 stated she again noticed nothing was done about the inappropriate relationship so she decided to make an anonymous call herself to the State to report it. She stated there were rumors all over the facility about what was going on with Resident #7 and CNA #24 and none of the staff were doing anything about it. She stated Resident #7 was telling everyone CNA #24 was calling and texting his/her phone and harassing him/her and he/she just wished it would stop. RN #3 stated after it came out about the photos, Resident #7 was telling other residents and staff the facility's management team were badgering him/her and harassing him/her about it. During interview CNA #24 stated she had been a CNA for fifteen (15) years and had worked at the facility through a staffing agency staff for about two (2) months. CNA #24 stated she had worked all the units including the Lotus Unit. She stated she had been last educated on the facility's Abuse Policy a couple of weeks ago by the Staff Development Coordinator (SDC). The CNA stated the different types of abuse, and said sexual abuse would be touching inappropriately, making someone feel uncomfortable, and that walking in the shower would not be considered sexual unless it was intentional. She stated she had been texting with Resident #7 and the resident would text her about how he/she was feeling or if he/she wanted her to buy him/her something. CNA #24 stated she sent Resident #7 pictures of herself and her kids, family type pictures; however, now that she had researched it, she realized maybe she should not have done that. She stated she also sent Resident #7 pictures of herself fully clothed so the resident could show his/her aunt what she looked like. The CNA stated she wished she had known that her friendship with Resident #7 was not appropriate. CNA #24 stated there had never been any kissing or nude photos involved. She stated she was told Resident #7 reported he/she was being taken advantage of by her and he/she was vulnerable. The CNA stated they told her Resident #7 said she walked in on him/her in the shower, and she acknowledged she had walked in on the resident in the shower by accident before. She further stated, knowing what she knew now, she would never have let Resident #7 have her phone number, would never have sent him/her photos, and would never have sent text messages to him/her. During an interview with LPN #11, on 07/28/2023 at 4:00 PM, she stated she worked as the night shift supervisor on the 11:00 PM to 7:00 AM shift and had been employed by the facility for three (3) years. She stated she had been trained on abuse by the DON and ADON almost daily for the last several weeks, and verbalized the different types of abuse, including sexual. She stated if an allegation of abuse occurred, staff were to immediately contact the ED who would then contact the DON, who was supposed to start an investigation and suspend the worker during the investigation. LPN #11 stated she overheard staff talking about an aide (CNA #24) on the Lotus Unit who was going into Resident #7's room when the aide was not assigned to work that unit, and was calling the resident on phone. She stated she also heard the aide looked Resident #7 up on Facebook and started having an inappropriate relationship with the resident that involved sending sexual pictures to him/her. The LPN stated when she heard about the relationship, she contacted the DON who said they already knew about it the week before and the ED was already investigating it. She stated she wrote a signed statement on 07/25/2023 at 12:14 AM, and gave it to the DON at the end of her shift In continued interview with LPN #11, on 07/28/2023 at 4:00 PM, she stated the week before the DON and ED moved CNA #24 to another unit to prevent her from having contact with Resident #7. The LPN stated however, on night shift on 07/23/2023, CNA #24 was assigned to work another unit, but she kept seeing the CNA coming in and out of Resident #7's room when she was not supposed to be on the unit. The LPN stated LPN #1 asked CNA #24 if she had been reassigned to work the Lotus Unit that night and CNA #24 stated no and left the unit. She stated she and LPN #1 then went to talk with Resident #7 about the relationship between him/her and CNA #24, but the resident stated there was no relationship between them. LPN #11 stated LPN #1 had a better rapport with Resident #7, and asked LPN #11 to leave the room so she could talk to Resident #7. She stated a few minutes later, LPN #1 called her back into Resident #7's room and the resident told her he/she had something going on with CNA #24; however, did not want the relationship anymore because he/she was trying to get clean. The LPN stated Resident #7 told her CNA #24 kept bothering him/her and kept coming into his/her room. LPN #11 further stated Resident #7 told her he/she just wanted CNA #24 to leave him/her alone. During an interview with the ED, on 07/29/2023 at 1:55 PM, he stated he had been a Long Term Care (LTC) Director for fifteen (15) years and had been working as the facility's Interim ED since 06/14/2023. He stated he had been educated on the facility's Abuse Policy by the [NAME] President of Operations (VPO) when he took over as the Interim ED in June. The ED stated staff were to immediately report any signs of abuse to their supervisor or call him since he was the Abuse Coordinator. The ED stated abuse was to be reported in two (2) hours, and the report was to be sent to the State Agency (SA), Adult Protective Services (APS), and the Ombudsman. He stated all staff were responsible for protecting residents from abuse. The ED stated if a staff member was the reported perpetrator in an allegation, the staff member should be escorted out of the facility and suspended immediately pending the outcome of the investigation. He stated an investigation should be started immediately into any and all allegations of abuse and was to be initiated by the DON or ADON. The ED stated written statements and interviews were to be obtained quickly and the Social Worker (SW) was to be involved immediately because it was important for the resident to have another set of ears to listen to them and make sure nothing was being covered up. He stated the SW was to conduct a psychosocial assessment of the resident to determine if the resident had experienced harm, such as potential psychosocial harm. In continued interview with the ED, on 07/29/2023 at 1:55 PM, he stated on 07/20/2023 he received an anonymous call saying nude pictures had been sent to a resident (Resident #7) by somebody identified by first name only, no last name given. He stated after he received the call, he tried to figure out who the staff member was, and notified the Human Resource (HR) department who tried to find out who all the staff members with the identified first name were working. The ED stated he interviewed Resident #7 and the resident denied anything had occurred and he/she stated he/she had not been abused. The ED stated after discussing the incident with the Corporate [NAME] President of Operations (VPO), they decided the incident was not reportable because everyone denied there being a relationship or that abuse had occurred on 07/20/2023. He stated the facility had not sent in a reportable on 07/20/2023, because after hearing the relationship between Resident #7 and CNA #24 was consensual, and since the resident had a BIMS of fourteen (14) and denied any abuse, feeling stressed, or coerced, they felt it had not rose to the level of being reportable. The ED stated on 07/24/2023, a second allegation came in involving the same individuals, and he and the DON questioned Resident #7 again; however, the resident again told them he/she was fine and did not feel abused. The ED stated he again called HR to discuss what should be done about the second allegation. He stated he was told the allegation was not abuse and not reportable because the resident denied it happened. In further interview on 07/29/2023 at 1:55 PM, the ED stated on 07/26/2023, Resident #7 confided in his/her Peer Support Specialist (PSS) in the Lotus Program and a lot more information came out then. The ED stated the Interdisciplinary Team (IDT) met as a QA team on 07/26/2023, and that was when it was determined an investigation should be cited. He stated on 07/26/2023, it was determined the facility should have reported the incidents that occurred on 07/20/2023 and 07/24/2023 immediately to the State Agency as abuse and investigations should have been started. The ED stated he was not aware CNA #24 had been told to stay off the Lotus Unit where Resident #7 resided, and was not aware she worked two (2) more shifts at the facility after the 07/20/2023 allegations were made. He stated, in thinking about the 07/20/2023 incident, obviously the facility should have made a very different decision regarding the allegation, and it should have been reported because a caregiver in any role allegedly sending nude pictures to a resident was considered abuse. The ED stated he expected all facility staff to follow the abuse process and policy and expected them to report abuse without fear of retaliation. Additionally, he stated he felt the IDT had met substantially and had a QAPI meeting to discuss other concerns but had not specifically discussed the incidents involving Resident #7 and CNA #24. During an interview with the DON on 07/29/2023 at 2:47 PM, she stated she had been the DON at the facility since May 2023, and had been educated on abuse by the SDC multiple times since then. The DON stated sending pictures was not inappropriate if the individuals were involved in a consensual relationship. She stated on 07/20/2023, the ED told her he received an anonymous call who said an employee only known has first name only had been sending inappropriate pictures to Resident #7. She stated she did not report the allegation to the State Agency (SA), Adult Protective Services (APS), or the Ombudsman because the ED already knew about it. The DON stated the facility started an investigation immediately by contacting HRD because they did not know who the staff member was since the caller only identified her by first name. She stated she, the HRD, and ED interviewed Resident #7 and the resident denied everything and said he/she had not been abused. The DON stated she and the HRD started interviewing all the staff members that had the identified first name that was provided by the anonymous caller. Per the interview, CNA #24 was interviewed; however, denied calling, texting, or sending any pictures to Resident #7. She stated she did not know why the facility should have reported the allegation because Resident #7 denied the relationship occurred and the resident had a BIMS score of fourteen (14), and had the right to a consensual relationship. In continued interview with the DON, on 07/29/2023 at 2:47 PM, she stated on 07/26/2023, the PSS for the Lotus Program came to the ED and told him Resident #7 had not been honest in his/her interviews and admitted to being involved in a friendship with CNA #24. The DON stated Resident #7 told the PSS the CNA had walked in the shower room a few times when he/she was unclothed and showering, and gave the name of who the CNA was (CNA #24). She stated after receiving the information from the PSS, we started resident interviews, skin assessments, and called CNA #24. The DON stated she felt the facility had conducted a thorough investigation because they had interviewed Resident #7 and interviewed every staff member with the first name only and all those interviewed denied everything. She stated she guessed however, the relationship between CNA #24 and Resident #7 should have been reported on 07/20/2023, when the initial call came in because it was an allegation of abuse. In further interview on 07/29/2023 at 2:47 PM, the DON stated on 07/26/2023, LPN #11, the nighttime supervisor, called her after midnight and told her an aide had been at the desk and said a staff member identified by first name only, was in a relationship with a resident, Resident #9, but at the time she thought all the staff were just gossiping. The DON stated she asked LPN #11 to call the ED and go interview Resident #9. She stated she was on the phone when LPN #11 interviewed Resident #9 and the resident just laughed and said he/she was not involved with a staff member. The DON stated Resident #9 wrote a statement and signed it, and said he/she did not know what they were talking about. According to the DON, LPN #11 called her back later and said the staff member got the resident's name wrong and it was actually Resident #7. Further, on 07/29/2023 at 2:47 PM, the DON stated she told LPN #11 it sounded like staff were just gossiping and got the information wrong because she and the ED had already investigated that allegation. The DON stated LPN #1 later talked to Resident #7, and he/she admitted to the LPN he/she had been involved in a friendship with CNA #24. She stated at that point, she and the ED went and interviewed Resident #7 again and he/she admitted he/she and CNA #24 were just friends. The DON stated on 07/27/2023, Resident #7 then told the PSS in the Lotus Program what had happened between him/her and CNA#24. She stated she did not think Resident #7 was a victim, and felt the resident manipulated CNA #24 and since they were both adults they had the right to a consensual relationship. The DON stated all staff were to report abuse immediately so an investigation could be initiated, and the two (2) hour reporting time frame meant the facility had two (2) hours to investigate an abuse allegation before reporting it to the State Agency (SA), APS, and the Ombudsman. She stated all staff and residents should be able to report allegations of abuse without fear of retaliation. She further stated the QA team was meeting almost daily to discuss abuse; however, had not discussed the 07/20/2023 incident, as they had determined the allegation was not abuse. During an interview with the VPO, on 07/29/2023 at 3:35 PM, he stated an anonymous call was received on 07/20/2023, regarding an inappropriate relationship between a staff member and a resident should not have been reported because Resident #7 had a BIMS score of fourteen (14) which indicated the resident was of sound mind, and he/she had the right to have a relationship of his/her own choosing. The VPO stated Resident #7 was interviewed about the incident several times and said nothing inappropriate was going on every time. According to the VPO, all staff members with the first name provided by the anonymous caller were interviewed, and they all said they had not had an inappropriate relationship with a resident. She stated Resident #7 later told his/her counselor in the Lotus Program that a CNA made him/her uncomfortable when she came in when he/she was showering. The VPO stated we found out it was CNA #24, and the management team viewed the text messages in which Resident #7 stated over and over that he/she wanted a relationship with the CNA. He stated based on the text messages the incident was not a reportable event. The VPO stated the facility's process was for any allegation of abuse to be reported timely by the definition of the State Operations Manual (SOM), which would be within two (2) hours. He stated the Abuse Coordinator or designee should report abuse immediately; however, anyone could report an abuse allegation. In addition, the VPO further stated staff should be able to report without fear of retaliation to ensure the safety of all residents. During an interview on 08/09/23 at 10:43 AM, the Regional Human Resource Business Partner (RHSBP) stated her responsibilities included being involved in assisting with investigations, compliance, and development of leadership. She stated she was made aware the end of July, by the ED and DON, of an inappropriate relationship involving Resident #7 and CNA #24. The RHSBP stated the ED said he had gotten a call, on 07/20/2023, about a possible allegation of a relationship with a staff member involving nude pictures and a resident and did not know what do. She stated she did not know the protocol; however, told them the allegation might be a reportable incident and informed the ED and DON they should do whatever needed to be done on that side of things. The RHSBP stated she told them they needed to launch an investigation and the ED sa[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility documents and policy, it was determined the facility failed to ensure allegations of sexual and physical abuse were reported to State Agencies and local law authorities immediately, but no later than two (2) hours after the allegations were made for two (2) of thirty-nine (39) sampled residents ( Residents #7 and #1). 1. On 07/20/2023 the Executive Director (ED) received an anonymous call reporting an inappropriate relationship between a staff member and Resident #7 that involved text messages and nude photos. Review of the facility's documentation; however, revealed the facility failed to notify/report the allegations of potential abuse to the state agencies and law enforcement, to protect its resident, even though staff had been trained on abuse to include reporting requirements. 2. On 12/10/2022 Resident #1 ran into the hallway yelling help me, she is hitting me. However, LPN #11 failed to report the allegation as abuse. The facility's failure to ensure allegations of sexual and physical abuse were reported to State Agencies and local law authorities immediately has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 07/29/2023 at 483.12 Freedom from Abuse, Neglect, and Exploitation (F600), at the highest Scope and Severity (S/S) of a K; 483.12 Freedom from Abuse, Neglect, and Exploitation (F607 & F609), at the highest S/S of a J; Substandard Quality of Care (SQC) was identified at 42 CFR 483.12, Free from Abuse, Neglect, and Exploitation (F600). The Immediate Jeopardy was determined to exist on 07/20/2023. The facility was notified of the Immediate Jeopardy on 07/29/2023. IJ is ongoing. The findings include: Review of the facility's, Compliance and Ethics - Communication Policy dated December 2020, revealed the Compliance and Ethics Committee was responsible for establishing, implementing and overseeing the methods by which information associated with the Compliance and Ethics Program were communicated. Continued review revealed employees were encouraged to report suspected civil, criminal or administrative violations to the Compliance and Ethics Committee and were protected from retaliation and retribution. Review revealed internal and external reporting systems had been established and could be accessed anonymously. Per policy review, reporting systems included: an internal tollfree reporting hotline; a landing page on the company's intranet with information and tools for reporting; the name and address for sending written reports to the Compliance Officer; names and contact information of the State Survey Agency, and Ombudsman program. Further review revealed all pertinent information regarding how and where to report were prominently posted in a notice approved by the Compliance and Ethics Committee; and all reports of suspected violations were reviewed by the Compliance and Ethics Committee. In addition, review revealed investigations were conducted as necessary to address any allegations that were deemed credible. Review of the facility's, Freedom from Abuse and Neglect Policy, undated, revealed all residents would be protected from harm, and all allegations involving staff was to necessitate suspension pending investigation. Per facility policy, the definition of abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Continued review revealed staff members were to identify and assess suspected or alleged reports of abuse and neglect. Review of the facility's, Abuse Prevention Program Policy revised December 2016, revealed in the Policy Statement, residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Continued review revealed as part of the resident abuse prevention, the administration was to protect residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. 1. Review of Resident #7's admission Record revealed the facility admitted the resident on 05/29/2023 with diagnoses to include Osteomyelitis, Anxiety, Opioid Abuse, and other Stimulant Abuse. Review of Resident #7's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Review of the facility's Alleged Abuse Investigation Nursing Incident Description note dated 07/26/2023 at 6:26 PM, entered by the Director of Nursing (DON), revealed the Executive Director (ED) received an anonymous call on 07/20/2023, stating Resident #7 was involved in a relationship with a staff member known by first name only. Per review, the caller was unable to give a description of or last name of the employee. Continued review revealed the caller stated the employee and resident had been texting and sending inappropriate pictures via text messages. Review revealed Resident #7 was interviewed at the time and denied any inappropriate relationship with a staff member or receiving any inappropriate pictures via text messages. Review further revealed the Human Services Director (HSD) and DON interviewed all employees with the first name identified by the anonymous caller, and all denied any inappropriate relationship with a resident or sending inappropriate pictures. Review of the Alleged Abuse Investigation Nursing Incident Description note, Facility Resident Description section review revealed Resident #7 was interview on 07/20/2023. Further review of the Alleged Abuse Investigation Nursing Incident Description note dated 07/26/2023 at 6:26 PM, revealed Resident #7 spoke with the Peer Support Specialist (PSS) and stated he/she had not been honest when first interviewed. Review revealed Resident #7 told the PSS he/she did have a friendship with Agency CNA #24, and attempted to cut the relationship off; however, the CNA came to his/her room and in the shower room which made him/her feel uncomfortable. Per review, Resident #7 stated he/she realized now he/she was in a vulnerable state due to his/her sobriety and thought he/she could handle the situation on his/her own. Review of the Facility Resident Description section review revealed on 07/26/2023 Resident #7 told the PSS CNA #24 kept coming to his/her room and coming in the shower room when he/she did not require assistance. Continued review of the Facility Resident Description revealed Resident #7 stated CNA #24 never physically touched him/her; however, she just made him/her feel uncomfortable. In addition, review of the facility's Alleged Abuse Investigation Immediate Action Taken Description section dated 07/26/2023 at 6:26 PM, revealed CNA #24 was removed from the schedule and the CNA's agency notified of the allegations and that the employee would no longer be able to pick up shifts at the facility. Further review revealed on 07/26/2023 Resident #7 received a psychiatric (psych) telehealth visit to ensure he/she was not having any psychosocial distress and his/her Care plan was review and updated with an intervention to monitor for signs and symptoms (s/s) of psychosocial distress. Observation on 07/27/2023 at 9:00 AM, revealed Resident #7 fully and appropriately dressed lying on his/her bed awake. In an interview at the time of observation Resident #7 stated CNA #24 sent him nude photos of herself on his/her phone using Snapchat (a social media app). Resident #7 stated at first their relationship was consensual and as friends because it was nice to have someone to talk to as he/she had no family or friends. The resident stated the relationship progressed and CNA #24 kissed him/her which made the resident uncomfortable. Resident #7 stated he/she told CNA #24 he/she did not feel comfortable having that kind of relationship because of being in treatment for his/her addiction, and he/she needed to continue to work the program to recovery before having an intimate relationship with anyone. The resident stated however, CNA #24 continued to send nude photos of herself after being told to stop and woke him/her at all hours of the night coming into his/her room when she worked her shifts at the facility. Resident #7 stated he confided in two (2) other residents on his/her unit regarding his/her concerns and the other residents asked to see the photos. The resident stated he/she showed the other residents the photos, and told them he/she told CNA #24 to stop because it was making him/her uncomfortable because she was coming into his/her room at night and entering the bathroom when he/she was showering. Resident #7 stated CNA #24 entered the shower room multiple times when he/she was in there even though the resident kept telling her to stay out of the shower. In continued interview on 07/27/2023 at 9:00 AM, Resident #7 stated a rumor had gotten out all over the community about what was going on and the DON and the HR person called him/her into their offices to talk about the incidents. The resident stated he/she only admitted to the shower incidents because he/she was embarrassed and ashamed about the photos and did not want to get CNA #24 in trouble. Resident #7 stated he/she was afraid if he/she told the truth about the texting and photos, the facility would move him/her out, and he/she really liked it there and wanted to finish out his/her program. The resident stated the photos of CNA #24 topless, showing her bare breasts were sent through a social media app called Snapchat and the photos deleted after twenty-four (24) hours. Resident #7 stated he/she was now feeling harassed by CNA #24 because of her continuing to come to his/her room late at night and by her entering the shower room when he/she was unclothed and showering. The resident stated CNA #24 entered his/her room the other night on the 7:00 PM to 7:00 AM shift when she was not even assigned to work the Lotus Unit. Resident #7 stated LPN #1 saw CNA #24 coming in and out of his/her room that night and asked the CNA why she was on the unit when she was supposed to be working on another unit. Resident #7 stated after the incident, LPN #1 and LPN #11 came in and talked with him/her about why CNA #24 was in his/her room, and the resident told them the CNA would not leave him/her alone. The resident stated he/she told the LPN's about the shower incidents and that he/she was feeling harassed, shamed, and embarrassed by CNA #24 and by the facility managers who kept asking him/her about the relationship. Resident #7 further stated he/she did not want to get CNA #24 in trouble or cause her to get fired; however, just wanted her to leave him/her alone. In a phone interview on 07/27/2023 at 8:00 PM, LPN #1 stated she had been working on the Lotus Unit where Resident #7 resided since February 2023. She stated she worked at a jail for fifteen (15) years prior to coming to work at the facility, and had a lot of experience working with clients who had substance abuse problems. LPN #1 stated she overheard staff talking on the unit on 07/24/2023, about something going on between CNA #24 and Resident #7. She stated her supervisor LPN #11 was there at the time, and she asked her if that information should be reported. LPN #1 stated her supervisor agreed it should be reported and made a call to the DON that night to report CNA #24 and Resident #7 being in a relationship. She stated she and LPN #11 went to talk with Resident #7 after hearing of the relationship, and the resident said he/she and CNA #24 had been talking, but he/she decided to cut it off. LPN #1 stated Resident #7 told them CNA #24 then started harassing him/her and invading his/her space. She stated she had Resident #7 sign a written statement which she gave to the Assistant Director of Nursing (ADON) at the end of her shift that morning. LPN #1 stated Resident #7 said he/she ended the relationship because he/she needed to work on his/her sobriety and CNA #24 did not accept it well. She stated Resident #7 told her he/she was embarrassed and uncomfortable talking about the relationship with CNA #24. In continued phone interview on 07/27/2023 at 8:00 PM, LPN #1 stated Resident #9 and Resident #13 told her CNA #24 had been harassing Resident #7 and told her there were pictures sent by CNA #24 on Resident #7's phone. LPN #1 stated she saw CNA #24 enter Resident #7's room on the Lotus Unit in the middle of the night when she was not assigned to the unit. She stated the DON knew about all of this and did not interview Resident #7 because she told the ADON to interview him/her. LPN #1 stated she tried to tell Resident #7 he/she was the victim in the situation and he/she needed to be honest and report it. She stated she reported the information to Unit Manager/Infection Prevention Nurse (UM/IP) #1 and Registered Nurse (RN) #2 who both defended CNA #24 and said Resident #7 was manipulating and taking advantage of the CNA. LPN #1 stated they made Resident #7 the perpetrator in the situation and revised his/her care plan to make the resident care in pairs and for seeking relationships with staff. In interview on 07/27/2023 at 8:50 PM, RN #3 stated she had been at the facility for almost two (2) years, and primarily worked the Lotus Unit. RN #3 stated there was an inappropriate physical relationship between CNA #24 and Resident #7, where the CNA was pursuing the resident and always going to his/her unit and into his/her room. The RN stated CNA #24 would constantly be wherever Resident #7 was and was always in his/her space. RN #3 stated she first heard about the inappropriate relationship between CNA #24 and Resident #7 about two (2) weeks ago and told the DON. She stated the DON said she would take care of it; however, RN #3 said she could not see where anything had happened after she reported the incident to the DON. The RN stated after a week went by, she heard about photos on Resident #7's phone. She stated Resident #9 reported having seen photos and text messages CNA #24 had sent to Resident #7, which included a naked photo. RN #3 stated after reporting the inappropriate relationship to the DON she started to received a lot of backlash from the DON, ADON, and the Unit Manager. She stated they gave her a lot a papers back to redo and said she was not doing her job. The RN stated after the backlash started she was too scared to say anything to the DON about the photos when she found out about them, so she told her brother about the relationship and he reported it in anonymously to the ED. In continued interview on 07/27/2023 at 8:50 PM, RN #3 stated she again noticed nothing was being done about the inappropriate relationship so she decided to make an anonymous call to the State to report it herself. She stated after it came out about the photos, Resident #7 was telling other residents and staff the facility's management team was badgering him/her and harassing him/her about it. According to RN #3, there were rumors all over the facility about what was going on with Resident #7 and CNA #24; however, none of the staff were doing anything about it. The RN stated Resident #7 was telling everyone CNA #24 was calling and texting his/her phone and harassing him/her and he/she just wished it would stop. RN #3 stated the Unit Manager told staff Resident #7 was a manipulator, and he/she would lie on staff and how was the management team to know that CNA #24 was not the victim in the situation. She further stated they made the victim, Resident #7, into the guilty party. In interview on 07/28/2023 at 2:45 PM, CNA #24 she stated she had been a CNA for fifteen (15) years and had worked at the facility through a staffing agency staff for about two (2) months. CNA #24 stated she had heard rumors she was having a relationship with a resident, came on to Resident #7, and was showing favoritism to him/her. She stated Resident #7 wanted to have a relationship, and she wanted to call the resident to set him/her straight. The CNA stated she had texted with Resident #7 and he/she also texted her, and sent a picture of his/her daughter and a shirtless picture of himself/herself to show he/she was gaining weight. CNA #24 stated she sent him/her pictures of herself and her kids, family type pictures; however, realized maybe she should not have done that. She stated the DON called her on Wednesday and said Resident #7 said he/she was being taken advantage of and he/she was vulnerable. The CNA stated she was told Resident #7 said she walked in on him/her in the shower, and she said she had done so by accident. CNA #24 stated the only time she visited Resident #7 in the middle of the night was if he/she asked her for something, and she stopped doing that because she did not feel like it was appropriate to go into his/her room late at night. In interview on 07/28/2023 at 4:00 PM, LPN #11 stated she worked as the night shift supervisor on the 11:00 PM to 7:00 AM shift and had been employed by the facility for three (3) years. LPN #11 stated if abuse allegations occurred staff were to immediately contact the ED who would then contact the DON, who who was supposed to start an investigation and suspend the worker during the investigation. LPN #11 stated she felt comfortable reporting allegations of abuse to the DON or ED. She stated she heard staff talking about an aide (CNA #24) being on the Lotus Unit and going into Resident #7's room when the aide was not assigned to work that unit and was also calling the resident on phone. The LPN stated she heard the aide looked Resident #7 up on Facebook and started having an inappropriate relationship with the resident that involved sending sexual pictures to the resident. She stated when she heard about the relationship, she contacted the DON who said they already knew about that information a week ago, and the DON told her the ED was already investigating it. LPN #11 stated she wrote a signed statement on 07/25/2023 at 12:14 AM, and gave it to the DON at the end of her shift. In continued interview on 07/28/2023 at 4:00 PM, LPN #11 stated the DON and ED moved CNA #24 to another unit the week before to prevent her from having contact with Resident #7; however, on 07/23/2023, she kept seeing the CNA going in and out of Resident #7's room. She stated she and LPN #1 went to talk with Resident #7 about the relationship and the resident said there was no relationship between him/her and CNA #24. The LPN stated LPN #1 had a better rapport with Resident #7, and asked her to leave the room so she could talk to the resident. She stated a few minutes later, LPN #1 called her back and Resident #7 told her he/she did have something going on with CNA #24; however, did not want it anymore because he/she was trying to get clean. LPN #11 stated Resident #7 reported CNA #24 kept bothering him/her and kept coming into his/her room. She stated the resident said he/she did not want to get anyone in trouble and that's why he/she had not said anything. The LPN further stated Resident #7 told her he/she just wanted CNA #24 to leave him/her alone. In interview on 07/29/2023 at 1:55 PM, the ED stated staff were to immediately report any signs of abuse to their supervisor or call him since he was the Abuse Coordinator. The ED stated abuse was to be reported in two (2) hours, and the report was to be sent to the State Agency (SA), Adult Protective Services (APS), and the Ombudsman. The ED stated on 07/20/2023 he received an anonymous call saying there were nude pictures which had been sent to a resident (Resident #7) by somebody only identified by her first name, no last name given. He stated Resident #7 and CNA #24 were interviewed and denied a relationship. The ED stated after discussing the incident with the Corporate VPO, they decided the incident was not reportable because everyone denied there being a relationship or that abuse had occurred on 07/20/2023. The ED stated the facility had not sent in a reportable on 07/20/2023, because after hearing the relationship between Resident #7 and CNA #24 was consensual, and since the resident had a BIMS of fourteen (14) and denied abuse, feeling stressed, or coerced, they felt it had not rose to the level of being reportable. In continued interview on 07/29/2023 at 1:55 PM, the ED stated a second allegation came in involving the same individuals on 07/24/2023, and he and the DON questioned Resident #7 again; however, the resident again said he/she was fine and did not feel abused. The ED stated he called HR to discuss what should be done about the second allegation and was told the allegation was not abuse and not reportable because the resident denied it happened. He stated on 07/26/2023, Resident #7 confided in his/her Peer Support Specialist (PSS) and a lot more information came out, and the Interdisciplinary Team (IDT) met as a QA team, and determined an investigation should be started. The ED stated after being made aware on 07/26/2023, of the 07/24/2023 allegation, it was determined the facility should have reported the incidents which occurred on 07/20/2023 and 07/24/2023 immediately to the State Agency as abuse. He stated in thinking about the 07/20/2023 incident, obviously we should have made a very different decision regarding the allegation, and it should have been reported because a caregiver in any role allegedly sending nude pictures to a resident was considered abuse. The ED further stated he expected all facility staff to follow the abuse process and policy. In interview on 07/29/2023 at 2:47 PM, the DON stated on 07/20/2023, the ED told her he received an anonymous call who said an employee identified by her first name had been sending inappropriate pictures to Resident #7. She stated she did not report the allegation to the State Agency (SA), Adult Protective Services (APS), or the Ombudsman because the ED already knew about it. The DON stated she did not know why the facility should have reported the allegation because Resident #7 denied the relationship occurred and the resident had a BIMS score of fourteen (14), and he/she had a right to a consensual relationship. She stated she did not think Resident #7 was a victim, and felt the resident manipulated CNA #24 and since they were both adults, they had the right to a consensual relationship. The DON stated she guessed the relationship between CNA #24 and Resident #7 should have been reported on 07/20/2023 though, when the initial call came in because it was an allegation of abuse. The DON stated all staff were to report abuse immediately so an investigation could be initiated, and the two (2) hour reporting time frame meant the facility had two (2) hours to investigate an abuse allegation before reporting it to the State Agency (SA), APS, and the Ombudsman. She further stated the QA team was meeting almost daily to discuss abuse; however, had not discussed the 07/20/2023 incident, as they had determined the allegation was not abuse. In interview on 07/29/2023 at 3:35 PM, the VPO stated the anonymous call received on 07/20/2023, regarding an inappropriate relationship between a staff member and a resident should not have been reported because Resident #7 had a BIMS score of fourteen (14) which indicated the resident was of sound mind, and he/she had the right to have a relationship of his/her own choosing. The VPO stated Resident #7 was interviewed about the incident several times and said nothing inappropriate was going on every time. The VPO stated we found out it was CNA #24, and the management team viewed the text messages in which Resident #7 stated over and over that he/she wanted a relationship with the CNA. He stated based on the text messages the incident was not a reportable event. The VPO stated the facility's process was for any allegation of abuse to be reported timely by the definition of the State Operations Manual (SOM), which would be within two (2) hours. He stated the Abuse Coordinator or designee should report abuse immediately; however, anyone could report an abuse allegation. In interview on 08/09/23 at 10:43 AM, the Regional Human Resource Business Partner (RHSBP) stated she was made aware the end of July, by the ED and DON, of an inappropriate relationship involving Resident #7 and CNA #24. The RHSBP stated she did not know the protocol, and that the allegation might be a reportable incident and informed the ED and DON they needed to do whatever needed to be done on that side of things. The RHSBP stated when the anonymous call with the allegation came through on 07/20/2023, it should have been reported based on the facility's policy. She stated that was what she told the ED, and she was not aware it had not been reported by the facility. The RHSBP stated she received another call on 07/26/2023, involving another allegation with the same resident and staff member and both admitted to the allegation at that time. She further stated staff had not been following the facility's policies but should have been doing so. 2. Review of Resident #1's admission Record revealed the facility had admitted the resident on on 2/16/2022, with diagnoses to include Cognitive Communication Deficit, Unspecified Severe Protein-Calorie Malnutrition, Alzheimer's Disease, and Dementia. Review of Resident #1's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of seven (7) out of fifteen (15), indicating severe cognitive impairment. Review of the facility's Incident Report dated 12/12/2022 at 10:13 PM, revealed on 12/10/2022, Resident #1 came out of his/her room naked, saying please help me she hit me. Continued review revealed LPN #11 and CNA #33 assisted Resident #1 back to the room, dressed the resident, and helped him/her back to bed. Review of the Resident Description section revealed staff attempted to interview Resident #1, and the resident could not recall any events and denied any pain or discomfort, and no injuries were observed at time of incident. On 12/10/2022 CNA #33 told LPN #11 Resident #1 ran into the hallway yelling help me, she is hitting me. However, LPN #11 failed to report the allegation of abuse. (What document is it from? Progress Note? Incident Report? Please identify that source) Review of the Email submission sent by the ADON, revealed the incident had not been reported to the State Agency until 12/12/2022 at 10:07 PM. During an interview with LPN #11 on 7/18/2023 at 10:31 AM, she stated she had been in another resident's room administering medications, and when she exited the room she saw Resident #1 standing in the hallway naked. She stated CNA #33 walked up and assisted her in taking Resident #1 back into his/her room. LPN #11 stated they assisted Resident #1 to get dressed and back to bed. She stated CNA #33 then told LPN #11 she heard Resident #1 yelling Help me, she hit me. LPN #11 stated she did not hear Resident #1 say that so she did not report the incident. She stated she should have reported the incident even though she had not heard the resident yelling Help me, she hit me. She further stated any allegations of abuse should be reported immediately to the ED. During an interview with the Assisted Director of Nursing (ADON), on 7/18/2023 at 12:03 PM, she stated the unit manager, who was now the DON, called her on 12/12/2022 and asked her if she knew about an incident involving Resident #1 and asked if it had been reported. The ADON stated the now DON (former unit manager) said, CNA #33 told her Resident #1 came running into the hallway yelling Help me, she hit me on 12/10/2022. She stated she told the current DON/former unit manager she did not know about the incident. The ADON stated she reported the incident to the SA on 12/12/2022, after she being informed of the allegation of abuse. She stated LPN #11 should have reported the allegation of abuse to management immediately. The ADON further stated it was her expectation all staff follow the facility's abuse policy. During an interview with the current Director of Nursing (DON) on 07/19/2023 at 1:07 PM, who had been employed as the unit manager at time of the allegation, stated she became aware of the incident on 12/12/2022 when CNA #33 told her. She stated CNA #33 told her Resident #1 came running into the hallway yelling, Help me, she hit me. The DON stated LPN #11 should have notified the abuse coordinator immediately at the time CNA #33 informed her of the incident. The DON further stated all staff were to report allegations of abuse immediately to the ED even if they did not see it or hear it. During an interview with the Executive Director (ED) on 07/19/2023 at 1:21 PM, he stated the process for reporting allegations of abuse was to report all allegations immediately, and the facility had two (2) hours to report to the State Agency. The ED further stated the incident involving Resident #1 should have been reported immediately and staff had not followed the facility's policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of the facility's policy, it was determined the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice, that would meet the resident's physical, mental, and psychosocial needs for one (1) of thirty-eight (38) sampled residents (Resident #48). On 05/29/2023, Resident #48 was found by the driver of a transportation company seated in the lobby of the facility in his/her wheelchair, alone and unresponsive. The driver of the transportation company attempted to locate the facility staff but was unable to locate staff to assist the resident, and he attempted to call the facility several times and no one answered the phone. Subsequently, the driver of the transportation company drove the resident to his/her dialysis appointment, which was approximately eight (8) minutes away from the facility. Once the resident arrived at the dialysis clinic, the transportation driver alerted the dialysis staff to assist the resident who was assessed as being unresponsive and sweating profusely. The dialysis clinic staff called 911 immediately and the resident was admitted to the hospital with diagnoses to include Altered Mental Status, Pulmonary Edema (a condition where fluid accumulates on the lung tissue), and respiratory distress. The facility's failure to ensure residents received treatment and care in accordance with professional standards of practice has caused or is likely to cause serious harm or serious injury, impairment, or death to the residents if immediate action was not taken. Immediate Jeopardy (IJ) was identified on 08/11/2023 at 42 CFR 483.25 Quality of Care (F684) at the highest S/S of a J and was determined to exist on 05/29/2023 and is ongoing. The facility was notified of the Immediate Jeopardy on 08/11/2023. In addition, Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F684). The findings include: Review of the facility's policy titled, End-Stage Renal Disease, Care of a Resident with, revised September 2010, revealed residents with end-stage renal disease would be cared for according to currently recognized standards of care. Policy interpretation and implementation revealed that staff caring for residents with End-Stage Renal Disease (ESRD), including residents receiving dialysis care outside the facility, would be trained in the care and special needs of the residents. Education and training of staff included, specifically, a.) the nature and clinical management of ESRD (including infection prevention and nutritional needs); b.) signs and symptoms of worsening condition and/or complications of ESRD; c.) how to recognize and intervene in medical emergencies such as hemorrhages and septic infections; d.) timing and administration of medications, particularly those before and after dialysis; e.) the care of grafts and fistulas; and f.) the handling of waste. Review of the facility's policy titled, Change in Residents Condition or Status, revised February 2021, revealed the facility would promptly notify the resident, his or her attending physician, and the resident's representative of changes in the resident's medical/mental condition and/or status. Continued review revealed the nurse would notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. Further review revealed a significant change of condition was a major decline or improvement in the resident's status that would not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (was not self-limiting) or impacted more than one area of the resident's health status. Per the policy, prior to notifying the physician or healthcare provider, the nurse would make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact Situation-Background-Assessment-Recommendation (SBAR) Communication Form. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 2001, revised March 2022, revealed the purpose of the comprehensive, person-centered care plan was to describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the resident's care plan would reflect currently recognized standards of practice for problem areas and conditions. Continued review revealed care plan interventions were chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision-making. Review of Resident #48's admission Record revealed the facility had admitted the resident on 06/21/2020 with diagnoses to include End Stage Renal Disease (ESRD) stage 5; Diabetes Mellitus (DM), Congestive Heart Failure (CHF), Hypertension (HTN), Peripheral Vascular Disease (PVD), Right Above the Knee Amputation (RAKA), and Dysphagia. Review of Resident #48's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the facility had assessed the resident to have a Brief Interview for Mental Status score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Continued review of the MDS revealed the facility assessed Resident #48 to require extensive assistance of one (1) staff for bed mobility, dressing, toilet use (incontinent of bowel and bladder), personal hygiene; supervision of one (1) staff assistance for locomotion in his/her wheelchair on/off unit; setup supervision of one (1) staff for eating and bathing; extensive assistance of two (2) staff for transfers with the use of a mechanical lift. A continued review of Resident #48's MDS of special treatments revealed the resident had a diagnosis of End Stage Renal Disease (ESRD) with dependence on Hemodialysis (HD). Review of Resident #48's Comprehensive Care Plan, revealed Focus #1 to include the resident needed Dialysis HD related to ESRD with interventions that included: a Dietician consult; do not draw blood from or take blood pressure (BP) in arm with graft; monitor intake and output, monitor labs and report to the physician as needed, monitor vital signs as ordered and notify the physician of significant abnormalities, monitor/document/report as needed any signs/symptoms of infection; monitor/document/report as needed any signs/symptoms of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds, bleeding, hemorrhage, bacteremia, and septic shock. Further review of Resident #48's Comprehensive Care Plan, initiated on 12/27/2022, revealed the resident was care planned for altered respiratory status/difficulty breathing related to a history of Congestive Heart Failure. The goal of the care plan included: the resident would have no s/signs and symptoms of poor oxygen absorption through the review date. Further review of the care plan revealed interventions included: Administer medication/puffers as ordered; monitor for effectiveness and side effects; assist the resident/family/ caregiver in learning signs of respiratory compromise; elevate head of bed (HOB) to prevent shortness of breath (SOB) while lying flat. Continued review of the resident's Comprehensive Care Plan related to altered respiratory status, initiated on 12/27/2022 revealed further interventions to include: monitor /document changes in orientation; increased restlessness; anxiety; and air hunger; monitor for signs and symptoms of respiratory distress and report to the Medical Director (MD) as needed (PRN): when the resident experiences increased respirations; decreased pulse ox; increased heart rate (Tachycardia); restlessness; Diaphoresis (abnormal sweating); Headaches; Lethargy; and Confusion. However, the facility failed to implement the resident's interventions, including continuous monitoring, and assessing the resident for a change in condition, lethargy, and assessing the resident's respiratory by monitoring and documenting the resident's changes in orientation. Review of Resident #48's Advanced Registered Nurse Practitioner (ARNP) Regulatory Visit Note, dated 05/23/2023 at 4:00 PM, revealed the ARNP assessed the resident to have a cough, unspecified, and coughing after every bite of food or drink. Further review revealed the ARNP recommended having the Speech Therapist (ST) evaluate and treat the resident for concerns related to aspiration (when something swallowed goes down the wrong way and enters the airway or lungs). Review of Resident #48's Nurse's Notes dated 05/23/2023 at 7:29 PM, documented by Licensed Practical Nurse (LPN) #18, revealed the resident had a change in condition and was assessed to cough with his/her dinner. Continued review revealed no signs or symptoms (s/s) of distress was noted. Review of Resident #48's Speech Evaluation, dated 05/24/2023, completed by the Speech Language Pathologist (SLP) revealed she assessed the resident for his/her coughing after every bite of food or drink. Further review of the SLP evaluation revealed she recommended no further testing; however, recommended supervision for oral intake and strategic positioning of ninety (90) degrees upright, small bites/sips, thorough chewing, at a slow rate, and avoiding tough consistencies. However, the Speech Language Pathologist's recommendation was not added to the resident's care plan to prevent the resident from aspirating. Review of Resident #48's Nurse's Notes dated 05/29/2023 at 2:16 AM, entered by LPN #17 revealed the resident was resting in his/her bed with no signs and symptoms (s/s) of swelling or pain noted. However, there was no documented evidence to support the LPN implemented the resident's care plan which included assessing the resident for his/her altered mental status, vitals, and/or altered respiratory distress , prior to the resident being transported to his/her dialysis treatment at approximately 6:10 AM. Review of Resident #48's Dialysis Center Note dated 05/29/2023, revealed the resident arrived for his/her treatment at 6:16 AM and was unable to be aroused by multiple staff members. The resident was noted to be sweating profusely and leaning over to his/her right side, his/her tongue was protruding, and he/she had a large amount of drool and chewing tobacco falling from his/her mouth. Further, the resident had respirations of 22 (the normal respiratory rate for an adult is 12 to 20 breaths per minute at rest) and labored. Continued review of the Note revealed the resident did not respond to sternal rub or verbal commands. Staff from the Dialysis Center called 911 for the resident to be transported to the emergency room (ER). Review of Resident #48's Hospital Records dated 05/29/2023, revealed the resident presented to the emergency room (ER) with altered mental status, required fifteen (15) liters (L) of a non-rebreather to maintain a stable oxygen (O2) saturation, the resident's chest x-ray showed diffuse pulmonary edema (fluid on the lungs, making it difficult to breath). Further review of the ER Hospital Record revealed the resident was intubated (ventilation) and placed on the ventilator for airway protection and oxygen support. Resident #48 was diagnosed with acute hypoxemic respiratory failure (not enough oxygen in the blood) from pulmonary edema. During an interview on 08/11/2023 at 11:44 AM, Certified Nursing Assistant (CNA) #33 stated prior to his shift, he would go to the unit supervisor and nurse to get a full report; discuss the residents that were on dialysis, and isolation, had changes in their condition, and anything important about the residents. Also, he would review the resident's [NAME] (the nurse aide's care plan), to provide care to the residents. CNA #33; however, stated he did not recall Resident #48, nor any residents on his shift that had any issues the night/morning of 05/29/2023, or any other time that he could recall. CNA #33 stated he would assist in getting dialysis residents up in the mornings between 4:30 AM to 5:00 AM, provide personal care and assist with dressing and transferring the residents into their wheelchairs. Further, he stated that after the residents were dressed, he would assist with taking the residents to the nurse's station for the nurse to take over the resident's care. Per the interview, the CNA stated the nurse was responsible for assessing and performing vital signs on the residents prior to dialysis. CNA #33 added he had not assisted with the transfer of any dialysis residents to the lobby of the facility, nor stayed to supervise those residents until transportation arrived, adding, that would be the nurses' responsibility. During an interview on 08/11/2023 at 2:21 PM, CNA #32 stated she worked through the agency since May 2023. CNA #32 stated she would not be responsible for assessing the residents for their vital signs. She further stated the nurses would assess the residents. CNA #32 stated if she observed any change in a resident's status; new symptoms, such as a resident not feeling well and/or a change in their mental status, she would advise the nurse. In a continued interview with CNA #32, she stated CNAs would clean the residents, get them up for transfer, take them to the nurses' station and the nurse would take over the resident's care. The CNA stated she could not recall any residents with any problems before leaving for dialysis; however, she did not transfer residents to the lobby area of the facility, nor sit with the residents for pickup. Therefore, she could not say if the residents were experiencing any change in status and/or were in respiratory distress once she left the resident at the nurses' station. The CNA stated she thought it was normal practice; standards of nursing care that residents would be assessed and monitored prior to leaving the facility for an appointment. During an interview on 08/10/2023 at 7:25 PM with LPN#16 (agency nurse), she stated she had worked at the facility a few months and had only worked with Resident #48 a few times. She stated she remembered Resident #48 went to dialysis and that they had to get him/her up with the Hoyer Lift. She stated the process for dialysis residents was to get them up in a wheelchair, give them their snacks before they go, and take them to the lobby to wait for transportation. She stated as the nurse, she was responsible for passing medications, doing treatments, and assisting the aides when needed. She stated she was also responsible for getting the resident's vital signs and putting them in the resident's binder they would take with them to dialysis. She stated she did not have to document the resident's vital signs in Point Click Care (PCC). Per the interview, she stated after the aides got the residents up for dialysis, they would take the residents to the front lobby to wait by the door for transportation to come pick them up. She stated she did not know if anyone had to stay with the resident while they waited for transportation. She stated if a resident appeared to be in distress, she would have called the doctor and the resident would not have been transported to dialysis. During an interview on 08/10/2023 at 3:35 PM with Licensed Practical Nurse (LPN) #17, she stated residents who were on dialysis would be assessed upon return from dialysis. She stated dialysis residents would normally leave between 5:30 AM and 6:30 AM; however, the residents were gone before dayshift clocked in. LPN #17 further stated Resident #48 had a normal mental status and routinely he/she was up and moving in his/her wheelchair. LPN #17 stated prior to sending residents to dialysis, nurses were responsible for completing an assessment. She stated that if any issues during the assessment, such as changes in the resident's condition, which would include the resident being lethargic and unstable vital signs, then the resident would not go to dialysis and the physician would be notified. LPN #17 added, the facility had dialysis binders, that were resident-specific, that were located at the nursing stations with the resident's identity, vital signs, and changes. In addition, LPN # 17 stated she had not assessed the resident on 05/29/2023 and stated it was the night shift nurse's responsibility. She stated she was never informed of any changes or concerns that the resident had the night prior to dialysis on 05/29/2023. During an interview on 08/11/2023 at 2:21 PM with the Transportation Driver, he stated he was familiar with Resident #48 and stated he had been the resident's driver for over two (2) years. Per the interview, the driver stated he transported the resident to the dialysis clinic/center on Mondays, Wednesdays, and Fridays to the Dialysis Center at 6:00 AM. The driver stated the drive from the facility to the dialysis center was approximately nine (9) minutes; therefore, he would arrive at the facility approximately (20) minutes early, to ensure the resident arrived to his/her dialysis appointment on time. In a further interview with the Transportation Driver, on 08/11/2023 at 2:21 PM, he stated on 05/29/2023, he arrived at the facility at approximately 5:40 AM and could visually see Resident #48 sitting in the front lobby, without supervision. He added, the resident appeared to be sleeping with his/her head hung over in the wheelchair; therefore, he attempted to phone the resident several times, as normal routine on his/her cell phone. The driver, however, stated that on this day the resident would not answer his/her calls, as the resident appeared asleep through the front lobby window. Therefore, the driver stated due to him/her not having access to the facility's front door, he attempted three (3) times to call the facility due to no one being with the resident to open the front door, but no staff would answer the phone. Further interview, on 08/11/2023 at 2:21 PM, the driver stated, at approximately 6:01 AM, a staff member opened the facility door to allow the driver into the facility to assist the resident to the van. The driver stated he addressed the resident by stating, hello, however, the resident did not respond. Continued interview with the driver revealed he thought the resident was sleeping. Therefore, the driver stated he continued to transport the resident to the clinic; however, the resident did not interact with the driver during the transport, which was not the resident's normal behavior. Per the interview, the driver stated that once they arrived at the destination, the resident was not responding. He stated the resident was pale and weak and felt something was not right with the resident. The driver stated he immediately made the dialysis staff aware of the resident's condition. During an interview on 08/10/2023 at 2:01 PM with Dialysis Nurse #1, she stated she was Resident #48's nurse on 05/29/2023, at approximately 6:15 AM. Per the interview, she stated the resident was observed in his/her wheelchair slumped over, sweating profusely, and added the resident's shirt was soaked. Further, she stated the resident's skin was cold and clammy, his/her tongue was protruding outside of his/her mouth, as well as drool and chewing tobacco secretions coming out. Dialysis Nurse #1 stated the transportation driver had just dropped the resident off, and she was unsure how long the resident had presented with these types of symptoms. She stated she was unsure if any other nurse at the Dialysis Clinic had received a report from the transportation driver; however, she stated the resident was not responding to her voice nor several staff sternal rub attempts. Dialysis Nurse #1 stated she contacted Emergency Medical Services (EMS) with the resident remained unresponsive. She further stated she attempted to contact the facility several times by phone, to obtain the resident's assessments related to his/her vital signs, mental status, and medication administration, prior to the resident leaving the facility on the morning of 05/29/2023; however, she was unable to reach anyone at the facility. During an interview on 08/11/2023 at 12:11 PM with the Advanced Registered Nurse Practitioner (ARNP), stated she was very familiar with Resident #48 and would provide regulatory visits every month and/or as needed. ARNP stated Resident #48 was readmitted to the facility in May 2023, from the hospital on continuing antibiotics related to pneumonia with a pleural effusion that had not been resolved, and the resident developed a cough that would not subside. The ARNP stated, since Resident #48's return from the hospital she felt the resident was mentally sharp, alert and oriented; however, physically fragile and he/she would attempt to self-propel and stay up in his/her wheelchair most of the day. The ARNP added she was aware Resident #48 chewed tobacco, she was concerned from her regulatory visit/assessment on 05/23/2023, of the resident's cough after every bite of food and/or drink; therefore, she ordered a chest x-ray and consult for a Speech Language Pathologist (SLP) evaluation. In addition, ARNP stated she would have expected the SLP recommendations to be followed through and care planned appropriately and immediately for the safety and wellbeing of her resident. In addition, ARNP stated she also would have expected Resident #48 to have been care planned appropriately for chewing tobacco use related to risk of aspiration. The ARNP stated that since the resident's return from the hospital, he/she had not been himself/herself and was weak and fragile. During an interview on 08/11/2023 at 4:51 PM with the Assistant Director of Nursing (ADON), she stated that it was the expectation that with dialysis residents, staff would get the resident up, check their vital signs and nurses would perform an assessment and document all findings on the dialysis communication sheet, as well as, document in the nurse progress notes. Per the interview, she stated staff would transport the resident to the common area in the front lobby to wait until transportation arrived. The ADON stated those residents would not need one-on-one supervision due to staff walking the halls, so they would see the residents constantly and have eyes on the resident. She further stated that the normal procedure would be for transportation to ring the doorbell and a staff member would answer the door. The ADON further stated that if no one answered the door, transportation should have called the facility. However, interview with the transportation driver revealed he called the facility three (3) times and no one answered the facility's phone. During an interview on 08/11/2023 at 5:00 PM, with the Director of Nursing (DON), she stated she did not require her staff to obtain vital signs, weights and/or assessments prior to the resident leaving the facility for dialysis but would attain upon the residents return to the facility. The DON added staff could sit residents in the front lobby to wait for transportation; however, there should have been a staff member in the front lobby to allow visitor access into the facility or answer the phone in a timely manner. The DON stated it would have been her expectation that the speech therapy recommendations would be followed up with the Medical Director and/or ARNP and discussed in the Interdisciplinary Team (IDT) meeting, and the morning Clinical Meetings, and should have been care planned by the Minimum Data Set (MDS) Coordinator; however, anyone could have care planned as soon as possible. In addition, the DON stated if a resident was unresponsive, staff should never place that resident in the lobby, unsupervised and the nurse should have assessed the resident. Further, she stated the physician should have been notified to obtain further orders, in order to ensure the resident's safety. Continued interview with the DON revealed it was her expectation that nursing would have assessed all residents prior to leaving the facility for dialysis, especially if altered mental status was noted. During an interview on 08/11/2023 at 5:25 PM with the Medical Director (MD), he stated he was in the MD position less than a year. He expected staff to follow the facility policies and would expect a resident to be assessed if they presented with altered mental status. The MD stated, for medical necessity, he would expect staff to follow the speech therapist recommendations and would expect all recommendations to be care planned appropriately. He further stated, if a resident was chewing tobacco, he/she should have been care planned appropriately to prevent the risk of aspiration. In addition, the MD stated he would expect the facility to keep him informed or to notify the ARNP of resident changes in condition, for the safety and well-being of the resident. During an interview on 08/11/2023 at 5:33 PM with Executive Director (ED), stated he would expect staff to follow the recommendations of the therapist for the safety of the residents. He further stated the recommendations should have been care planned and discussed with the resident and/or the Resident Representative (RP), so the IDT and staff were on the same page and that all staff knew what care needed to be provided. The ED stated the resident should have been care planned appropriately for his/her safety. Further, he stated, if a resident was found unresponsive, he would have expected staff to assess the resident, act immediately, and call the MD for recommendations. Additionally, the ED stated he would have expected staff to utilize the MD as a resource daily, and the MD to participate in Quality Assurance Performance Improvement (QAPI) and assist to make recommendations as needed to assist the facility in running safely and efficiently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's documentation and policy, it was determined the facility failed to protect residents from abuse for six (6) out of thirty-nine (39) sampled residents. (Resident #7, Resident #4, Resident #70, Resident #15, Resident #89, and Resident 46). 1. The facility failed to protect Resident #7 from abuse. On 07/20/2023 the Executive Director (ED) received an anonymous call reporting an inappropriate relationship between a staff member and Resident #7 that involved text messages and nude photos. The facility, however, failed to protect the resident from abuse and continued to allow the staff member to work, gaining access to the resident to potentially abuse the resident further. Subsequently, on 07/26/2023, Resident #7 reported to the facility staff allegations of sexual abuse when Certified Nursing Assistant (CNA) #24, would come into his/her shower room while he/she was undressed, which made him/her feel uncomfortable and harassed. 2. On 07/24/2023, Resident #4 and Resident #70 reported to staff that Resident #3 made vulgar comments to them. Interviews with the residents and staff revealed there was no supervision in the dining room to prevent the verbal abuse. 3. On 02/18/2023, Resident #20, picked a cup of water off the medication cart and threw the water onto Resident #15's upper body. Interview with staff revealed Resident #20 required supervision and monitoring to prevent physical abuse to other residents. 4. On 07/11/2023, Resident #12 kicked Resident #89 in the leg while waiting to go outside to smoke. 5. On 07/15/2023, Resident #19 attempted to throw his/her bedside table at Resident #46, his/her roommate, and grabbed Resident #46's arm instead. 6. On 08/03/2023, Resident #70 hit Resident #39 with a plastic bag when Resident #39 refused to give Resident #70 a coke. The facility's failure to ensure residents were protected from abuse is likely to cause serious injury, impairment, or death if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 07/29/2023 and was determined to exist on 07/20/2023 in the areas of 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation, Free from Abuse and Neglect (F600) at the highest scope and severity S/S of a K and (F607, F609), at the highest scope and severity S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation, Free from Abuse and Neglect (F600, F607, and F609). The facility was notified of the Immediate Jeopardy on 07/29/2023. IJ is Ongoing. The findings include: Review of the facility's policy titled, Freedom from Abuse and Neglect, undated, revealed: all residents were to be protected from harm; the Executive Director was responsible for oversight of abuse prohibition standards; and all allegations involving staff would necessitate suspension pending investigation. Per review of the policy, the definition of abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Review revealed abuse also included the deprivation by an individual, including a caretaker, of goods or services that were necessary to attain or maintain physical, mental, and psychological well-being. The policy review revealed instances of abuse included verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Continued review of the facility's policy, Freedom from Abuse and Neglect, undated, revealed sexual abuse was defined as non-consensual sexual contact of any type with a resident. Further review revealed staff members were to identify and assess suspected or alleged reports of abuse and neglect. Per review, types of abuse would include humiliation, harassment, threats, punishment, or deprivation, taking unauthorized resident photos or video recordings, posting of ANY resident photos, video recordings or other resident information on social media networks. Further review revealed rape or other sexual abuse included: sexual harassment, sexual assault, and sexual coercion. Review of the facility's policy titled, Abuse Prevention Program, revised December 2016, revealed it was the facility's policy that residents had the right to be free from abuse. This included but was not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse. Continued review revealed as part of the resident abuse prevention, the administration would protect residents from abuse which included facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Review of a document titled, Lotus, Pathway to Addition and Recovery undated, revealed the goal of the program was to build a community that provided each resident with a safe, drug-free, environment that promoted health and healing. A continued review of the document revealed staff was to cultivate a caring, sober environment. Further review revealed the resident waived his/her normal privacy standards as part of the drug and alcohol treatment (ARC) program when admitted to the facility on [DATE]. This included but was not limited to, scheduled visitations would be virtual visits only, a phone would be available for use for personal telephone communication, random drug screenings would be completed, personal items would be searched in view of the resident, and no sexual activity. Further, the program was to provide a safe, therapeutic environment for all the residents. 1. Review of Resident #7's admission Record revealed the facility admitted Resident #7 on 05/29/2023 with Diagnoses which included: Osteomyelitis, Anxiety, Opioid Abuse, and other Stimulant Abuse. Review of Resident #7's admission Minimum Data Set (MDS), dated [DATE], revealed the facility had assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), which indicated the resident was cognitively intact. Review of the facility's Alleged Abuse Investigation Nursing Incident Description Note, dated 07/26/2023 at 6:26 PM, entered by the Director of Nursing (DON), revealed on 07/20/2023 the Executive Director (ED) received an anonymous call that Resident #7 was involved in a relationship with a staff member,with only first name given. The caller was unable to give a last name or description of the employee. The caller stated the resident and facility staff member had been texting and sending inappropriate pictures via text message. Resident #7 was interviewed at this time and denied any inappropriate relationship with a staff member or receiving any inappropriate pictures via text messages. The Human Services Director (HSD) and DON interviewed all employees with the first name provided by the anonymous caller, and all denied any inappropriate relationship with a resident or sending inappropriate pictures. Continued review of the facility's investigation revealed the staff members matching the first name given were not suspended while the facility conducted its investigation. Further review of the facility's Alleged Abuse Investigation Nursing Incident Description Note, dated 07/26/2023 at 6:26 PM, entered by the DON, revealed on 07/26/2023 Resident #7 spoke with his/her Peer Support Specialist (PSS) and reported to him that he/she had not been honest when he/she was first interviewed and stated that he/she had a friendship with the agency's Certified Nursing Assistant (CNA) #24, and that he/she attempted to cut the friendship/relationship off, but the CNA would come to Resident #7's room and shower room, and this made him/her feel uncomfortable. Further review of the facility's investigation, dated 07/26/2023 at 6:26 PM, revealed Resident #7 reported he/she realized he/she was in a vulnerable state due to his/her sobriety and that he/she thought he/she could handle the situation on his/her own. Ongoing review of the Alleged Abuse Investigation revealed CNA #24 kept coming to his/her room and knock on his/her door. He/She further reported the CNA would come in the shower room when he/she did not require assistance. Resident #7 stated the CNA never physically touched him/her, but she made him/her feel uncomfortable. Review of Resident #7's Activities of Daily Living (ADL) Logs for July 2023 revealed CNA #24, who was assigned to the Lotus Unit, had charted she had provided care to Resident #7 on 07/04/2023, 07/16/2023, and 07/19/2023. Review of CNA #24's Clock In and Out Sheet revealed she had worked on Saturday 07/22/2023, from 7:00 AM - 7:00 PM, and on Sunday 07/23/2023, from 7:00 AM - 11:00 PM, which allowed the CNA access to the resident after an allegation of abuse was made on 07/20/2023, exposing the resident to continued potential abuse. Review of Resident #7's Psychiatric (Psych) Note, dated 07/26/2023, revealed the Psych Advanced Registered Nurse Practitioner (PARNP) saw Resident #7 at the request of the facility after inappropriate sexual behavior was reported. Resident #7 reported he/she was at the facility for rehabilitation after having spinal surgery. Resident #7 had approximately two (2) weeks left in the Lotus Addiction Recovery Program and reported one (1) facility staff member, who was a female, kept coming into his/her room multiple times throughout the day, even when he/she did not need his/her help. Continued review of the Note revealed Resident #7 reported the facility staff member would go into the shower room while he/she was taking a shower, even though he/she needed no assistance with showering. Continued review of the Psychiatric Note, dated 07/26/2023, revealed the resident reported that the staff member never touched him/her inappropriately but made him/her feel very uncomfortable. Resident #7 reported the staff member texted him/her multiple flirty comments and constantly followed him/her into the shower room, even when she was not supposed to be on his/her floor. Per the note, this happened multiple times over the past month. Additional review revealed after this was reported, the resident came clean in his/her own words, that CNA#24 had tried to be in the shower with him/her multiple times over the past month. Ongoing review of the Note revealed Resident #7 reported the CNA constantly harassed him/her throughout the night and would not let him/her sleep. During an interview with Resident #7, on 07/27/2023 at 9:00 AM, the resident stated Certified Nursing Assistant (CNA) #24 sent photos through a social media application of herself topless and showing her bare breasts, and the photos were deleted after twenty-four (24) hours. Resident #7 stated if he/she could retrieve the photos, he/she would send them to the State Survey Agency (SSA) surveyor, as proof. The resident, however, was unable to provide the pictures to the SSA surveyor prior to exiting the facility. Resident #7 stated that at first, he/she was friends with the CNA, and they began talking a lot. Per the interview, the resident stated the friendship was consensual as he/she did not have any family or friends and it was nice having someone close to talk to. Resident #7 stated the relationship progressed and CNA #24 kissed him/her which made the resident feel uncomfortable. Resident #7 stated he/she told CNA#24 he/she did not feel comfortable having that kind of relationship because he/she was in treatment for his/her addiction, and he/she needed to continue to work the program for recovery before having an intimate relationship with anyone. Further interview with Resident #7, on 07/27/2023 at 9:00 AM, he/she stated CNA#24 continued to send nude photos after being told to stop. The resident further stated the CNA would wake him/her up at all hours of the night coming into his/her room when she worked her shifts at the facility. Resident #7 stated he/she confided in two (2) residents (Resident #9 and Resident #13) on the Lotus Unit about his/her concerns and Resident #9 asked to see the photos. Per the interview, Resident #7 stated he/she showed the photos to the residents. Resident #7 stated he/she told Resident #9 and Resident #13 he/she told CNA#24 to stop sending text messages and photos, and that it was making him/her feel uncomfortable, harassed, embarrassed, and shameful, because she was coming into his/her room at night and entering the bathroom when he/she was unclothed, while showering. Resident #7 stated a rumor had gotten out all over the community about what was going on and the Director of Nursing (DON) and the Human Resource (HR) person called him/her into their offices to talk about the incidents. Resident #7 stated he/she only admitted to the shower incidents because he/she was embarrassed and ashamed about the photos and did not want to get CNA# 24 in trouble. During an interview with Resident #13, on 07/27/2023 at 11:15 AM, he/she stated about three (3) days ago he/she noticed CNA #24 was after Resident #7 hot and heavy. Resident #13 stated Resident #7 told him/her the CNA had been sending him/her text messages and nude photos on his/her phone. Resident #13 stated he/she did not look at the text messages or photos, but stated every time Resident #7 went outside, the CNA would find a reason to go outside. Resident #13 stated that if Resident #7 was in the dining room, the CNA would come into the dining room. Resident #13 also stated the CNA smoked and was always asking Resident #7 to go outside and smoke with her, even though Resident #7 did not smoke. Resident #13 further stated, anywhere Resident #7 was, the CNA would find a reason to follow him/her. Resident #13 stated CNA #24 would not be back to work at the facility because when you mess with a resident, that was not a good reputation to have. During an interview with Resident #9, on 07/31/2023 at 3:00 PM, he/she stated CNA #24 and Resident #7 were friends; however, the CNA was a little extra with Resident #7. Per the interview, CNA #24 would come over to Resident #7's room even when she was not assigned to be on the unit. Further, the CNA would ask Resident #7 to go outside and smoke with her, even though the resident did not smoke. Resident #9 stated CNA #24 would stay over on her shifts to be near Resident #7. Per the interview, Resident #9 stated he/she never saw CNA #24 kiss Resident #7; however, stated Resident # 7 told him/her the CNA sent him/her nude pictures of herself and sent pictures of her family to Resident #7's phone. Resident #9 stated, I think she had a crush on Resident #7. Resident #9 stated Resident #7 told CNA #24 she needed to stop calling and texting him/her. Resident #9 stated he/she thought the CNA's behavior was very unprofessional and inappropriate. During an interview with CNA #24 on 07/28/2023 at 2:45 PM, she stated she had been a CNA for fifteen (15) years and had worked at the facility through a staffing agency for about two (2) months. CNA #24 stated she had worked all units including the Lotus unit. Per the interview, the CNA stated sexual abuse would be touching inappropriately, making someone feel uncomfortable, and that entering in the shower while a resident was showering would not be considered sexual unless it was intentional. CNA #24 stated she had heard rumors that she had a relationship with a resident, that she came on to Resident #7, and that she was showing favoritism to him/her. CNA #24 stated she would buy items for several residents who felt alone, like buying soda for a resident. CNA #24 stated Resident #7 stated he/she was all alone, and he/she hated to ask for help. The CNA stated Resident #7 would offer her his/her cash app (a mobile payment service) to buy On Pouches (nicotine pouches) because he/she was a dipper of tobacco, not a smoker. Further, she stated the resident was ask her to buy him/her soap. CNA #24 stated they were only friends. CNA #24 stated she had been texting Resident #7 and he/she would text her about how he/she felt. CNA #24 further stated Resident #7 sent her a picture of his/her daughter and a shirtless picture to show her he/she was gaining weight. In a continued interview, on 07/28/2023 at 2:45 PM, CNA #24 stated she sent Resident #7 pictures of herself and her kids, adding, they were family type pictures. CNA #24 denied she sent the resident nude pictures of her and denied kissing the resident. However, stated that now she has researched it, she realized maybe she should not have been texting or sending photos to Resident #7. CNA #24 stated she wished she had known that her friendship with Resident #7 was not appropriate and had been considered abuse based on the facility's policy. Further, the CNA stated she was informed by the DON that since her relationship with Resident #7 was consensual she was still hirable. The CNA stated she later received a call from the facility's Human Resource Director and DON stating she was not allowed to return to the facility. During a phone interview with Licensed Practical Nurse (LPN) #1, on 07/27/2023 at 8:00 PM, she stated she had been working the Lotus Unit since February 2023. LPN#1 stated that prior to working at the facility she had worked for fifteen (15) years at the jail and had a lot of experience working with Substance Abuse clients and had a lot of education in substance abuse, detox, mental illness, behaviors, and meth-induced psychosis. LPN #1 stated on 07/24/2023 she heard from staff members talking on the unit that something was going on between CNA #24 and Resident #7. LPN #1 stated her supervisor LPN #11 was there, and asked if it should be reported. The supervisor agreed it should be reported and made a call to the DON that night to report CNA #24 and Resident #7 were in a relationship. LPN #1 stated she and her supervisor, LPN #11, went to talk with Resident #7 and he/she reported he/she talked on the phone with CNA #24 and sent text messages and photos. The resident stated he/she decided to cut off the relationship/friendship, but CNA #24 started harassing him/her and invading his/her space. LPN #1 stated she had Resident #7 sign a statement about his/her relationship/friendship with the CNA, and she handed it to the Assistant Director of Nursing (ADON) at the end of her shift that morning. During an interview with Registered Nurse (RN) #3, on 07/27/23 at 8:50 PM, she stated she primarily worked the Lotus Unit and had been at the facility for almost two (2) years. RN #3 stated there was an inappropriate relationship between CNA #24 and Resident #7. Per the interview, RN #3 stated CNA #24 was pursuing Resident #7 and she was observed going to the resident's unit and into his/her room. RN #3 stated she heard about the inappropriate relationship about 2 weeks ago (the week of 07/10/2023) and told the DON. RN #3 stated the DON said she would take care of it; however, she could not see where anything had been done to address the allegation after she reported the incident to the DON. The RN stated a week went by and then she heard about the photos from Resident #9. RN #3 stated Resident #9 stated CNA #24 sent Resident #7 naked photos of herself. Per the interview, Resident #9 stated he saw the photos and text messages sent to Resident #7 on his/her phone. RN #3 stated after she reported the inappropriate relationship to the DON, she started to receive a lot of backlash from the DON, ADON, and the Unit Manager. She stated they gave her a lot of paperwork to redo and stated she was not doing her job. Per the interview, RN#3 stated, the facility did not protect Resident #7 from abuse. She further stated, in this case they treated Resident #7 like a perpetrator and said the resident had manipulated CNA#24 and she was the victim, not the resident. During an interview with LPN #11 on 07/28/2023 at 4:00 PM, she stated she worked as the night shift supervisor on the 11:00 PM - 7:00 AM shift Continued interview with LPN #11, she stated she heard staff talking about an aide (CNA #24) on the Lotus Unit was going into Resident #7's room when the aide was not assigned to work that unit and was calling the resident on phone. LPN #11 stated on the night shift on 07/23/2023, CNA #24 was assigned to work another unit. However, she kept seeing her coming in and out of Resident #7's room when she was not supposed to be on the unit. LPN #11 stated LPN #1 asked CNA #24 if she had been reassigned to work the Lotus Unit that night and CNA #24 stated no and left the unit. LPN #11 stated she and LPN #1 went to talk with Resident #7 about their relationship and he/she stated there was no relationship between him/her and CNA #24. LPN #1, who had a better rapport with Resident #7, asked LPN #11 to leave the room so she could talk to Resident #7. LPN #11 stated a few minutes later, LPN #1 called her back in the room and Resident #7 told LPN #11 he/she did have something going on with CNA #24, but he/she did not want it anymore because he/she was trying to get clean, but CNA #24 kept bothering him/her and kept coming into his/her room. The LPN stated Resident #7 stated he/she just wanted CNA #24 to leave him/her alone. Per interview, LPN #11 stated the facility did not protect Resident #7 from abuse. During an interview with the DON on 07/29/2023 at 2:47 PM, she stated she had been the DON at the facility since May 2023 and she had been educated on Abuse several times in the last few months by the Staff Development Coordinator (SDC). She stated calling, texting, and sending pictures to a resident would not be considered sexual abuse or inappropriate if the relationship was consensual. She further stated that on 07/20/2023, the Executive Director (ED) told her he had received an anonymous call on 07/20/2023 from a male caller who stated an employee, identified by first name, had been sending inappropriate pictures to a resident, identified by first name and last initial (Resident #7). The DON stated an investigation was initiated immediately by contacting the Human Resource Director (HRD) because they did not know who the employee was because they only had a first name. She stated she, the HRD, and the ED interviewed Resident #7 and he/she denied an inappropriate relationship had occurred. The DON then stated she and the HRD started interviewing all the staff members identified by the first name provided by the caller, and all the staff members interviewed denied having an inappropriate relationship with a resident, and denied texting, calling, or sending photos to a resident in the facility. Per the interview, no employees were suspended during the investigation because all had denied a relationship had occurred with a resident. Further interview with the DON, on 07/29/2023 at 2:47 PM, revealed Resident #7 later told his/her Peer Support Specialist (PSS) in the Lotus Program, that he/she had not told the truth to the DON and ED about exchanging phone calls, text messages, and photos with CNA#24. The DON stated after hearing the information provided by the PSS, she and the HRD called CNA #24 and she stated Resident #7 had pursued her and he/she had initiated the interaction with her. The DON stated she asked CNA #24 for copies of her text messages and CNA #24 sent them the next day, and there were only pictures of her in her bathing suit at the pool with her kids. She stated she asked CNA #24 why she did not come forward and report the relationship and she said because she and Resident #7 were just friends, and she did not think she was doing anything wrong. The DON stated she did not think Resident #7 was a victim, that he/she manipulated CNA #24. She then stated, she did not know why the facility should have reported the incident because the resident had a BIMS of fourteen (14), denied the allegations in the beginning, and had the right to a consensual relationship. Review of the facility's policy; however, revealed the resident had the right to be protected from abuse, to include staff members. Further, review of the Lotus Program document revealed the resident would be provided a safe and therapeutic environment. The facility failed to ensure its policy and procedures were followed to protect the resident from potential abuse. During an interview with the Regional Human Resource Business Partner (RHRBP) on 08/09/2023 at 10:43 AM, she stated she was involved in assisting the facility with investigations, compliance, and development of leadership in all the corporation's buildings. The RHRBP stated the ED had received a call on 07/20/2023 about a possible allegation of a resident having a relationship with a staff member that included nude pictures and was told the staff members first name, no last name, and the ED did not know what do. The RHRBP stated she told the ED she did not know the protocol, and that it might be a reportable incident. She stated she informed the ED and DON they needed to do whatever needed to be done based on policy. Further, she stated they needed to launch an investigation and the ED said how, I have vague information. The RHRBP stated she told the ED that he was provided the staff members first name, so have the DON pull a roster of staff members with the first name provided, both agency and facility staff, and begin interviewing all of them. She then stated she instructed the ED to also conduct an interview with Resident #7. The RHRBP stated she interviewed Resident #7 and all staff members with the first name provided by the anonymous caller, and all denied having an inappropriate relationship involving texting, phone calls, and nude photos. In a continued interview with the Regional Human Resource Business Partner (RHRBP), on 08/09/2023 at 10:43 AM, she stated she spoke with Certified Nursing Assistant (CNA) #24 and the CNA stated she was taken advantage of and was manipulated by Resident #7. Further, the RHRBP stated she told CNA #24 she made the decision to be in a relationship with the resident and the CNA cried, asking if she would lose her license. The RHRBP stated she asked the CNA if she had text messages from the resident and the CNA stated she had deleted them, at first, but later produced the text messages the next day. The RHRBP stated the facility failed to ensure its policies were followed. In terms of reporting the allegations of abuse, the RHRBP stated both allegations should have been reported to State Agencies. She further stated she was not aware the allegations had not been reported. During an interview with the Executive Director on 07/29/2023 at 1:55 PM, he stated on 07/20/2023 he received an anonymous call saying there were nude pictures sent to a resident (Resident #7) by a staff member identified by first name only, no last name was given. He stated after he received the call, he tried to figure out who the resident and the staff member were. The ED stated he notified the RHRBP who advised him to compile a list of all staff with the first name provided by the caller. The ED stated he interviewed Resident #7 and he/she denied anything had occurred. Per the interview, the facility did not send in a reportable on 07/20/2023. Further, the ED stated, after discussing the allegation made in the call with the Corporate [NAME] President of Operations (VPO), it was decided the allegation made on 07/20/2023 was not reportable. Review of the facility's policy related to abuse; however, revealed that all allegations related to abuse would be reported and the residents would be protected from abuse to include staff members. The ED, during the interview on 07/29/2023 at 1:55 PM, stated a 2nd allegation of abuse was reported involving the same individuals on 07/24/2023 and the DON and ED questioned Resident #7 again, and he/she again denied an inappropriate relationship with a staff member. The ED stated he again called the RHRBP to discuss what should be done about the allegation and was told it was not abuse and was not reportable because the resident denied it happened. The ED stated on 07/26/2023, Resident #7 then confided in his/her Peer Support Specialist (PSS) in the Lotus Program and a lot more information came out. After the second report came in on 07/26/2023, the Interdisciplinary Team (IDT) met as a Quality Assurance (QA) team and that's when it was determined to start an investigation. CNA #24 had her agency contract terminated because the facility's investigation determined the CNA had an inappropriate relationship and an inappropriate way to act with residents. The ED stated we felt the relationship became more personal with text messages being sent and the fact that she was seeing the resident in his/her room and shower when she was not assigned to work the Lotus Unit. He further stated he was not aware she had worked 2 more shifts at the facility after the 07/20/2023 allegation was made. The ED stated his expectation was for staff to follow the abuse policy process and report allegations of abuse immediately, without fear of retaliation, and he expected a full thorough investigation be conducted on all allegations of abuse. During an interview with the [NAME] President of Operations (VPO) on 07/29/2023 at 3:35 PM, he stated the 07/20/2023, an anonymous call regarding an inappropriate relationship between a staff member and a resident should not have been reported because Resident #7 had a BIMS of 14, the resident was of sound mind, and the resident had the right to have a relationship of his/her choosing. Review of the facility's Lotus Program for substance abuse; however, revealed the resident signed a document upon admission which waived his/her rights to visitors, which would be virtual contact only, his/her phone, as one would be available for use for personal telephone communications, and sexual activity, while being a resident within the facility. Further, the program stated the resident would be provided a safe, therapeutic environment. In a continued interview with the VPO, on 07/29/2023 at 3:35 PM, Resident #7 was interviewed about the incident several times and said nothing inappropriate was going on every time. Per the interview, all staff members with the first name provided by the anonymous caller were interviewed and all stated they had not had an inappropriate relationship with a resident. He stated Resident #7 later told his/her Peer Support Specialist (PSS) on the Lotus Program that one CNA made him/her feel uncomfortable when she came into his/her shower uninvited. He stated the facility found out staff member was CNA #24, and the Management Team viewed the text messages provided by the CNA and Resident #7 and determined their relationship was not a reportable event (even though the resident expressed the CNA made him/her feel uncomfortable, harassed, and uninvited in his/her space). Per the interview, the facility's process was that any allegation of abuse would be reported timely by the definition of the State Operations Manual (SOM). The VPO further stated staff should be able to report without fear of retaliation to ensure the safety of all the residents. Review of the facility's Freedom from Abuse and Neglect Policy, undated, revealed all residents were to be protected from harm. Continued review of the policy revealed types of abuse included: physical assault or abuse; hitting, slapping, pinching, and kicking. Further review revealed verbal abuse included: oral, written, and gestured language including, but not limited to, disparaging or derogatory terms directed to or within hearing distance of the resident. Review of the facility's Five (5) Day Follow Up Investigation revealed a statement from the DON stating she heard Resident #70 yelling in the dining room and when she went to check to see what was going on and Resident #70 stated Resident #3 told him/her to shut the hell up and stated nasty things. Continued review revealed Resident #70 was removed from the dining room. 2 a) Review of Resident #3's admission Record revealed the facility admitted the resident on 05/10/2019 with diagnosis to include Anxiety Disorder, Bipolar Disorde[TRUNCATED]

Based on interview, record review, review of the facility's policies, documents, Job Descriptions, and Plan of Correction (PoC) submitted for the 06/10/2023 and 09/13/2021 it was determined the facility failed to have an effective system 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 psychosocial well-being of each resident. Review of the facility's Standard Recertification and Abbreviated Plan of Correction (POC) for the 06/11/2023 survey revealed the facility was cited at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F609) failure to report allegations of abuse to State Agencies. During an Abbreviated/Partial Extended Survey initiated on 07/12/2023, the State Survey Agency (SSA) identified continued non-compliance in the area of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F609) on 07/29/2023. The facility's Administration failed to report an allegation received on 07/20/2023 of sexual abuse of a resident by a Certified Nursing Assistant (CNA). The facility's Administration failed to facility's ensure its Quality Assurance Performance Improvement (QAPI) Committee reviewed, discussed, and tracked its past noncompliance regarding abuse. The facility's Administration additionally failed to ensure its QAPI Committee reviewed the current sexual abuse allegation reported on 07/20/2023, in order to determine the root cause of the abuse and implement person centered interventions to prevent further and/or future sexual abuse encounters of the affected resident or other residents. Interview and record review revealed the facility's Administration had no system in place to thoroughly investigate and determine the root cause of abuse allegations. In addition, the facility's Administration failed to ensure its QAPI program analyzed data collected to protect residents from abuse, and failed to ensure its QAPI program took effective measures to prevent and implement corrective actions for those residents affected by abuse. The facility's failure to have an effective system 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 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 07/20/2023 and was determined to exist on 07/20/2023 in the areas of of 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F607, and F609). Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F-600 and F-609). The facility was notified of the Immediate Jeopardy on 07/29/2023 and is ongoing. In addition, Immediate Jeopardy (IJ) was also identified on 08/09/2023 and was determined to exist on 07/20/2023 in the areas of 42 CFR 483.70 Administration (F835), and 42 CFR 483.75 Quality Assurance and Performance Improvement, (F867). The facility was notified of the Immediate Jeopardy on 08/09/2023 and is ongoing. Immediate Jeopardy (IJ) was also identified on 08/11/2023, and was determined to exist on 05/29/2023 in the area of 42 CFR 483.25 Quality of Care (F684). The facility was notified of the Immediate Jeopardy on 08/11/2023 and is ongoing. SQC was identified at 42 CFR 483.25 Quality of Care (F684). The findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement Program, revised March 2022, revealed the Executive Director was ultimately responsible for the QAPI program, and for interpreting its results and findings to the Governing Body. Continued review revealed the responsibilities of the QAPI committee were to collect and analyze performance indicator data and other information, identify, evaluate, monitor and improve facility systems and processes that support the delivery of care and services, identify and help to resolve negative outcomes and/or care quality problems identified during the QAPI process. Review further revealed the QAPI committee was to utilize root cause analysis to help identify where identified problems point to underlying systematic problems, and coordinate the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals. Review of the facility's Executive Directors (ED) Position Description, undated, revealed the ED was responsible for the undertaking of corrective action, if applicable. Per review, the ED was also responsible for directing and performing quality assessment and assurance functions, including but not limited to regulatory compliance rounds to monitor performance and to continuously improve quality. Review revealed the ED's responsibilities included: implementing programs to gather and analyze data for trends and to institute actions to resolve problems promptly; and reporting and making recommendations to appropriate committees. Review of the facility's Freedom from Abuse and Neglect Policy revealed all allegations involving staff necessitated suspension pending investigation. Continued review revealed allegations of abuse were to be reported immediately to the ED. Further policy review revealed the facility was to report all alleged violations and substantiated incidents to the State Agency and to all other agencies as required and was to take all necessary corrective actions depending on the results of the investigation. During an interview on 07/29/2023 at 3:35 PM with the the [NAME] President of Operations (VPO), he stated the process of any allegation of abuse was it should be reported timely by the definition of the State Operations Manual (SOM). He stated the Abuse Coordinator (ED) or designee was to report to all appropriate agencies immediately; however, he felt anyone could report abuse. The VPO stated any type of abuse could cause psychological harm to a resident resulting in fear, intimidation, embarrassment, and shame. He further stated therefore, abuse should be taken seriously and reported immediately, and staff should be able to report without fear of retaliation to ensure the safety of all the residents. During an interview on 08/09/2023 at 10:43 AM, with the Regional Human Resources (RHR) Business Partner, she stated she had been with the facility since January 2023, and her responsibilities included orientation, onboarding, connecting with operational leadership, being involved in employee investigations, compliance, and development of leadership. The RHR Business Partner stated she lead the facility's staff investigations, collecting statements, conducting interviews, making formal decisions and keeping leadership informed on what actions needed to be taken. She stated she was made aware the end of July 2023, about a possible allegation of a relationship with a staff member (CNA #24) involving a Resident (Resident #7). The RHR Business Partner stated when the allegation of sexual abuse was reported to the ED on 07/20/23, it should have been reported at that time based on facility policy, and CNA #24 should have been suspended immediately. She stated she was not aware the allegation had not been reported then, and felt the Corporate Operations (CO) should have made that call. According to the RHR Business Partner, she received a call on 07/24/2023, of another allegation involving the same resident (Resident #7) and same staff member (CNA #24) and both admitted to the allegation made on 07/20/2023. She stated from her investigation and being informed that even after the ED received the anonymous call of sexual abuse allegation on 07/20/2023, and CNA #24's contact with Resident #7 being validated the CNA continued to work at the facility, therefore, she was reporting her concerns to the VPO. In continued interview on 08/09/2023 at 10:43 AM, the RHR Business Partner stated the ED and DON had continued with plans to hire CNA #24 as a full-time employee and had already made her an offer of full-time employment, even after the allegation was reported. She stated through validated interviews with the facility's Human Resources (HR), the DON was pushing for hire of CNA #24 and planned to place her on a different unit and the ED had approved the CNA's hire, so she expedited a meeting with the Corporate VPO to discuss the need for immediate action. The RHR Business Partner stated at that time on 07/24/2023, she made all management aware to include the ED and DON that CNA #24 must be taken off the schedule and could not enter the facility and most definitely could not be hired, and she ensured the ED implemented this immediately. She stated the process the Corporate HR had in place was how they were able to prevent CNA #24 from further employment and ensured resident safety; however, she felt the situation could have been prevented if an appropriate DON had been in place in the facility at the time. The RHR Business Partner further stated an experienced DON would not have allowed the incident to have happened and would not have even considered doing things the way they occurred. Additionally, she stated she did not see any clinical oversight from the DON and ADON in the facility. During an interview on 07/29/2023 at 1:55 PM, with the ED, he stated he had been a Long-Term Care Director for fifteen (15) years, and worked as Interim ED at the facility since 06/14/2023. He stated he was responsible for the day-to-day functioning of the facility; and for ensuring the facility operated within the State and Federal Guidelines and maintained regulatory compliance regarding previously cited deficiencies. The ED stated he was the Quality Assurance (QA) Coordinator and was responsible for the QA program in the facility and for ensuring the ongoing audits related to previously cited deficiencies were completed. He stated any concerns of allegations, such as abuse should be identified, addressed and corrected immediately. The ED stated he was also the facility's Abuse Coordinator and had received education by the VPO on the facility's Abuse Policy which included physical, verbal, mental, misappropriation, sexual, exploitation, neglect, and seclusion when he started as the Interim ED. He stated it was his responsibility to report allegations, and he had two (2) hours to report to State Agencies and the Ombudsman. According to the ED, it was his and his staff's responsibility to protect residents first and foremost, and alleged staff should be escorted out of the building and suspended immediately pending the outcome of the investigation. He stated he expected himself and his staff to follow that process and to be able to report immediately and freely without fear of retaliation. In continued interview on 07/29/2023 at 1:55 PM, the ED stated the facility's investigation should be initiated by nursing as soon as they were informed, with statements obtained, interviews and education conducted. He stated the DON and Social Services Director (SSD) should immediately start resident and staff interviews, and skin assessments of noninterviewable residents. The ED stated he felt the SSD should be involved in that process because it was important for the resident to have another set of ears to listen to them to make sure nothing was being covered up. He stated he also felt it was important for the SSD to be involved to address potential psychosocial harm which might occur, as abuse of any type could manifest itself in a resident such as changed behavior, physical distress, upset stomach, anxiety, insomnia, stress, and affect their overall health. The ED stated in regards to the recent allegation of sexual abuse that involved Resident #7, the facility failed to decide whether the allegation of sexual involvement between a staff member and a resident met the criteria of sexual abuse. He stated however, he and the facility had since recognized that failure, and informed the State Survey Agency (SSA) Surveyor it had been sexual abuse, and the allegation should have been reported immediately, instead of trying to determine if it was actual or not. The ED stated we as management should have followed through on this issue for the safety of all the facility's residents. He further stated his expectation was that the facility followed its policies, so that every incident/allegation was consistent and thoroughly investigated, in order to determine the root cause through analysis to properly address concerns of residents and ensure their safety and protection, as well as to avoid repeated tags of deficient practice.

Based on interview, record review, review of the Administrator's Job Description, review of the Statement of Deficiencies (SoD) submitted for the 06/11/2023 and the Plan of Correction (POC) submitted for the 09/17/2021 survey and review of the facility's policy, it was determined the facility failed to have an effective process in place to address systemic failures through regularly scheduled Quality Assurance Performance Improvement (QAPI) process. As a result, the facility failed to ensure they developed, implemented, and maintained an effective, comprehensive, data driven QAPI program that focused on indicators of the outcomes of care and quality of life. The facility was aware of potential allegations of abuse; however, failed to report to the State Survey Agency (SSA); conduct thorough investigations; develop and implement policies; monitor and audit identified non-compliance; and ensure the QAPI program comprehensively developed, implemented, and monitored its plan to ensure effectiveness in addressing repeat noncompliance and allegations of abuse to maintain substantial compliance. This was evidenced by review of the facility's deficient practice cited on an Extended Survey initiated on 06/10/2023 and concluded on 06/11/2023. Immediate Jeopardy (IJ) was identified on 06/10/2023 and was determined to exist on 04/22/2022 in the areas of 42 483.21 Comprehensive Resident Centered Care Plan, F656; and 42 CFR 483.25 Quality of Care, F689 all at a Scope and Severity (S/S) of J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care, F689. Additional deficiencies were cited at 42 CFR 483.10 Resident Rights Exercise of Rights, F558 at a S/S of a D, and F584 at a S/S of an E; 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation F609 at a S/S of a D; 42 CFR 483.20 Resident Assessments F641 at a S/S of a D; 42 CFR 483.25 Quality of Care F686, F690, F691, F693, and F695, at a S/S of a D; 42 CFR 483.45 Pharmacy Services F761, at a S/S of a D; 42 CFR 483.60 Food and Nutrition Services F812 at a S/S of an E; and 42 483.80 Infection Prevention and Control F880 at a S/S of an D. Review of the facility's history revealed Immediate Jeopardy was identified on 09/17/2021, and was determined to exist on 04/17/2021, in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, Free from Abuse and Neglect (F600) at a S/S of J, and 42 CFR 483.25 Quality of Care, Pain Management (F697) at a S/S of J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, Free from Abuse and Neglect (F600), and 42 CFR 483.25 Quality of Care, Pain Management (F697). The facility was notified of the Immediate Jeopardy on 09/13/2021. Continued review of the facility's history revealed on 06/29/2023, the SSA validated the facility removed the IJ, prior to exit on 06/29/2023, which lowered the S/S to a D at 42 CFR 483.21 Comprehensive Resident Centered Care Plan, (F656), and 42 CFR 483.25 Quality of Care, (F689), while the facility developed and implemented a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitored to ensure compliance with systemic changes. The facility's failure to have an effective system in place to address systemic failures through regularly scheduled Quality Assurance Performance Improvement (QAPI) process has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 07/20/2023 and was determined to exist on 07/20/2023 in the areas of of 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F607, and F609). Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F-600 and F-609). The facility was notified of the Immediate Jeopardy on 07/29/2023 and is ongoing. In addition, Immediate Jeopardy (IJ) was also identified on 08/09/2023 and was determined to exist on 07/20/2023 in the areas of 42 CFR 483.70 Administration (F835), and 42 CFR 483.75 Quality Assurance and Performance Improvement, (F867). The facility was notified of the Immediate Jeopardy on 08/09/2023 and is ongoing. Immediate Jeopardy (IJ) was also identified on 08/11/2023, and was determined to exist on 05/29/2023 in the area of 42 CFR 483.25 Quality of Care (F684). The facility was notified of the Immediate Jeopardy on 08/11/2023 and is ongoing. SQC was identified at 42 CFR 483.25 Quality of Care (F684). The findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement Program, revised March 2022, revealed the Executive Director (ED), whether a member of the QAPI Committee or not, was ultimately responsible for the QAPI program, and for interpreting its results and findings to the Governing Body. Continued review revealed the responsibilities of the QAPI Committee were to collect and analyze performance indicator data and other information, identify, evaluate, monitor and improve facility systems and processes which support the delivery of care and services. Review revealed the QAPI Committee was also to identify and help to resolve negative outcomes and/or care quality problems identified during the QAPI process, utilize root cause analysis to help identify where identified problems point to underlying systematic problems, and coordinate the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals. Further review of the policy revealed the QAPI Committee had the full authority to oversee the implementation of the QAPI program, including but not limited to, establishing performance and outcome indicators for quality of care and services delivered in the facility. Review of the facility's Executive Director's (ED) Position Description, undated, revealed the ED was responsible: directing and performing quality assessment and assurance (QAA) functions, including but not limited to regulatory compliance rounds to monitor performance and to continuously improve quality. Continued review revealed the ED's responsibilities also included: the undertaking of corrective action, if applicable; implementing programs to gather and analyze data for trends and to institute actions to resolve problems promptly; and reporting and making recommendations to appropriate committees. Review of the Facility's Freedom from Abuse and Neglect Policy, undated, revealed all allegations involving staff was to necessitate suspension pending investigation. Per review of the policy, allegations of abuse was to be reported immediately to the ED. Further review revealed the facility was to report all alleged violations and substantiated incidents to the State Agency and to all other agencies as required and was to take all necessary corrective actions depending on the results of the investigation. Review of the Plan of Correction (POC), for the survey dated 09/17/2021, revealed for the Immediate Jeopardy identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F600 the facility educated staff and the DON and/or the ED were to report the audit results weekly to the QAPI Committee for four (4) weeks. Continued review of the 09/17/2021, POC revealed Immediate Jeopardy was also identified at 42 483.21 Comprehensive Resident Centered Care Plan, F656 which revealed the facility's ED, DON, and/or SSD were to submit results of the audit findings weekly times six (6) months to the QAPI Committee until the issue was resolved. The ED, DON, and SSD received education regarding care plans and the discharge process to include resident change in condition, discharge without proper medical authority and care plan revision, with a posttest. Review of the Statement of Deficiencies (SoD) for the Recertification Survey dated 06/11/2023, revealed 42 483.21 Comprehensive Resident Centered Care Plan, F656 was cited at Immediate Jeopardy again. In addition, 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation, F609 was cited at Immediate Jeopardy. During the Abbreviated Survey on 08/11/2023, 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F600 and F609 were cited at Immediate Jeopardy. In addition, 42 483.21 Comprehensive Resident Centered Care Plan, F656 was also cited at Immediate Jeopardy. Review of the facility's monthly QAPI Committee meeting minutes, from 10/25/2022 through 07/28/2023, revealed the Committee members noted as present, but not limited to, were the Medical Director via phone; Assistant Director of Nursing (ADON); Minimum Data Set (MDS); MDS Coordinator; Activities Director (AD); Business Office Manager (BOM), DON; Advanced Practice Registered Nurse (APRN); Unit Managers (UM); Social Services Director (SSD); Staff Development Coordinator (SDC); and Maintenance Director. Continued review of the QAPI meeting minutes for the dates of 10/25/2022, 06/20/2023, 06/23/2023, 06/28/2023, 06/30/2023, 07/07/2023, 07/14/2023, 07/21/2023, 07/24/2023, 07/27/2023, and 07/28/2023, revealed no documented evidence the minutes included discussion of any type of resident abuse and neglect, and/or to include the 07/20/2023, the allegation of sexual abuse involving perpetrator, CNA #24 towards Resident #7. During an interview with Licensed Practical Nurse/Infection Preventionist/Assistant Director of Nursing (LPN/IP/ADON) on 08/09/2023 at 2:13 PM, she stated she started working at the facility in September 2021, and reported to the DON, ED, and the Regional Clinical Nurse (RCN) and/or Regional Compliance Officer (RCO). The LPN/IP/ADON stated she assisted with QAPI through gathering information for audits from a nursing standpoint, and through any additional concerns that needed to be addressed in the QAPI meetings. She stated she was informed that QAPI was planned to go over incidents; self-identified issues; and the team was to come up with a plan, review it, and review some more until QAPI determined whether the goals had been met. The LPN/IP/ADON stated QAPI met once a month routinely; however, had met more frequently the last couple months related to the increase in facility reportable allegations which included abuse. The LPN/IP/ADON was unable to provide any information confirming QAPI had met and/or discussed the 07/20/2023, Resident #7 allegation of staff (CNA #24) sexual abuse. During an interview with the DON on 08/09/23 at 4:00 PM, she stated she reported to the ED and RCN. The DON stated she had been working at the facility for two (2) years and in the DON position since 05/15/2023. She stated she was responsible to ensure clinical processes were being followed, and monitoring and ensuring compliance and staff performance. The DON stated her responsibilities also included to ensure regulations were being followed per staff documentation review; holding/attending clinical meetings; reviewing resident laboratory work (labs); reviewing incident reports, and attending QAPI meetings at least monthly, or sooner if something arose. The DON stated the facility had been instituting QAPI meetings daily and weekly for the last month related to incidents. She stated the purpose of QAPI was to identify areas of improvement; set a plan; follow it; track it with department heads; and ensure the facility's systems did not fail. She stated the importance of a system-wide approach was to ensure resident safety and improve the investigation process. The DON further stated the deficient practice and failure related to the allegation of sexual abuse involving a staff member and a resident occurred because the facility failed to follow through with the investigation process, utilize the abuse policy, and implement the staff code of ethics. During an interview on 08/09/2023 at 4:31 PM, with the ED, he stated he had been the Interim ED since 07/14/2023. He stated he reported to the Regional [NAME] President of Operations (RVPO), and his responsibilities included to run the daily operations and oversight of the facility and staff. The ED stated his responsibilities also included continued communication with staff through morning meetings to discuss issues/incidents in different departments, staffing, supplies and equipment that was needed, any admissions, or discharges, and to give opportunity for each department to communicate with the whole Interdisciplinary Team IDT. He stated the IDT included the DON, ADON, SDC, UM's, MDS, AD, SSD, BOM, Dietary Manager (DM), Admissions Director, Maintenance Director, and Human Resources Director. The ED stated he was also to report to the Governing Body (GB); however, he was not sure who all that involved, other than the VPCO and the facility board representatives. He stated they would supply him with plenty of resources to operate the facility efficiently and effectively. According to the ED, he and the VPCO had routine conference calls, emails, text messages and routine in-person meetings to discuss issues and collaborate to best address the concerns; and the VPCO advised and offered services to obtain necessary resources. In continued interview on 08/09/2023 at 4:31 PM, the ED stated the facility's QAPI should identify and address all and any resident issues, to include involvement of the Medical Director, and the IDT to discuss areas that needed to be improved and/or what the facility could implement to ensure residents achieved the highest practicable mental, physical, and social well-being. He stated the QAPI met frequently and sometimes daily to discuss issues; to look at tracking and trending; conduct audits; and ensure education of staff. The ED stated QAPI met; however, failed to discuss the incident on 07/20/2023, related to a staff member having an inappropriate relationship with Resident #7. The ED stated the facility needed to recognized the importance to do a more thorough root cause analysis and get to the root of the problem with more emphasis on QAPI discussion and involvement. He stated the QAPI process failed due to a difference of opinion, and by not performing a thorough investigation. The ED stated the facility failed in deciding whether the allegation of sexual involvement between a staff member and a resident met the criteria of abuse; however, he and the facility had since recognized their failure. The ED informed the State Survey Agency (SSA) Surveyor, the incident involving the perpetrator, Certified Nursing Assistant (CNA) #24 and Resident #7 had been abuse and the allegation should have been reported immediately. He stated instead of the facility trying to determine if it was actual abuse or not, we as management should have followed through for the safety of all residents. The ED stated his expectation was that the facility followed its policies, so that every incident/allegation would be consistent and thorough, in order to perform the root cause analysis to properly address the concerns of residents and ensure they were safe and protected, as well as to properly avoid repeated deficient practice tags.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the facility's policies and investigations, it was determined the facility failed to ensure the Comprehensive Care Plan was developed and/or implemented for four (4) of twenty-four (24) sampled residents (Residents #160, #310, #359, and #161). 1. Resident #160 expressed to staff his/her desire to be discharged home and he/she was anxious about his/her upcoming court hearing. The resident reported his/her concerns to staff on [DATE]; the week of [DATE], and on [DATE]; however, the facility failed to develop the resident's individualized person-centered care plan to include adequate supervision and monitoring. Therefore, on [DATE], the resident exited his/her window, climbed on a table with a chair stacked on top of the table and climbed across the facility's six (6) foot fence. The facility was unaware of the resident's whereabouts for approximately one (1) day, twelve (12) hours, and forty-five (45) minutes. 2. Review of Resident #310's Comprehensive Care Plan dated [DATE], revealed the facility care planned the resident for impaired lung function related to Chronic Obstructive Pulmonary Disease (COPD). Continued review revealed interventions which included to encourage the resident to wear his/her nasal cannula when he/she removed it. Further review revealed however, the facility failed to develop Resident #310's care plan with an intervention for staff to ensure the resident's oxygen cannula stayed on as ordered. As a result, the resident experienced periods of confusion on [DATE] and [DATE]. 3. Review of Resident #359's Comprehensive Care Plan (CCP), initiated on [DATE], revealed the facility had care planned the resident for skin integrity with a goal for the resident's skin to remain intact. Continued review revealed the resident was care planned for (1) or two (2) staff to turn and reposition him/her in bed as needed. However, the facility failed to develop the resident's care plan related to his/her assessed needs of requiring the assistance of two (2) or more staff to assist with bed mobility and transfers. Additionally, the facility failed to ensure the resident's care plan was developed to include interventions to prevent skin tears during his/her wound dressing changes. This caused the resident to experience preventable skin tears on his/her right, posterior, lateral thigh, and of the right, lower knee, which occurred during his/her wound dressing changes, and a skin tear occurred on his/her upper arm, which occurred during a one (1) person assist. 4. The facility admitted Resident #161 on [DATE] and failed to assess the resident for his/her smoking safety upon admission. On [DATE], the resident exited the facility to smoke independently and fell out of his/her wheelchair, causing him/her to sustain a small abrasion to the resident's left below the knee amputation. The facility failed to develop the resident's care plan to include the need for assisted and supervised smoking. The facility's failure to have an effective system in place to ensure the residents' Comprehensive Care Plans were developed and/or implemented with a comprehensive person-centered care plan for each resident, consistent with the residents' rights has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F656, at a Scope and Severity (S/S) of a J; and 42 CFR 483.25 Free of Accidents/Hazards/Supervision, F689 at a S/S of a J, along with Substandard Quality of Care (SQC). The facility was notified of the Immediate Jeopardy (IJ) on [DATE] and is ongoing. The findings include: Review of the facility policy titled, Safety and Supervision of Residents, revised [DATE], revealed the Interdisciplinary Team (IDT) was to target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Review of the facility policy titled, Comprehensive Care Plan, dated [DATE], revealed the facility was expected to develop a person-centered care plan for each resident to enable the resident to live with dignity. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, dated 2001, revised [DATE], revealed the comprehensive, person-centered care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and reflected currently recognized standards of practice for problem areas and conditions. Continued review revealed care plan interventions were chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 1. Review of Resident #160's closed medical record revealed the facility admitted him/her on [DATE], with diagnoses of Type II Diabetes Mellitus, Nontraumatic Intracerebral Hemorrhage, and Heart Failure. Review of Resident #160's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed him/her as having a Brief Interview for Mental Status (BIMS) score of twelve (12), indicating he/she had moderately impaired cognition. Review of the resident's admission History and Physical Hospital Record, dated [DATE], revealed the resident had a history of attention and memory deficits. Further review revealed the resident gave convoluted details of his/her history that had to do with the resident's recent release from jail and had been living in the wild. Further review of the hospital record revealed the resident was diagnosed with Encephalopathy (a form of brain damage) with motor planning and higher cognitive deficits over and above previous baseline. Review of a Nurse's progress note dated [DATE] at 4:40 PM, revealed Resident #160 expressed to Registered Nurse (RN) #2 a desire to be discharged from the facility so he/she could go back home. Review of Resident #160's Care Plan, dated [DATE], revealed the facility assessed the resident for impaired cognitive function/dementia or impaired thought processes related to the resident's Brief Interview of Mental Status (BIMS) score less than 13. Review revealed the interventions included: administration of medications as ordered, monitor/document side effects and effectiveness; staff were to encourage the resident to verbalize feelings and fears; approach resident in a calm; friendly, non-rushed manner; use the resident's preferred name; identify yourself at each interaction; face the resident when speaking and make eye contact; reduce any distractions - turn off the television, radio, close his/her door; and the resident understands consistent, simple, directive sentences; provide the resident with necessary cues. Additionally, staff were to stop and return if agitated. Further review revealed however, there was no documentation to support the interdisciplinary team (IDT) targeted interventions to reduce individual risks related to accidents and incidents, to include adequate supervision and monitoring of the resident's environment for his/her safety, as per the facility's policy. Review of the facility's investigation initiated on [DATE], revealed Resident #160 had exited the facility through his/her window, into the courtyard and over the fence. Continued review revealed Resident #160 was last seen by staff on [DATE] at 10:30 PM, when his/her nurse administered his/her medications. Per review, Resident #160 was reported as missing on [DATE] at approximately 12:30 AM. Further review revealed staff notified the administrative team, and the police. Additional review revealed on [DATE] at 11:15 AM, the facility received a call from a local shelter who reported Resident #160 was located. Staff were unaware of the resident's whereabouts for approximately one (1) day, twelve (12) hours, and forty-five (45) minutes. Review of a Nurse's Progress Note dated [DATE] at 4:40 PM, revealed Resident #160 expressed to Registered Nurse (RN) #2 a desire to be discharged from the facility so he/she could go back home. In an interview on [DATE] at 11:16 AM, Certified Nursing Assistant (CNA) #19 stated Resident #160 had reported to her he/she wanted to get his/her own place when he/she was better. The CNA stated Resident #160 had been anxious about an upcoming court hearing. CNA #19 further stated she did not report this information to anyone. Review of the former Social Service Director (SSD) typed statement from the investigation, dated [DATE], revealed the SSD approached the resident the week of [DATE]-[DATE], she added she could not recall the exact date. Per review of the statement, the resident voiced questions about his/her discharge and wanted to know how much more time he/she had in the facility. Further review revealed the resident asked if he/she could be discharged to a halfway house. Review of the witness statement for the former Director of Nursing (DON), undated, revealed she received a call from Licensed Practical Nurse (LPN) #1, on [DATE] at 12:33 AM, and she informed her the resident was missing and she stated, I think he/she went out the window. Further review of the statement revealed the former DON responded by stating, OMG we were just talking about discharge. In an interview on [DATE] at 4:21 PM, the former Minimum Data Set (MDS) Nurse stated staff communicated with other staff and discussed any care plans that needed to be initiated or revised. She further stated if a new intervention had been put into place, the care plan would have been completed in the morning meeting. In an interview on [DATE] at 10:42 AM, the new MDS Nurse stated she was new at the facility having only started on [DATE]. She stated in general, if a resident had a BIMS score of twelve (12), she would have initiated a care plan related to any cognitive changes the resident might have. In an interview on [DATE] at 6:35 PM, the Assistant Director of Nursing (ADON), stated she completed the admission assessment for Resident #160. The ADON stated she recalled Resident #160 was not exhibiting any symptoms that might have indicated the resident was at risk for wandering. However, review of the staffs witnesses statements revealed the resident was anxious and discussed with staff his/her concerns with his/her court hearing and wanted to be discharged to return home on [DATE]; sometime within the week of [DATE]; and the day before he/she went missing on [DATE]. She stated residents' care plans were created by the interdisciplinary team (IDT); however, any nurse was able to update a resident's care plan as needed. The ADON further stated if Resident #160 had been at risk for wandering, his/her care plan would have been updated with increased supervision. 2 a). Review of Resident #310's closed admission Record revealed the facility admitted the resident on [DATE], with diagnoses including Chronic Respiratory Failure with Hypoxia, Bipolar Disorder, and Schizoaffective Disorder. Review of the facility document, Provisional Report of Death, revealed Resident #310 died on [DATE]. Review of Resident #310's admission MDS assessment dated [DATE], revealed the facility assessed the resident with a BIMS score of twelve (12) out of fifteen (15), indicating moderate cognitive impairment. Review of Resident #310's Comprehensive Care Plan dated [DATE], revealed the facility care planned the resident for impaired lung function related to Chronic Obstructive Pulmonary Disease (COPD). Continued review revealed interventions which included to encourage the resident to wear his/her nasal cannula when he/she removed it. Further review revealed however, the facility failed to develop Resident #310's care plan with interventions that directed staff to ensure the resident's oxygen cannula stayed on as ordered. Review of Resident #310's Treatment Administration Record (TAR) dated 08/2022, revealed the task for ensuring the resident's oxygen cannula was in place was only scheduled for once per shift, for a total of three (3) times in each twenty-four (24) hour period. Review of the facility's investigation into sexual abuse allegations made by Resident #310, on [DATE], revealed the resident removed his/her supplemental oxygen, became hypoxic and confused. Continued review revealed Resident #310 was found by staff in his/her bed, naked, and covered in feces and reported staff had raped him/her. Further review revealed when staff replaced the supplemental oxygen, Resident #310 recanted his/her statement about being sexually abused. In an interview on [DATE] at 3:51 PM, State Guardian #2 stated her expectation for the care of a resident under State Guardianship was for facility staff to ensure care was provided according to Physician' orders and the resident's care plan. In an interview on [DATE] at 2:25 PM, CNA #6 stated she remembered Resident #310 removed his/her oxygen frequently, especially when moving from the oxygen concentrator in his/her room to an oxygen tank for mobility around the facility. She stated she did her best to monitor when Resident #310 left his/her room so that she could ensure the resident had a nasal cannula connected to a full oxygen tank. CNA #6 stated however, if she did not see Resident #310 leave his/her room, there was not a specified time frame specified in the resident's care plan for when staff should ensure the resident's oxygen was in place. She further stated the importance of residents' care plans was to make sure each resident received the care they needed. In an interview on [DATE] at 2:28 PM, CNA #23 stated Resident #310 had often taken his/her oxygen off; however, had been very social and frequently out in the hallway, where staff were able to remind the resident to put his/her oxygen cannula back on when it was not in place. She stated staff did not have a specified interval for ensuring Resident #310's oxygen cannula was in place. She further stated care plan interventions needed to be implemented to ensure each resident could have the care they needed. In an interview on [DATE] at 9:33 PM, LPN #1 stated she recalled Resident #310 removing his/her oxygen while self-propelling himself/herself throughout the facility. She stated she did not follow a schedule for checking Resident #310's nasal cannula to ensure it was in place. LPN #1 stated therefore, she would not be able to determine how long Resident #310 had been without his/her prescribed supplemental oxygen at any given time, such as on the day of the incident. In an interview on [DATE] at 1:32 PM, RN #2 stated Resident #310 was noncompliant with wearing his/her oxygen cannula, so staff assisted him/her in replacing the nasal cannula whenever they noticed he/she had removed it. She further stated there was not a specified time frame for checking the nasal cannula to ensure Resident #310 was wearing it as ordered. In an interview on [DATE] at 9:54 AM, LPN #12/Unit Manager stated Resident #310 was noncompliant with wearing his/her oxygen nasal cannula as prescribed. She stated it was her expectation the care plan would include monitoring the resident frequently enough to prevent hypoxia. 2 b). Review of the facility's investigation into a second sexual abuse allegation involving Resident #310 dated [DATE], revealed the resident had removed his/her oxygen again, became hypoxic, confused, smeared feces on his/her body, and rolled around in the hallway naked. Continued review revealed CNA #10 took Resident #310 into the shower room alone, not following the Care in Pairs, intervention to give the resident a shower, at which time, the resident said, She's raping me. Further review revealed that once Resident #310's oxygen was replaced and his/her oxygenation levels returned to normal, the resident recanted his/her statement. Review of CNA #10's written statement from the investigation revealed she took Resident #310 into the shower room to clean the feces off the resident's body; however, failed to take another staff member with her. Further review revealed that when Resident #310 stated, She's raping me, CNA #10 took the resident back to his/her room and reported the allegation. Review of Resident #310's care plan dated [DATE] revealed Care in Pairs was added as an intervention on [DATE], after the first incident. Further review revealed the facility added an intervention on [DATE] that re-iterated that staff should perform Care in Pairs. Telephone interview was attempted with CNA #10 on [DATE] at 1:25 PM and [DATE] at 3:36 PM; however, a message was received stating the phone number was not in service. In an interview on [DATE] at 1:52 PM, the Social Services Director (SSD) stated the IDT discussed CNA #10 going into the shower room alone with Resident #310 even though the care plan specified she should have performed the task with another staff member as care planned. She further stated she believed CNA #10 received education about following the care plan. In an interview on [DATE] at 3:52 PM, the former Minimum Data Set (MDS) Coordinator stated that reminding Resident #310 to wear his/her oxygen cannula once per shift would not have been a sufficient intervention due to the resident's impaired cognition. She stated an appropriate, resident-specific intervention was to specify more frequent checks of Resident #310's oxygen, such as every two (2) hours. The former MDS Coordinator stated her process for care plan development was to review the care areas to ensure the care plan developed addressed all relevant disciplines for a resident's care. Additionally, she stated that all IDT members were able to modify residents' care plans when they identified a need for a different or more specific intervention. In an interview on [DATE] at 3:34 PM, the former DON stated that she believed the care plan which had been developed for maintaining Resident #310's oxygenation had been appropriate because the resident was out in the common areas of the unit where he/she could be easily monitored without requiring a specified time frame for monitoring. She stated on [DATE] and [DATE], Resident #310 removed the nasal cannula as soon as staff replaced it; and she did not believe there had been another intervention the facility could have implemented that would have been effective. In addition, she stated care plans were an important communication tool to ensure residents received the individualized care they required. In an interview on [DATE] at 11:54 AM, the ADON stated she was aware Resident #310 frequently removed his/her oxygen nasal cannula. The ADON stated she expected residents requiring supplemental oxygen to have that care planned. She further stated she expected staff to encourage a resident who required supplemental oxygen therapy to wear their nasal cannulas as care planned and prescribed. In an interview on [DATE] 11:31 AM, the DON stated that she was acting as the Unit Manager at the time of Resident #310's admission to the facility. She stated she did not recall what the IDT determined the root cause of Resident #310's increased confusion. The DON further stated Resident #310's care plan interventions included providing Care in Pairs and encouraging the resident to wear his/her nasal cannula. 3. Review of Resident #359's closed medical record revealed the facility admitted the resident on [DATE], with diagnoses of Type II Diabetes, Chronic Kidney Disease, Stage Four (4), and Acquired Absence of Left Leg Above Knee. Review of Resident #359's admission MDS assessment dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated the resident was cognitively intact. Continued MDS review revealed the facility assessed Resident #359 to require assistance of two (2) or more people with his/her bed mobility and transfers. Review of Resident #359's Comprehensive Care Plan (CCP), initiated on [DATE], revealed the facility had care planned the resident for skin integrity with a goal for the resident's skin to remain intact. Continued review revealed interventions included: using a pressure reducing mattress; turning and repositioning; assistance with bed mobility by using one (1) or two (2) staff to turn and reposition his/her in bed as needed. However, the facility failed to develop the resident's care plan related to his/her assessed needs of requiring the assistance of two (2) or more staff to assist with bed mobility and transfers. Additionally, the facility failed to ensure the resident's care plan was developed to include interventions to prevent skin tears during his/her wound dressing changes. Review of the Wound Physician's Progress note dated [DATE], revealed Resident #359 had been treated for five (5) wounds/skin tears. Per review the sites were noted as: Site one (1) a skin tear to the right, posterior thigh and was resolved; Site two (2) was a skin tear to the right shin; Site three (3) a Stage two (2) pressure wound to the right buttock. Continued review revealed Site four (4) was noted as a skin tear wound to the right, posterior, lateral thigh, and Site five (5) a skin tear of the right, lower knee. Per review of the Wound Care Nurse's written statement wound sites 1, 2, and 3 had all been present at the time of Resident #359's admission. Further review of the documentation revealed the skin tears listed as sites 4 and 5 resulted from dressing changes being performed of wound sites 1 and 2. Review of Resident #359's Skin Observation Tool, dated on [DATE] revealed a new skin tear to left upper arm/antecubital. Review of Nursing Progress Notes, dated [DATE] at 9:37 PM, revealed the skin tear to the resident's left upper arm was documented to have occurred. Continued review of the Note revealed no indication or description of how the skin tear occurred. Further review revealed the Nurse Practitioner was notified, and orders were received for care to the new wound. Interview on [DATE] at 3:41 PM, revealed CNA #9 stated he pulled Resident #359 up in bed without assistance of another staff person. He stated pulling Resident #359 up alone resulted in the resident getting a skin tear on his/her arm. He further stated he felt he could pull the resident up on his own and did not need another staff member to assist him. Interview on [DATE] at 8:35 PM, revealed Registered Nurse (RN) #2 stated she remembered an incident where CNA #9 told her he pulled Resident #359 up in bed by himself. She stated she recalled the CNA reported Resident #359 sustained a skin tear to his/her upper arm. Interview on [DATE] at 6:40 PM, revealed RN #2 stated Resident #359 had skin tears, and there were things she would have done to prevent skin tears, such as be gentle with the resident. She stated however, she was unsure whether there were interventions to prevent skin tears on Resident #359's care plan or not. RN #2 stated she would have put an intervention on Resident #359's care plan for staff to be gentle with the resident's skin so the CNAs would know they needed to be. She further stated she was unaware Resident #359's skin was fragile until [DATE], when the resident sustained the skin tear from the CNA pulling him/her up in bed by himself. Interview with RN #4/Wound Care Nurse/Weekend Unit Manager, on [DATE] at 10:40 AM, she stated that it would have helped prevent the resident's risk of skin tears if the person-centered care plan had been developed for the resident. Interview on [DATE] at 3:56 PM, revealed the former MDS Coordinator stated care plans should be specific to residents. She stated a resident with skin tears should have specific interventions for preventing skin tears such as prevention of skin tears when removing bandages. The former MDS Coordinator reviewed Resident #359's care plan and stated she did not see interventions in place to prevent skin tears; however, she felt there should have been interventions in place since the resident was admitted with skin tears. She further stated she felt the interventions on Resident #359's care plan were not adequate and could have caused the resident to have a bad outcome. Interview on [DATE] at 5:42 PM, revealed the Director of Nursing (DON) stated she expected nursing staff to assess residents for all skin issues when the resident was admitted . She further stated skin must be included for Resident #359's plan of care to meet the facility's goal of providing person-centered care. Interview on [DATE] at 7:17 PM, revealed the Executive Director (ED) stated she expected her staff to develop person-centered care plans for the residents in her facility. She stated she wanted the culture to be all about them, for example, when they (the resident) wanted something and how they wanted it. The ED stated her expectation was that care plans included providing interventions for the skin issues of residents to keep them safe. She further stated her expectation was that extra precautions would be put in place to prevent skin tears for any resident with thin skin. In addition, the ED stated that information should have been included on the care plan for a resident with those needs. 4. Review of Resident #161's closed medical record revealed the facility admitted the resident on [DATE], with diagnoses which included Cognitive Communication Deficit, Left below the Knee Amputation and Bipolar Disorder. Review of the five (5) day MDS assessment dated [DATE], revealed the facility assessed Resident #161 as having a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident's cognition was intact. Review of the Long-Term Care Self-Report Incident Investigation Form, initiated on [DATE], revealed Resident #161 exited the back door of the facility by pushing the egress bars until it released. Per the review, Resident #161 was in his/her wheelchair which he/she was able to self-propel. Continued review revealed the door alarm sounded on [DATE] at 9:40 PM, which alerted staff and staff responded. Certified Nursing Assistant (CNA) #26 located the resident outside of the facility, on the ground. Continued review revealed the wheels of the resident's wheelchair ran off the edge of the sidewalk, which caused the wheelchair to tilt, and the resident turned over. Continued review revealed Licensed Practical Nurse (LPN) #12 also responded and helped the CNA assist Resident #161 back into his/her wheelchair and back into the building. Review further revealed LPN #12 and observed an abrasion to his/her left stump (a residual limb). Review of the Nursing Progress Note documented as a Late Entry on [DATE] at 9:45 PM, by Licensed Practical Nurse (LPN) #12 revealed Resident #161 had been found outside an exit door. Per review of the Note, Resident #161 was assessed for injuries and a small abrasion was observed to the resident's left below the knee amputation (L BKA) area. Review of Resident #161's smoking assessment, dated [DATE], revealed the resident was assessed to require the use of a smoking apron and assessed to have supervision while smoking. Review of Resident #161's Comprehensive Care Plan dated [DATE] revealed the facility care planned the resident for a risk to exit seek related to his/her desire to smoke without supervision. However, the facility failed to assess the resident for his/her smoking safety upon admission to ensure his/her care plan was developed to indicate a need for assisted and supervised smoking. Review of a Social Service Progress Note, dated [DATE] at 1:02 PM, revealed the Social Worker had met with Resident #161 to review the facility's smoking policy. Continued review revealed Resident #161 verbalized understanding of the policy. In an interview on [DATE] at 9:14 AM, the Director of Nursing (DON) stated care plans were to be person-centered with the individual resident's needs in mind when developed. She stated she expected care plans to be developed and revised to meet the needs of each resident. In an interview on [DATE] at 6:42 PM, the Executive Director (ED) stated her expectation was for care plans to be resident-specific and developed to address all care areas impacting resident care.

**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 the residents' environment remained as free of accident hazards as possible, and each resident received adequate supervision and assistance devices necessary to prevent accidents for three (3) of twenty-four (24) sampled residents (Residents #160, #161, and #359). 1. On 04/22/2022 at approximately 12:30 AM, Resident #160 exited the facility through his/her window without staff's knowledge. The facility was unaware of Resident #160's whereabouts until a local shelter notified staff by telephone on 04/23/2022 at 11:15 AM of the resident's location. The resident was last seen on 04/21/2022 at 10:30 PM by Licensed Practical Nurse (LPN) #13, who checked his/her blood sugar and administered insulin as ordered at that time. Review of the local weather for 04/22/2022, per historical data, showed a low temperature of fifty-nine (59) degrees Fahrenheit with high temperature around seventy-nine (79) degrees Fahrenheit with light rain showers in the area. 2. On 08/14/2022 at 9:40 PM, Resident #161 exited the back door of the facility and the alarm sounded, alerting staff. The resident was found on the ground where he/she had fallen out of his/her wheelchair to smoke independently. The facility failed to assess the resident for smoking safety and supervision when the resident was admitted on [DATE]. As a result, the resident sustained a small abrasion on his/her left below the knee amputation. 3. Resident #359 was pulled up in bed by only one (1) CNA which resulted in the resident sustaining a skin tear to his/her left upper arm. In addition, during wound care as the dressings were removed the adhesive resulted in Resident #359 sustaining two (2) additional skin tears. The facility's failure to have an effective system in place to ensure the residents' environment remained free of accident hazards and failed to ensure the residents received adequate supervision and assistance to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 06/10/2023 and was determined to exist on 04/22/2022 in the areas of 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F 656, at a Scope and Severity (S/S) of a J; and 42 CFR 483.25 Free of Accidents/Hazards/Supervision, F 689 at a S/S of a J, along with Substandard Quality of Care (SQC). The facility was notified of the Immediate Jeopardy (IJ) on 06/10/2023 and is ongoing. The findings include: Review of the facility policy titled, Safety and Supervision of Residents, revised July 2017, revealed the facility was to strive to make the environment as free from accident hazards as possible. Per policy review, resident safety and supervision and assistance to prevent accidents were facility-wide priorities, and the facility utilized an individualized, resident-centered approach for safety. Continued review revealed the interdisciplinary team (IDT) was to analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. Further review revealed the IDT was to target interventions to reduce individual residents' risks related to hazards in the environment, including adequate supervision and assistive devices. Additionally, policy review revealed interventions implemented reduced accident risks and hazards. Review of the facility policy titled, Increased Supervision, undated, revealed increased supervision referred to the supervision of residents by staff to prevent opportunities for altercations or situations for the resident to harm themselves or others. 1. Review of Resident #160's closed medical record revealed the facility admitted the resident on 03/10/2022, with diagnoses which included Partial Traumatic Amputation of right foot, Nontraumatic Intracerebral Hemorrhage, Diabetes Mellitus with Diabetic Neuropathy and Heart Failure. Review of the resident's admission History and Physical Hospital Record, dated 02/01/2022, revealed the resident had a history of attention and memory deficits. Further review revealed the resident gave convoluted details of his/her history that had to do with the resident's recent release from jail and had been living in the wild. Further review of the hospital record revealed the resident was diagnosed with Encephalopathy (a form of brain damage) with motor planning and higher cognitive deficits over and above previous baseline. Review of a Nurse's Progress Note dated 03/20/2022 at 4:40 PM, revealed Resident #160 expressed to Registered Nurse (RN) #2 a desire to be discharged from the facility so he/she could go back home. Review of Resident #160's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated he/she had moderate cognitive impairment. Review of Resident #160's Care Plan, dated 03/25/2022, revealed the facility assessed the resident for impaired cognitive function/dementia or impaired thought processes related to the resident's Brief Interview of Mental Status (BIMS) score less than 13. Review revealed the interventions included: administration of medications as ordered, monitor/document safe effects and effectiveness; allow, encourage resident to verbalize feelings and fears; approach resident in a calm; friendly, non-rushed manner; use the resident's preferred name; identify yourself at each interaction; face the resident when speaking and make eye contact; reduce any distractions - turn off the television, radio, close his/her door; and the resident understands consistent, simple, directive sentences; provide the resident with necessary cues. Additionally, staff were to stop and return if agitated. Further review revealed however, no documented evidence of interventions to increase Resident #160's supervision related to his/her verbally expressing the desire to go home on [DATE]. Review of the Long-Term Care Self-Report Incident Investigation Form, attachment to Section C, dated 04/22/2022, revealed Resident #160 exited the facility by circumventing the safety mechanism on the window by physically shoving the window up and bending the window stops to get out into the secured courtyard. Per review, it was determined Resident #160 stacked a table and chair from the courtyard next to the fence and the building, to crawl over the fence. The investigation revealed the resident was located on 04/23/2022 at approximately 11:15 AM at a local shelter. Continued review of the investigation noted all the windows in the facility were checked and in good order with the appropriate safety mechanisms in place. Review of the witness statement for Certified Nursing Assistant (CNA) #19, dated 04/22/2022, revealed the CNA gave her statement over the phone. Per review of the statement, the CNA reported the resident was anxious about an upcoming hearing. Review of the former Social Service Director (SSD) typed statement from the investigation, dated 04/22/2022, revealed the SSD approached the resident the week of 04/11/2022-04/14/2022, she added she could not recall the exact date. Per review of the statement, the resident voiced questions about his/her discharge and wanted to know how much more time he/she had in the facility. Further review revealed the resident asked if he/she could be discharged to a halfway house and the former Social Service Director explained to the resident he/she had rights; however, based on the resident's wounds, it would have been an unsafe discharge. Review of Licensed Practical Nurse (LPN) #13's witness statement from the investigation, dated 04/22/2022, revealed on 04/22/2022 at 10:30 PM, she checked the resident's blood sugar and gave his/her insulin. Continued review revealed she remained at the facility until 12:10 AM. Review of Licensed Practical Nurse (LPN) #14 witness statement from the investigation, dated 04/22/2022, revealed that at approximately midnight she came out of room [ROOM NUMBER] and was informed by the CNA (identity not indicated on the statement) that the resident was not in his/her room and could not be located. Continued review revealed she looked in the rooms on the unit, the bathrooms, and {through} all doors that were open for the resident. Further, she stated Licensed Practical Nurse (LPN) #1 was on the phone with the Executive Director (ED). She revealed she walked outside of the building to look for the resident. Continued review revealed LPN #14 was informed by a CNA (identity not indicated on the statement) that when the CNA looked on the other side of the fence, the CNA did not see the resident. Review of LPN #1's witness statement from the investigation, dated 04/22/2022, revealed a CNA (identity not indicated on the statement) asked her on 04/22/2022 at 12:30 AM if she knew were Resident #160 was located. She reported she went to the resident's room, and he/she was not there. Further, she revealed she did not notice the widow. She reported the facility staff started to conduct a room search and a head count when someone stated, look his/her window was open. Per the review, the LPN reported the resident had a table with a chair stacked on top of it. Further review revealed the police were called and the police reported that if the resident did not have a court order then he/she would not have been a missing person. Continued review of the statement revealed the LPN; however, added, he (the police) did not ask about whether the resident was in his/her right mind. Review of the witness statement from the investigation for the former Director of Nursing (DON), undated, revealed she received a call from Licensed Practical Nurse (LPN) #1, on 04/22/2022 at 12:33 AM, and she informed her the resident was missing and she stated, I think he/she went out the window. Further review of the statement revealed the former DON responded by stating, OMG we were just talking about discharge. The former DON revealed LPN #1 reported to her the resident went over the fence. Review of the witness statement from the investigation for the former Executive Director (ED), not dated, revealed that on 04/22/2022 at 12:38 AM, LPN #1 called and informed him the resident left out of the window, over the fence. Further review revealed the former DON informed him the resident was of his/her own mind and the concern was not reportable. Continued review of the statement revealed the ED reported he told staff to notify the police. Review of Resident #160's statement from the investigation, dated 04/23/2022 with no time indicated, revealed the homeless shelter contacted the facility. Continued review of the statement revealed the resident stated he/she was frustrated with his/her court case and was needing to get to his/her county to work on a schedule. Further review revealed the resident stated he/she caught a bus to the hospital to obtain a list of medications. The resident stated someone saved him/her and gave him/her ten (10) dollars to catch the bus downtown. Additionally, the resident revealed he/she slept in the woods by the pond the first night and was in the shelter the second (2nd) night. An additional review of Resident #160's statement from the investigation, dated 04/24/2022, revealed the resident reported he/she exited from his/her window and stated he/she, just opened it, you can do that. Review of the local weather for 04/22/2022, per historical data, showed a low temperature of fifty-nine (59) degrees Fahrenheit with high temperature around seventy-nine (79) degrees Fahrenheit with light rain showers in the area. Observation on 06/02/2023 at 9:19 AM, of resident room [ROOM NUMBER]-2, where Resident #160 resided prior to discharge, and was now occupied by a different resident, revealed the window to be at ground level, covered with a blind and intact with window stops in place. Observations of other windows in residents' rooms were set up the same. In an interview on 06/11/2023 at 11:16 AM, CNA #19 stated Resident #160 had reported to her he/she wanted to get his/her own place when he/she was better. The CNA stated Resident #160 had been anxious about an upcoming court hearing. CNA #19 further stated she did not report this information to anyone. In interview on 06/02/2023 at 1:33 PM, the Maintenance Director stated the window in Resident #160's room was forced open by bending the window stops which made it possible for the window to be raised completely allowing the resident to escape out of it. The Maintenance Director stated he repaired the window after the incident with heavy-duty screws put into place. A telephone interview was attempted with LPN #13 on 06/11/2023 at 11:39 AM; however, was unsuccessful as there was no answer and voicemail had not been set up, so the State Survey Agency (SSA) Surveyor was unable to leave a message requesting a return call. In an interview on 06/10/2023 at 11:11 AM, the former SSD stated she had attempted to have a conversation with Resident #160 about a court date he/she was concerned about which was coming up; however, the resident would not open up to her about it. She further stated the week before Resident #160 exited the facility he/she had asked her about his/her discharge plan from the facility. In an interview on 06/10/2023 at 6:35 PM, the Assistant Director of Nursing (ADON), stated she completed the admission assessment for Resident #160. The ADON stated she recalled Resident #160 was not exhibiting any symptoms that might have indicated the resident was at risk for wandering. However, review of the staffs witnesses statements revealed the resident was anxious and discussed with staff his/her concerns with his/her court hearing and wanted to be discharged to return home on [DATE]; sometime within the week of 04/11/2022; and the day before he/she went missing on 04/21/2022. Review of Resident #160's closed medical record revealed there was no documentation to support the interdisciplinary team (IDT) analyzed information obtained from the resident's assessments and observations to identify specific accident hazards or risks for individual residents, to include adequate supervision and monitoring the resident's environment for his/her safety, as mentioned in the facility's policy. In an interview on 06/10/2023 at 9:14 AM, the DON (the former Unit Manager) stated she had received a text from LPN #14 on 04/22/2022 at 12:52 AM alerting her that Resident #160 had left the facility without staff's knowledge. She stated the facility was unaware of Resident #160's location until she received a phone call from staff at a local shelter. The DON stated she and two (2) other staff left to go pick up Resident #160 and he/she agreed to return to the facility with them. Per the interview with the DON, Resident #160 told her people owed him/her money, and stated I just wanted to leave, not getting my med's. The DON stated Resident #160 also told her he/she had already planned to leave. Further, the DON stated Resident #160 told her he/she had taken a nap by the pond near the hospital, and someone came along and gave him/her $10 which the resident used for transportation to the shelter. Review of the facility's smoking policy, effective date 10/08/2017, revealed it was the policy to provide a safe, functional, sanitary, and comfortable environment for all residents, including those that did not smoke, regarding smoking, smoking areas, and smoking safety. 2. Review of Resident #161's closed medical record revealed the facility admitted the resident on 08/10/2022, with diagnoses which included Type I Diabetes Mellitus, Chronic Kidney Disease (CKD), Cognitive Communication Deficit, Left below the Knee Amputation and Bipolar Disorder. Review of the five (5) day MDS assessment dated [DATE], revealed the facility assessed Resident #161 as having a BIMS score of fifteen (15) which indicated the resident's cognition was intact. Review of the Long-Term Care Self-Report Incident Investigation Form, initiated on 08/14/2022, revealed Resident #161 exited the back door of the facility by pushing the bar until it released. Per the review, Resident #161 was in his/her wheelchair which he/she was able to self-propel. Continued review revealed the door alarm sounded on 08/14/2022 at 9:40 PM, which alerted staff and staff responded. Certified Nursing Assistant (CNA) #26 located the resident outside of the facility, on the ground. Continued review revealed the wheels of the resident's wheelchair ran off the edge of the sidewalk, which caused the wheelchair to tilt, and the resident turned over. Continued review revealed Licensed Practical Nurse (LPN) #12 also responded and helped the CNA assist Resident #161 back into his/her wheelchair and back into the building. Review further revealed LPN #12 assessed Resident #161, provided first aid, and observed an abrasion to his/her left stump (a residual limb). Review of Resident #161's smoking assessment, dated 08/15/2022, revealed the resident was assessed to require the use of a smoking apron and assessed to have supervision while smoking. Review of Resident #161's Comprehensive Care Plan dated 08/15/2022 revealed the facility care planned the resident for a risk to exit seek related to his/her desire to smoke without supervision. The facility; however, failed to assess the resident for smoking upon admission to ensure his/her care plan was developed and implemented to indicate a need for assisted and supervised smoking. Review of the Nursing Progress Note documented as a Late Entry on 08/14/2022 at 9:45 PM, by Licensed Practical Nurse (LPN) #12 revealed Resident #161 had been found outside an exit door. Per review of the Note, Resident #161 was assessed for injuries and a small abrasion was observed to the resident's left below the knee amputation (L BKA) area. Continued review revealed his/her vital signs were assessed and neurological checks were initiated and were noted to be within normal limits (WNL). Review revealed Resident #161 was assisted up and back into the wheelchair, and back into the building and then to bed. Further review revealed the resident reported to LPN #12 that he/she had gone out to smoke. Review further revealed Resident #161 was educated by LPN #12 of the facility's smoking policy and was to adhere to it. Review of a Social Service Progress Note, dated 08/15/2022 at 1:02 PM, revealed the Social Worker had met with Resident #161 to review the facility's smoking policy. Continued review revealed Resident #161 verbalized understanding of the policy; however, he/she refused to give staff his/her smoking materials and told the Social Worker, I will smoke when and where I want. I feel like you are trying to control me and take away my independence. Interview on 06/02/2023 at 10:54 AM, revealed Licensed Practical Nurse (LPN) #4 stated she was passing medications when another resident needed to go to the bathroom, so she stopped and took care of that resident. LPN #4 stated next, she headed to pass medications to Resident #161; however, the resident was not in his/her room. The LPN further stated she did not recall much about the incident since it had been so long ago. Telephone call attempts made to contact CNA #28, on 06/02/2023 at 10:50 AM and on 06/04/2023 at 3:38 PM were unsuccessful. 3. Review of Resident #359's closed clinical record revealed the facility admitted the resident on 02/16/2023, with diagnoses of Chronic Kidney Disease, Stage Four (4) (Severe); Type Two (2) Diabetes; and Acquired Absence of Left Leg Above Knee. Review of the admission MDS Assessment for Resident #359 dated 02/20/2023, revealed the facility assessed the resident as having a BIMS score of fifteen (15) out of a possible fifteen (15) (BIMS), which indicated he/she was cognitively intact. Continued review of Section G of the MDS revealed the facility assessed Resident #359's functional status and Activities of Daily Living (ADL) support to require assistance of two (2) plus persons for bed mobility and transfers. Review of Resident #359's Comprehensive Care Plan (CCP), initiated on 02/16/2023, revealed the facility had care planned the resident for skin integrity with a goal for the resident's skin to remain intact. Continued review revealed interventions included: using a pressure reducing mattress; turning and repositioning; assistance with bed mobility by using one (1) or two (2) staff to turn and reposition him/her in bed as needed. Further review revealed the resident was assessed to have two (2) persons assist for bed mobility and transfers; however, the facility failed to care plan, related to the resident's assessed needs and failed to ensure interventions related to the monitoring and documentation of the resident's dressing changes that resulted in the resident's skin tears. Review of the Wound Physician's Progress note dated on 03/06/2023, revealed Resident #359 had been treated for five (5) wounds/skin tears. Continued review of site one (1) revealed it was resolved and was a skin tear to the right, posterior thigh, and site two (2) was a skin tear of the right shin. Continued review revealed site three (3) was a Stage two (2) pressure wound of the right buttock, and site four (4) was a skin tear wound of the right, posterior, lateral thigh, and site five (5) was a skin tear of the right, lower knee. Further review revealed according to a written statement from the Wound Care Nurse, wound sites 1, 2, and 3 were present upon Resident #359's admission to the facility. In addition, review revealed skin tears, listed as sites 4 and 5 resulted from changing the dressing on the wounds at sites 1 and 2. Review of Resident #359's Skin Observation Tool dated on 03/07/2023, revealed a new skin tear had occurred to his/her left upper arm/antecubital area (region of the arm in front of the elbow). Review of Nursing Progress Note dated 03/07/2023 at 9:37 PM, revealed the skin tear to Resident #359's left upper arm was documented and the Nurse Practitioner was notified with orders received for care to the new wound. Continued review of the Note revealed there was no documentation to support the reason for the resident's skin tear. Further review of Resident #359's closed clinical record revealed the resident was discharged on 03/08/2023. In an interview on 06/01/2023 at 3:41 PM, CNA #9 stated he pulled Resident #359 up in bed by himself which resulted in the resident getting a skin tear on his/her arm. The CNA stated he felt he could pull the resident up on his own, and he did not need another staff member to help. In an interview on 06/01/2023 at 11:20 AM, CNA #6 stated when Resident #359 was admitted to the facility, his/her skin had bruising and wounds. She stated Resident #359 had sustained additional skin tears while at the facility; however, she was unsure of where they came from. Further, she stated Resident #359 had not reported to her of any staff member that was rough providing his/her care, although she admitted the resident's skin was fragile and prone to tearing. In an interview on 06/01/2023 at 8:35 PM, Registered Nurse (RN) #2 stated she remembered an incident with Resident #359 in which CNA # 9 told her he pulled up the resident in bed by himself. RN #2 stated the CNA reported as a result Resident #359 sustained a skin tear to his/her left upper arm. In an interview on 06/03/2023 at 8:50 AM, RN #4/Wound Care Nurse stated Resident #359 had three (3) wounds on admission to the facility. She stated the resident sustained two (2) skin tears that were documented by the wound care physician as a result of wound care dressings being changed and the removal of the dressing by nursing resulted in skin tears. In an interview on 06/10/2023 at 5:42 PM, the DON stated her expectation was that if a skin tear happened during a dressing change, she expected it to be documented and an incident report completed. She further expected proper notification of the provider and the family if an incident occurred. She stated treatment orders were needed, as well as, a skin assessment, and a pain evaluation. The DON stated that if the process was not followed, she would have educated the nursing staff, because not following the process would cause a delay in care, treatment, or even cause the resident to suffer an infection. Interview with Executive Director (ED), on 06/10/2023 at 7:17 PM, she stated her expectation was that skin tears were documented. She stated the resident must first be assured that they were safe. Following that, the provider should have been notified, and the staff were expected to follow the physician's orders. She stated the process was in place to protect the resident and to ensure the healing of the resident's skin tear.